Project Summary

This implementation project is complete.

PCORI implementation projects promote the use of findings from PCORI-funded studies in real-world healthcare and other settings. These projects build toward broad use of evidence to inform healthcare decisions.

This PCORI-funded implementation project made surveys of patient-centered factors part of regular care for patients at pain clinics.

Chronic pain, which may last for months or even years, can disturb people’s daily lives and their relationships with others. Patient-centered factors, such as patient beliefs and expectations about their pain and how treatments work, can affect how they respond to treatment. Measuring these factors and addressing them in clinic visits can help improve patients’ health.

What was the goal of this implementation project?

Healing Encounters and Attitudes Lists, or HEAL, is a set of surveys that measure patient expectations about treatment. They also measure patients’ outlook on life and their connections with their doctors and nurses. HEAL offers doctors and patients a way to understand and talk about patient beliefs and expectations. They can use this information to choose treatments that work well for each patient. A PCORI-funded study used HEAL and found that patients with chronic pain who had higher HEAL scores reported greater symptom improvement after two and four months of treatment than patients with lower HEAL scores.

This project worked to make HEAL part of regular care at seven pain clinics in one health system to improve care for patients seeking treatment for chronic pain.

What did this project do?

The project team successfully put HEAL in place at seven pain clinics that are part of the University of Pittsburgh Medical Center. Clinics were in urban, suburban, and rural areas. They used HEAL and another survey called CHOIR to learn how pain affects patients’ lives. They also used the surveys to learn how patients view their treatments.

Patients filled out the surveys at the clinic or at home. Clinicians could view a report with patients’ responses in patients’ charts. Clinicians were doctors, nurse practitioners, physician assistants, or psychologists. Patients and clinicians could then discuss the results during visits.

To make HEAL part of care at pain clinics, the project team:

  • Talked with patients and staff at pain clinics to understand how they could use HEAL to plan treatment
  • Programmed HEAL to be part of the online survey that clinics already used
  • Created a set of training materials
  • Trained 74 pain clinic staff at lunch and learns, staff retreats, and at video trainings on how to use HEAL as part of patient care
  • Identified a champion at each clinic to promote the use of HEAL
  • Provided regular feedback reports to clinics about patient and clinician use of HEAL
  • Provided ongoing support to clinics in using HEAL

What was the impact of this project?

During the project, 23,475 patients with chronic pain completed more than 58,000 surveys. Of patients who had a clinic visit, 80% had completed HEAL. Clinicians viewed 49,772 reports, or 86% of patients’ completed surveys. Before the project, clinicians viewed 76% of completed surveys.

The project team’s evaluation showed that, over 27 months:

  • The number of patients prescribed strong opioids (Schedule II) decreased from 2,313 to 1,719. This number represented a decrease from 28% to 21% of all prescriptions ordered for these patients.
  • Among patients who had a clinic visit after completing HEAL, referrals for injections decreased from 39% of patients to 27%.
  • Counter to expectations, referrals for mental health services decreased from 17% to 9%. Also, referrals for physical or occupational therapy decreased from 23% to 19%.
  • Referrals to integrative medicine increased from 0.8% to 2%. But the number of referrals was low compared with other types of referrals.
  • Use of emergency care did not change.
  • After adding HEAL at the clinics, patient-reported outcomes related to pain, function, depression, sleep, and anxiety showed greater improvements compared with outcomes before adding HEAL.

All clinics will continue to use HEAL. The health system is also expanding the use of HEAL to other clinics. Future sites can use the training materials and consult with a clinic administrator to put HEAL in place. The project team has made the training materials publicly available upon request.

Cost of Implementation:

This Project Team examined the costs associated with making the HEAL surveys a part of regular patient care at seven UPMC pain clinics.

The largest cost was for staff time to program the HEAL questions into the CHOIR survey. Other costs were for site preparations during the pre-implementation phase, as well as training staff to deliver and use the HEAL questions.

For more details, view this project’s Cost of Implementation Report, which will be posted here when available.

PCORI supplemental funding supported project activities to capture and analyze the costs of implementation during this project. PCORI’s goal is to provide decision-makers at future sites with information they can use when considering adoption of the intervention that was the focus of this PCORI-funded implementation project.

