Healthcare Providers’ Implementation of Patient-Centred Outcome Measures (PROMs) and Patient-Reported Experience Measures (PREMs) in Practice: A Protocol for a Mixed Method Systematic Review

Background: Substantial literature has highlighted the importance of patient-reported outcome and experience measures (PROMs and PREMs, respectively) to collect clinically relevant information to better understand and address what matters to patients. The purpose of this systematic review is to synthesize the evidence about strategies for implementing individual-level PROMs and PREMs data by healthcare providers in their everyday practice. Methods: This mixed method systematic review protocol describes the design of our synthesis of the peer-reviewed research evidence (i.e., qualitative, quantitative, and mixed methods), systematic reviews, organizational implementation projects, expert opinion, and grey literature. Keyword synonyms for “PROMs,” PREMs,” and “implementation” will be used to search eight databases with limiters of English from 2009 to 2019. Study selection criteria includes implementation at the point-of-care by healthcare providers in any practice setting. Eligible studies will be critically appraised using validated tools (e.g., Joanna Briggs Institute). Guided by the review questions, data extraction and synthesis will occur simultaneously to identify biographical information and methodological characteristics as well as classify study ndings related to implementation processes and strategies. As part of the narrative synthesis approach, two frameworks will be utilized: (a) Consolidated Framework for Implementation Research (CFIR) to identify inuential factors of PROMs and PREMs Implementation and (b) Expert Recommendations for Implementing Change (ERIC) to illicit strategies. Data management will be undertaken using NVivo 12 TM . Discussion: Data from PROMs and PREMs are critical to adopt a person-centred approach to healthcare. Findings from this review will guide subsequent phases of a larger project that includes interviews and a consensus-building forum with end users to create guidelines for implementing PROMs and PREMs at the point of care. to incorporate patients’ voice and inform their care (2). Our aim is to conduct a mixed methods systematic review to synthesize existing knowledge on effective methods for implementing individual-level PROMs and PREMs data by HCP in their everyday practice. The protocol for this systematic review is part of a larger study to create user guidelines that support clinical decision-making and care planning, wherein HCP interviews and a deliberative dialogue, consensus-building forum with key stakeholders will also contribute to guideline development. The patient-centred measurement (PCM) implementation guidelines for HCPs will support routine collection, interpretation, and integration of these data in everyday practice, contributing to effective, quality health care.

