161 General discussion & future perspectives 8 to data if the aim is to compare patients. In addition, it will increase the risk of over asking the patients and demotivating them. Implementing of the OQUA in routine clinical care The OQUA has now been introduced and implemented in daily care in the Amsterdam UMC at the outpatient clinic for all patients with one or multiple ear complaints who are planned for a surgical intervention. The OQUA can be related to any intervention, but till now it is only connected to scheduled surgery to assure reliable and valuable PROM measurements before surgery and post operatively (3 and 12 months) to convince all users of its’ added value. During the implementation process, trust in OQUA and the use of PROMs among providers grew. However, incorporating PROMs into routine care demands a change in the daily routine and long lasting behaviour concerning’ approach, preparation, and execution of consultations.17,18 As can be expected during implementation we ran into some problems for which we designed an implementation strategy based on the barriers and enablers of the OQUA as described in chapter 7. When considering the implementation of a PROM in general, barriers may emerge at various levels: the patient level, the provider team or group level, the organizational level, and the market or policy level 19. Most of the barriers that we found are comparable with implementation of PROM in healthcare in general and include lack of knowledge, skills and motivation regarding the relevance, clinical usefulness and clinical benefit.17,18,20-22 One of the enablers for good implementation is the feasibility of the PROM, with factors such as the ease of administration, scoring, and interpretation. In the Amsterdam UMC, the OQUA is now integrated in the electronic health record (EHR) EPIC23 and patients can prepare their consultation at home by filling out the OQUA online. The provider dashboard of the OQUA module was implemented and built to calculate different complaints scores and an impact score. Individual answers on the items can be seen by hoovering on the complaint score. With repeated measures, an arrow up or down is displayed next to the score. The arrow is in blue if the score improves (less complaints or lower impact scores) or in red if the score deteriorates (chapter 6, figure 2). This makes scores easy to interpretate. To discuss the results, OQUA scores should also be easy interpretable and meaningful to the patients. In our implementation study (chapter 7) one of the key barriers from the patient’s perspective was insufficient feedback on the results of the OQUA in the consultation (pointed out by 14 out of 25 patients). This might be partially resolved
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