More about this implementation project:

Stakeholders Involved in This Project

  • University of Pittsburgh School of Medicine Chronic Pain Research Program and the Center for Innovation in Pain Care (CIPC)
  • Patient and stakeholder advisors including an occupational therapist, a physician with expertise in chronic pain, patients with chronic pain, and a representative from the American Chronic Pain Association

Publicly Accessible Project Materials

For more information about these materials, please contact the Project Team leader at [email protected].

The project team developed these materials, which may be available for free or require a fee to access. Please note that the materials do not necessarily represent the views of PCORI and that PCORI cannot guarantee their accuracy or reliability.

    Project Achievements

    • Demonstrated the feasibility of implementing HEAL in chronic pain settings
    • Programmed HEAL into the Collaborative Health Outcomes Information Registry (CHOIR), an electronic platform that allows patients to complete surveys about their health
    • Created education materials to facilitate the use of HEAL
    • Trained 74 clinic staff in using HEAL
    • Reached 23,475 patients with chronic pain who were seeking and receiving treatment at 7 University of Pittsburgh Medical Center Pain Medicine clinical sites
    • Successfully implemented strategies to maximize uptake of HEAL/CHOIR during telemedicine visits in response to the COVID-19 pandemic

    Implementation Strategies

    • Used a clinical decision support tool
    • Adapted HEAL based on patients’ and clinics’ preferences and to work with sites’ existing resources and workflows
    • Incorporated HEAL into CHOIR and enabled the generation of completed reports for patients and clinicians
    • Used data warehousing techniques
    • Used a train-the-trainer approach
    • Trained clinicians, through in-person meetings and online videos, to access, interpret, and use the HEAL reports during a clinic visit
    • Trained front desk staff and medical assistants to support patients’ use of HEAL
    • Provided tools to support implementation of HEAL, including clinician FAQs
    • Provided clinic-specific audit and feedback reports
    • Identified and prepared champions at each site
    • Provided educational materials to patients, including FAQ sheets
    • Provided technical assistance to sites, including ongoing consultation and practice facilitation

    Evaluation Measures

    To document implementation:

    • Number of unique patients eligible to complete HEAL
    • Number of surveys completed during the project
    • Patient survey completion rate (number of surveys completed relative to the number of appointments for which a survey was requested)
    • Number of views of clinician PDF reports of patient surveys
    • Number of clinic staff trained

    To assess healthcare and health outcomes:

    • Non-opioid pain management and reduced use of strong opioids
    • Referrals to nonpharmacologic treatment approaches such as psychology, physical therapy, or occupational therapy
    • Healthcare utilization
    • PROMIS outcomes: pain intensity, pain interference, physical function, depression, anxiety

    COVID-19-Related Project Activities

    PCORI supplemental funding supported project activities to address evolving or emerging needs in the context of the COVID-19 public health crisis.

    To reduce the risk of spreading the COVID-19 virus, many health systems shifted from in-person care to telehealth. Telehealth is a way to provide care to patients remotely using phone, video, or monitoring devices that can help manage care.

    With the enhancement, the project team developed supports in using HEAL for patients with chronic pain during telehealth visits, including training for clinicians. Patients filled out the survey at home instead of in the waiting room. The team found that clinics continued to use HEAL during the pandemic. The patient survey completion rate was high (83%), and clinician views of the reports were also high (96%).

    Project Information

    Carol Greco, PhD
    University of Pittsburgh School of Medicine
    Implementing Contextual Factors Assessment in Clinical Settings

    Key Dates

    April 2022

    Study Registration Information

    Initial PCORI-funded Research Study

    This implementation project focuses on putting findings into practice from this completed PCORI-funded research study: Using Surveys to Assess Patient-Centered Factors that May Affect Responses to Chronic Pain Treatment


    Project Status
    Health Conditions Health Conditions These are the broad terms we use to categorize our funded research studies; specific diseases or conditions are included within the appropriate larger category. Note: not all of our funded projects focus on a single disease or condition; some touch on multiple diseases or conditions, research methods, or broader health system interventions. Such projects won’t be listed by a primary disease/condition and so won’t appear if you use this filter tool to find them. View Glossary
    State State The state where the project originates, or where the primary institution or organization is located. View Glossary
    Project Details Type
    Last updated: April 12, 2023