The lack of apparent evidence regarding implementation methods and knowledge translation strategies that are most effective across practice areas justi es the need for our proposed systematic review. According to evidence-based practice guidelines for systematic reviews (27,28) and electronic searching strategies (29), limitations of a systematic review can be traced, for example, to the review's objectives/questions, search strategy, or selection criteria (i.e., inclusion and exclusion). First, getting the question right is of utmost importance in setting up and directing the entire review (27,30). It was identi ed that past reviews did not commonly employ the population, issue/interest, context/comparison, and outcome (PICO) format and often had several objectives in addition to PCM implementation by HCPs. Inter-related yet divergent objectives may have in uenced the search results for relevant citations putting into question the overall validity and thoroughness of the synthesis results (30).
Search terms in combination with relevant databases are fundamental to conducting a literature search at the appropriate level of speci city (i.e., precision and recall). This often elusive balance, when struck, provides the appropriate data to answer the review question (30). Search terms in previous reviews (see Table 1) have been narrow in scope thereby eliciting a low yield of relevant citations. For example, one author included less than ve keywords for patientreported measures (21) while others missed numerous synonyms and appropriate related terms to capture the concept of patient-reported measures (5, 10, 24, 25) or excluded publishing the search terms making the search irreproducible (31). Notably, one review included PREM search terms (24). Furthermore, search terms did not appear to capture the process of implementation in its entirety (10,11,(23)(24)(25) and were limited, in some instances to two words: barriers and facilitators (5,32). Lastly, some reviews (e.g., (24,25,31) had limited reporting of evidence-based electronic search strategies for systematic reviews such as truncation, alternate spelling, and proximity locators (29). When systematic review search strategies do not include search terms at an appropriate level of speci city, the retrieval of relevant citations can be threatened due to low yield. Likewise, robust systematic reviews seeking to balance recall and precision in the retrieval process must also attend carefully to database selection (30).
Selecting the right bibliographic databases to recall a maximum number of relevant sources is another critical aspect of the search process (30). In previous syntheses, the number of relevant citations identi ed and subsequently screened as eligible have been quite low, which may be associated with the databases used (see Table 1). Four reviews searched three or fewer databases with the most common being MEDLINE/PubMed, CINAHL, and PsycINFO (11,21,26,32). Given the nature of the previous systematic review questions, a broader scope of databases aligned with the population (i.e., all disciplines of HCPs) and the phenomena of interest is warranted to result in a higher yield of relevant citations from which to draw conclusions (30).
PICO elements of review question(s) are utilized to formulate selection criteria (i.e., inclusion and exclusion) to screen the resulting citations for relevance and determination of eligibility (30). Explicit criteria based on the review question(s) determines which citations are included in the reviews and mitigates systematic selection bias; both which are necessary for accurate conclusions to be made (33). Regarding the population element to explore PCM implementation in everyday clinical practice, some limitations were noted in previous reviews (see Table 1). Only three studies speci ed selection criteria about HCPs (e.g., allied health professionals) (11,21,32). Another review included a broad range of stakeholders extending beyond clinicians such as commissioners (e.g., local and national policy makers) and health service managers (24). In terms of context, in half of the published reviews (see Table 1) the selection criteria were limited to only speci c practice settings (e.g., palliative care (5); cancer care (10,23,26), and adult mental health (25).
Equally important to selection criteria are careful considerations of the types of evidence to include in the review so as to adequately represent the implementation experiences of providers (34). The purpose of mixed methods reviews is to conduct a comprehensive synthesis that includes the different types of evidence necessary to inform clinical practice, policy, or organizational decisions (35). The published systematic reviews (see Table 1) have included a mixture of qualitative and quantitative research-designed studies. However, only Gelkopf et al. (25) stipulated the inclusion of initiatives or projects (e.g., quality improvement and knowledge translation) exploring "real-world" PROM implementation. In recent years, there have been increasing numbers of published quality improvement, organization implementation, and knowledge translation projects exploring PROMs implementation in clinical practice. As such, there is a need to include peer-reviewed evidence about implementation projects and expert opinion because these contribute to a breadth and depth of understanding by capturing everyday experiences of end-users and that might con rm or dispute evidence (35). To date, no single review has captured the voice of end-users, the HCPs, vis-à-vis their experiences of implementing individual-level PCM data at the point of care.
This protocol builds on the work of the aforementioned reviews. Given the cumulative evidence concerning the barriers and facilitators faced by HCPs implementing PCMs in everyday practice, our project will be informed by knowledge translation and implementation science. To this end, our aim is to conduct a comprehensive mixed methods systematic review of a wide range of peer-reviewed literature, including all healthcare settings. The Population, Phenomenon of Interest, Context (PIC) format (see Table 2) review question guiding the protocol is "How do healthcare providers implement individual-level patient-centred measurement/assessment tools (and the resultant data) as a routine part of their everyday practice?" This includes the following secondary review questions: 1. What are HCPs' experiences in applying these tools in clinical practice?
2. How do HCPs interpret and integrate these tools to inform patient care?
3. What are the factors (barriers and facilitators) that in uence PCM implementation by HCPs at the point of care? In this review, patients complete a PROM or PREM in a given practice setting/health service area and then HCPs act on the resultant data in the provision of patient care.

Population (P)
Healthcare provider(s) Refers to individuals from any health discipline or profession that provide direct health services to patients, clients, and/or families. HCPs are regulated or licenced healthcare professional; however, this may vary by country. HCPs may be referred to as clinicians. Common HCPs include but are not limited to registered nurses, nurse practitioners, physiotherapists, occupational therapists, physicians, social workers, dieticians, psychologists, pharmacists, and midwifes.

Phenomena of interest (I)
Implement individual-level, patient-centred measurement/assessment tools (and the resultant data) In a broad sense, implementation is the process or act of making something active or effective. In the context of PROMs other synonyms include: employ, apply or application, utilize, use, integrate, interpret, draw on, make use of, and act on. The act of implementing PCMs in this review also captures the experiences, views, attitudes habits, practices, and routines of HCPs.
Patient-centred measurement as an umbrella term refers to standardized assessment tools or questionnaires classi ed as PROMs or PREMs that every patient is eligible to complete. Thus, the questions are completed by the patient and are about outcomes that matter to them. The results are individual level numerical or textual data that indicate the patient's current state or experience.

