Patient-reported Outcome Measures are increasingly being used in pediatric clinical care due to their ability to capture the patient “voice”, empower patients and families, and facilitate delivery of PFCC [8, 22]. However, there are myriad of challenges associated with their implementation in routine clinical care. We utilized TDF to systematically explore barriers and enablers to implementing PROMs in routine pediatric asthma care. TDF was chosen for this study because it provides a robust theoretical and comprehensive lens to view the cognitive, affective, social, and environmental influences on behavior and covers most of the potential reasons for implementation problems [23].

Seventeen barriers to behavioral change identified in our study were attributed to personal, clinical, non-clinical, and other system-level factors. The barriers such as limited awareness of PROMs and the need for PROMs data interpretation skills underline the role of healthcare systems, educational institutions, and professional organizations to create awareness about the use of PROMs and advance the skills required for frontline clinicians to implement PROMs in clinical care. Outside the clinical environment, language and technological barriers, and patient and family issues were associated with economic, social, and cultural aspects. The motivations for using PROMs might differ for clinicians and patients and their families, so non-alignment of their motivations could create barriers to implementing PROMs. Similarly, the emotional state of patients and families could deter them from completing PROMs and act as one of the barriers.

Among the 17 enablers, clinicians’ commitment to providing patient and family-centered care, excitement, high importance, and optimism about using PROMs to provide comprehensive healthcare was identified as a major enabler. Compatibility of using electronic PROMs with current practice, competency in communication around psychosocial questions, confidence in self-abilities, demonstrate feasibility of implementing PROMs in asthma clinics. Moreover, the perception of PROMs as tools to standardize care across asthma clinics and optimize healthcare delivery underlines the additional uses of PROMs in asthma clinics. Lastly, our team’s engagement with the senior leadership and all the staff at the asthma clinics was considered a major enabler.

AHS is currently rolling out a province wide EMR system. Therefore, the findings of this study will facilitate the integration of PROMs within this EMR system or through the KidsPRO program. Although mitigation of barriers related to clinical workflow, organizational culture and would warrant system-level changes, barriers such as the need for skills (data interpretation, etc.) identified by clinicians, would be utilized to develop user guides for planning the use of PROMs through the KidsPRO program [17]. To mitigate technological barriers, the KidsPRO program will have tablets and support mechanisms at the clinics for patients to complete PROMs at the clinics prior to their appointment [17]. Senior leaders and clinical leads will be presented with the findings of this study to develop a pan-hospital implementation and province-wide scale-up of the KidsPRO program.

Previous systematic reviews had found that healthcare organizations needed to invest time and resources in “designing” the context-specific PROM strategy and reported mixed results on the perceived impact of using PROMs on the average duration of an appointment or consultation [12, 24] corroborating with those study findings. Therefore, future studies should objectively measure the impact of implementing PROMs on the time of appointment. The findings of our study, like the need for professional development and training, including patient-family education, align with the findings from a study exploring stakeholder perspective on clinical implementation of PROMs in pediatric solid organ transplantation [25]. Similarly, barriers such as lack of organizational support to incorporating PROMs into existing workflows has been identified in a previous study [26]. On the other hand, similarities exist between enablers from our study and previous studies. For example, compatibility of PROMs implementation with clinicians’ values has been identified as a facilitator [27], which this aligns with one of the enablers identified in our study i.e. willingness to provide patient and family-centered care. Some of the barriers and enablers identified in our study might have been healthcare system and local context specific. But according to a recently published study, barriers and enablers to implementing PROMs are remarkably consistent across patient populations and care settings [14]. Therefore, many of the findings from our study apply to other healthcare settings.

The current Covid-19 pandemic has resulted in school closures and social isolations, which have increased psychosocial stress on children and adolescents [28]. Considering the role of PROMs in capturing the psychosocial concerns of patients, health systems around the world should expedite the implementation of PROMs in routine pediatric clinical care.

Strengths and limitations

One of the strengths of our study is the diversity in our sample, which included frontline clinicians, allied health professionals, and administrators, who provided diverse views of the barriers and enablers in asthma clinics. The systematic and theoretical domains framework-driven approach to identify potential barriers and enablers is another key strength of this study. The findings of this study must be interpreted with caution, keeping some limitations in mind. For instance, our use of PedsQL™ as an example of a typical PROM might have influenced some responses, especially around psychosocial questions. Also, this study was conducted at a single tertiary academic hospital and community clinics run by a single team, so the results might not be completely transferrable to other healthcare settings.

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