Introduction

Patient-reported outcomes (PRO) refer to any report of the health status of the patient’s health obtained directly from the patient without any interpretation by others \cite{administration2009}. The key elements of a PRO are that the outcome should be self-reported, and measurable in absolute or relative terms. Standardized measures to collect information on PRO are called patient-reported outcome measures (PROM). This umbrella term, in turn, can include measures that focus on understanding the quality of life (QoL), health-related quality of life (HRQoL), symptom burden (SB), and functioning \cite{Weldring2013}. Both generic measures, that are applicable across a wide range of normal population, as well as disease-specific measurement instruments are currently available.
Though originally developed as a research method, increasing emphasis has been placed on the routine collection of PROs during clinical encounters \cite{Black2013,Nelson2015}. For diseases like cancer where treatment is often toxic \cite{Henry_2008}, distressing \cite{Carlson_2004}, costly \cite{Knight_2018}, and time-consuming, integration of PROMs in routine clinical care makes sense as patients often have unmet needs \cite{Sanson-Fisher2000}. The National Health Services of the UK has implemented the routine collection of PROMs in some surgical disciplines as a method to assess the quality of care \cite{Kingsley_2017}. In a recent publication, Porter et al have identified several key considerations for implementation of PROMs in routine clinical practice \cite{Porter_2016}. It has been suggested that both the availability of a feedback system, where results of the PROM are available during the clinical interaction, as well as appropriate training of professionals in the interpretation of scores are vital \cite{Porter_2016}.
Over the past decade, efforts have been made to administer PROM electronically. Advantages of electronic PROM (e-PROM) administration include the ability to present questions with appropriate conditional (skip) logic, reducing faulty and missing answers, implementation of computerized adaptive testing, integration of media like audio and video along with the questions for elaboration as well as integration with voice-based response systems which can widen the scope of application to populations with limited literacy \cite{Coons_2014}. Furthermore, e-PROM systems allow data to be visualized in real-time at the time of clinical encounter and can be configured to provide information on time trends as well as comparisons with peer groups. Two meta-analyses have concluded that paper and electronic administration of PROM are psychometrically equivalent \cite{Gwaltney_2008,Rutherford_2015}. Several commercial and proprietary systems are available for e-PROM administration e.g. Assessment Center (NIH) \cite{center}, Ayva (Bravado Health) \cite{health}, EPIC (EPIC Systems Corporation) \cite{epic}, Patient IQ (PatientIQ) \cite{patientiq}, CHES platform(Evaluation Software Development (ESD)) \cite{platform} etc. An open-source project called openPRO also exists, but has seen limited development over the past few months \cite{goinvoopenpro}.
In the current manuscript, we describe the design and development of an open-source tool to capture e-PROMs and display them to physicians at points of encounter. The design choices and underlying open source technologies used are described. Preliminary results of user experience testing are also presented.