Context (C)
Routine part of their everyday practice Is an expression to describe an action that has been taken as a regular or common aspect of the HCP's role. It is usually in relation to a HCP's direct interaction between them and the patient/client/family. For example, in acute care or hospital settings this term used maybe point-of-care or bedside where patient and providers interact on a regular basis, such as daily, weekly or monthly. The context includes any practice setting or type of health service (e.g., acute care versus community care; private versus publicly funded, and community hospitals versus academic centers/teaching hospitals).

Methods
The systematic review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for Mixed Methods Systematic Review (MMSR) (35) and the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols (PRISMA-P) (36) [see Additional le 1]. To nd relevant research evidence, the population, phenomenon of interest, and context (PIC) format has been applied to formulate the review questions, devise a search strategy, and guide study selection criteria. The project will utilize an iterative process undertaken primarily by AW with input from members of the research staff and larger research team based on areas of expertise. A written record will be organized according to the Matrix Method (37).

Search strategy
The proposed search will be conducted in accordance with the checklist for Peer Review of Electronic Search Strategies (PRESS) Guideline for systematic reviews (29) to achieve a balance of recall and precision. With academic librarian support (DD), the search strategy, including all identi ed keywords will be adapted for each database. An initial limited search of two databases (MEDLINE and CINAHL) was undertaken to identify articles on the topic. Since controlled vocabulary is unique to each database, keywords (rather than subject headings) have been identi ed as the most reliable approach for suitable recall. We determined that keyword searching, with the generation of all synonyms, plurals, and alternate spellings (e.g., centred and centered), for the phenomenon of interest (i.e., PROM, PREM, and implementation) [see Additional le 2] produced high yield. Titles, abstracts, and keywords of relevant articles were used to assist in the identi cation of synonyms for each keyword. Although it is common to include a third keyword to represent the population or context elements of the PIC question, we found that it limited the precision of our results. As such, we decided to exclude a third concept for searching and instead include them as part of our selection criteria. Findings from our preliminary search informed the search for the project.
The evidence to answer our question will be retrieved by searching for the published literature between January 2009 and December 2019 using eight databases with the EBSCO platform that covers the subjects of nursing, allied health, health sciences, psychological literature, physical therapy, occupational health, nutrition, kinesiology, and evidence-based reviews (i.e., MEDLINE, CINAHL, PsycINFO, Web of Science, Embase, SPORTDiscus, Evidence-based Medicine Reviews, and ProQuest (Dissertation and Theses)). The reason for the 10-year date range was two-fold: rst, to keep the yield of records manageable and second, to synthesize evidence based on the current state of the eld. Limiters being used include: (a) scholarly/peer reviewed citations, (b) English language, and (c) date range. The two keywords will be utilized in conjunction with appropriate truncation (e.g., asterisks) to include multiple variants using the same truncated root or stem. In some circumstances the boolean "NEAR" or proximity locators will be used to link terms that may not be adjacent (e.g., barrier* n4 implement* and facilitat* n4 implement*) (30). All identi ed search terms will be linked using Boolean operators. The boolean "OR" operator will be used to link search terms as a union for each concept for the purpose of expanding and broadening a search. The interaction of these concept searches will then be combined with "AND" to narrow the search (30). Search histories [see example Additional le 3] from all databases will be retained.
Our exploration will be supplemented by using other searching strategies to carry out a comprehensive search and counterbalance the limits of keyword database searching (30). This includes: footnote chasing (i.e., scanning the references of "keeper" articles), author searching of those publishing extensively in their eld, and backward/forward citation searching of related systematic reviews and other seminal articles (e.g., large studies with numerous publications or those frequently cited) (30). Additionally, a search of authors most frequently publishing in the eld will be conducted. The ProQuest database will be used to search for eligible dissertations and theses. Upon completion of our database search, we will search the unpublished literature to lessen publication bias and to retrieve di cult to nd literature and information regarding implementation projects. To avoid bias, we will use two approaches. First, a judicious examination of the "grey" literature (e.g., research reports, practice guidelines, and user guides) will be conducted using the Google© search engine in 2020 from a university internet protocol address with the most cited search terms of the PIC concepts identi ed during our database searches. Second, we will access websites of credible organizations, agencies, and associations that may produce and publish knowledge translation documents supporting PCM implementation (30). These websites will be identi ed by seeking the opinions of experts in the eld. A PRISMA diagram (28) will be created to re ect the search strategy and study selection to reveal how the included studies were determined.

Types of Evidence
The MMSR methodology combines an assortment of evidence to create a breadth and depth of understanding of the review questions posed to inform practice and policy. The inclusion of all available evidence, regardless of type, allows for the degree of agreement or discrepancies between sources of evidence as well as validating or triangulating the ndings. Various aspects of a phenomenon of interest can be examined and the available data can contextualize the ndings (35). Furthermore, given that implementation at the point-of-care requires a variety of knowledge to inform practice, diverse evidence types will be sought. This review will consider peer-reviewed literature: quantitative, qualitative, and mixed methods studies in addition to reviews (i.e., systematic and literature), organizational implementation projects (e.g., quality improvement, knowledge translation project, implementation of PROMs, program evaluation, or pilot/feasibility project), and expert opinion (e.g., an individual, group or learned body that draws on their practical experience and understanding of the knowledge). We will include not only the evidence on the effectiveness of strategies for implementing PCM ('knowing what' type of evidence), but also evidence related to subjective experiences, attitude, behaviours and/or the accepted discourse at the time of practice ('knowing how' type of evidence) (34). Opinion-based evidence will be included when derived from expert opinions. That is, the opinions from experts in the eld that were gained through some form of consensus building process (e.g., conference, think tank, special interest group, panel, and current discourse) (34). Inclusion of the unpublished grey literature is unique to a systematic review of this nature.

Selection Criteria
The next step to nding relevant evidence for inclusion in this review is to de ne the selection criteria. To be included in the review, the literature needs to meet the following eligibility criteria (see Table 3): (a) HCPs in a clinical setting; (b) information pertaining to PROM or PREM implementation (e.g., HCP experiences, strategies for integrating into practice, in uential factors, or attitudes towards use); (c) data were at the individual level; and (d) any study design. Articles will be excluded if (see Table 3): (a) articles focused exclusively on decision-makers (e.g., managers) or patients; (b) information pertaining to when and why PROMs and PREMs are used as well as impact of their use; (c) studies about instrument development, testing and selection; or (d) implementation of aggregated data. Furthermore, to determine inclusion of studies in the review we will apply the criteria in a speci c order (Gough). After each citation is con rmed as written in English and within the date limit, we will ensure it meets the study design criterion. Next, the phenomenon of interest criterion will be applied followed by screening for population and context. Published scholarly work including research, pilot or feasibility projects, evidence-based implementation/quality improvement, systematic reviews, literature reviews, and expert opinion Published literature such as editorials, opinion or position papers, commentary, study protocols, conference proceedings or abstracts, and theory.

Insu cient information reported on study design
Study Selection Procedure Following the completion of these searches, all identi ed citations will be loaded into EndNote X9© (Version 9.3.3) (38) and duplicates removed. AW will provide a thorough orientation to those involved in the selection process to ensure rigor. Given the large quantity of records anticipated to be retrieved (e.g., greater than 20000) the rst 100 record titles and abstracts will be screened by two independent reviewers for assessment against the inclusion criteria to be identi ed as relevant, not relevant, or maybe relevant. Following that, AD will screen all other records to determine relevancy. AW to con rm eligibility will rescreened those identi ed as potentially relevant. To ensure validity of the selection criteria, in the EndNote© library for this project, AW will conduct keyword searches (e.g., outcome measure, patient outcome, patient-reported) of record titles of those deemed irrelevant to reapply the selection criteria. Finally, all relevant studies will be retrieved in full text and their citation details independently reviewed (AW and AD) against the selection criteria to con rm inclusion.
Reasons for further exclusion of all studies will be recorded. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion (33,37).

Assessment of Methodological Quality
Critical appraisal of included studies will determine the level of evidence and methodological quality as a basis for our con dence to act on the recommendations from our synthesis. Two independent reviewers, blinded to each other's assessments, will retrieve all included citations, and applicable supplemental les, in full text format for assessment. AW will provide a robust orientation to primary reviewers (AD, DG, SH, FH, LE, SL, LM, and two undergraduate research assistants) of the process and appraisal checklists to ensure rigor. Authors will be contacted to request missing or additional data for clari cation, where required. Any disagreements that arise between the reviewers will be resolved through consensus discussions among select team members, or a blinded third reviewer.
We will use the following standardized JBI critical appraisal instruments for assessing quality (see Table 4): systematic review, qualitative, cross-sectional, prevalence, case report, and text and opinion (27,39). To evaluate organizational implementation projects, three questions from the JBI case report checklist (40) were combined with questions from the Johns Hopkins' organizational experience checklist for non-research evidence (41) and questions for quality improvement interventions (42,43). Similarly, the JBI checklists for analytical cross-sectional (40) and prevalence survey (44,45) studies were modi ed to include four additional questions about the research questions, research methods, ethical approval, and justi ed conclusions (46)(47)(48). JBI checklists do not exist for mixed methods studies or literature reviews. AW conducted an extensive review of the literature to locate other standardized tools of high reliability and validity. Based on a parsimonious set of core criteria, the mixed method checklist focuses on both the effective integration of the quantitative and qualitative components of studies, as well as the provision of a rationale for using a mixed methods design (49)(50)(51). The checklist used for literature reviews will be based on the Johns Hopkins' form for non-research evidence (41).  (41)  5 All checklists contain a series of criteria (range 8 to 15 questions) scored as being "met" or "not met" or "unclear" and, in some instances, as "not applicable." Following critical appraisal, all studies will be given a percentage score with higher scores indicating a greater percentage of the quality criteria were met. The research team decided not to set a quality threshold to exclude evidence. Rather, once the data are synthesized we will determine the con dence to act based on the quality and level of the evidence. A modi ed version of the JBI levels of evidence (54,55) for meaningfulness will be used as it best aligns with our review questions and the nature of the evidence. The ve levels are: 1. Quantitative or mixed-methods systematic review; 2. Qualitative or mixed-methods synthesis and single experimental-based quantitative study; 3. Single qualitative and descriptive or observational quantitative study; 4. Systematic review of expert opinion and organizational implementation project single study (e.g., evidence-based practice, quality improvement, and knowledge translation); and 5. Expert opinion and literature review. Table 4 cross-references the types of evidence with levels of evidence. Each citation will be assigned a level during the extraction process to be subsequently used during data synthesis. Given the evidence in this review is explorative, descriptive, and interpretative in nature, the JBI Grades of Recommendation will be the criteria used to de ne the overall strength of the recommendation (i.e., strong or weak) (55,56).

Data Extraction
The data extraction step provides the means by which the most pertinent information about the topic (i.e., study characteristics and ndings) can be summarized and culled from the primary studies. All source documents will be loaded into the data management software NVivo™ (Version 12.6) (57). Using this software, a Review Matrix will be generated to maximize e ciency and create "order out of chaos" (37, p. 150). Column topics for the matrix will be de ned according to the purpose of the proposed systematic review to capture pertinent bibliographic information, methodological characteristics, and content-speci c characteristics (e.g., implementation theory) of each included citation (see Table 5) (37). Column topics for which there is a discrete response option (e.g., methodology) will be extracted using the NVivo™ le classi cation function. The NVivo™ codes function will be used to identify the column topic response for items that have more than one response option (e.g., studies conducted in multiple settings or involving multiple HCPs). These data will offer contextual and methodological data to support the data synthesis results (37). Select team members will be involved in assembling the extracted data from all included articles with relevant accompanying illustrations (e.g., participant quotes or statistical test values). Notes on the de nition of column topics and response options as well as the overall extraction process will be kept to ensure consistency amongst extractors. The next step will be the extraction of the pertinent study ndings, speci cally from the results and discussion sections of each citation. Using NVivo™ (57), the process of synthesis begins as the study ndings will be extracted into speci c codes. All study ndings from the included citations will be coded for analysis as textual descriptions. Qualitative data will be composed of themes or subthemes with corresponding illustrations (e.g., quotations, tables, and gures). The quantitative data (e.g., descriptive or inferential statistics) will be converted into "qualitized data." This process will involve the transformation of all quantitative data into textual descriptions or narrative interpretation in a way that answers the review questions. When necessary, corresponding statistical test results can be captured as part of the coding process. As per the narrative synthesis approach (58), code names will be based on a theoretical framework. In our study, we will use the Consolidated Framework for Implementation Research (CFIR) (59). The CFIR is an evidence-based guideline used to assess multiple contexts and identify factors that might in uence the process and effectiveness of the implementation of a speci c intervention, which, in our review, is PCM. The ve major domains are intervention characteristics (8 items), inner setting (5 items), outer setting (4 items), characteristics of individuals involved (5 items), and implementation process (4 items) (59). A further framework will be used to code the identi ed implementation processes or actions to support a practice change. For this, we will use the validated Expert Recommendations for Implementing Change (ERIC), which is a compilation of 73 discrete strategies in nine clusters (60,61). Codes not represented in either framework will be created, as determined, by AW to answer the review questions. In this manner, extraction and initial synthesis occur simultaneously. To reduce coding error during data extraction, we will develop a coding protocol, provide coder training, leverage our substantive expertise amongst team members, and use the NVivo coding comparison feature to improve reliability (30). In summary, the overall extraction process of transforming and coding these data will facilitate each element of the narrative synthesis to integrate the existing evidence and answer the review questions (35).

Data Synthesis
The synthesis will follow a convergent integrated approach as per the JBI methodology for MMSR. In this manner, data from all types of evidence will be simultaneously extracted and synthesized into meaningful codes. Furthermore, this integrated approach means that the transformed "qualitized" data will be combined to identify patterns across all the studies as well as explore relationships of the data between and within the studies (35). The integration of these data will be guided by a narrative synthesis approach (58), which is well suited for MMSR that utilize diverse types of evidence and has sample heterogeneity (35). Moreover, this approach allows for the use of theoretical frameworks to shape the analysis. In our case, the analysis will use two implementation science frameworks allowing us to focus broadly on the implementation process as well as effective strategies to implement and sustain changes in HCP's behaviour (58). Popay et al. identi es four iterative elements to a narrative synthesis. Element 1: The role of theory in evidence synthesis (p. 12). Contributing to knowledge translation theory on how PCM implementation works, why, and for whom we will use the CFIR (59) and ERIC strategies (60,61) that are based on theories of change. With the use of NVivo™ for extraction, the process of synthesis begins as the theory contributes to the interpretation of study ndings and determines how widely applicable the ndings may be. In this way theory building and theory testing can be incorporated as a key aspect of the proposed systematic review (58). Element 2: Developing a preliminary synthesis (p. 13). A preliminary synthesis is conducted to understand the codes identi ed and summarize the results of included studies. This will be achieved by de ning patterns of ndings simultaneously across all the studies. An initial description of the ndings will evolve based on similarity in meaning to produce an integrated synthesis (58). Furthermore, using NVivo™ to identify codes within each citation will subsequently lead to overarching categories and themes. Element 3: Exploring relationships of the data between and within the studies (p. 14). The purpose of the third element is to identify reasons that might explain any differences in the ndings regarding the successful implementation of PCMs. The emerging patterns identi ed in the pooled data will be further analysed to identify factors, study characteristics, and context explaining differences. Comparing and contrasting relationships across studies is important to this stage of the synthesis as a means to explore the in uence of heterogeneity (58). The NVivo™ relationship and query features will aid in our exploration of associations. Element 4: Assessing the robustness of the synthesis (p. 15). This element allows for the integration of the quality assessments to determine the strength of the evidence and support with the trustworthiness of the synthesis products (e.g., answers to the study questions and recommendations). Using NVivo™ the included studies will be assigned both a level of evidence, and a quality score that will be cross-linked to the products of the synthesis. From this, a nal determination of the strength of the evidence to support conclusions draw from the synthesis process can be made (58).
Thus, the results of this narrative synthesis approach will provide a critical analysis to determine effective methods for PCM implementation by HCPs in everyday practice.

Conclusion
The protocol for this systematic review meets an internationally clinically driven need to conduct a comprehensive synthesis of various types of evidence on (a) effective methods for HCP interpretation and integration of individual-level PCM data, (b) experiences of HCPs applying these tools, and (c) identi cation of relevant factors in uencing PCM implementation. This systematic review is one part of a larger three-phased project that will be followed by HCP interviews and a consensus-building forum to elicit input from key knowledge users. The outcome of the overall project is the development of evidenceinformed guidelines that outline effective implementation strategies for integrating PCM data into HCPs' everyday practice for shared decision-making and care planning with patients. These guidelines further build on other user guides for the implementation of PROMs in clinical practice (7,62,63). Overall, this project is intended to promote "shared ownership" of individual-level PCM data to better understand and address what matters to patients.