111 Clinicians’ perspective on PROM implementation the multidisciplinary teams, more attention should also be paid to the needs of non-native Dutch speakers and patients with low health literacy skills. Clinicians reported several main barriers for using PROMs via the KLIK portal. The first one is a lack of integration between KLIK and the EHRs. Opening a separate website to view the KLIK ePROfile is an added operation for clinicians, with the consequence that the KLIK ePROfile is sometimes not discussed with patients and/ or parents. Therefore, in September 2019 a front-end integration with the two most often used EHRs in the Netherlands, Epic© and HiX© was realized in four hospitals. Clinicians can now view the KLIK ePROfile via the EHR, which increases the userfriendliness and makes it a better fit into the clinical workflow. Second, clinicians indicated that they are not always satisfied with the content of PROMs. Reasons were mostly focused on the burden of completing PROMs for patients, such as a long completion time, many repetitions in questions and irrelevant questions. These challenges with PROMs correspond with previous research [20]. To address these problems, the National Institute of Health (NIH) developed the PatientReported Outcomes Measurement Information System (PROMIS) [21, 22]. PROMIS consists of various dynamic item banks (each measuring a separate construct) that can be administered through computerized adaptive testing (CAT) [20, 23]. By using a CAT, questions are offered based on the person’s previous answer. In this way, patients and/or parents only have to answer a few questions per PROMIS construct to get a reliable score. As a result, the burden for patients and/or parents can be reduced [24]. Since November 2019, it is possible to administer the PROMIS item banks via KLIK, by linking KLIK with the Dutch Assessment Center. To realize this, the PROMIS item banks were translated and validated in the Netherlands [11, 16]. Third, clinicians mentioned that the use of PROMs is time intensive. Clinicians indicated that it takes more time to prepare themselves for the consultation and to discuss the PROMs in the consultation room. This is a remarkable finding, since previous research has shown that the use of the QLIC-ON Profile did not lengthen the consultation [9]. In addition, clinicians who are responsible for inviting patients for the KLIK PROM portal indicated that it takes a lot of effort to motivate patients to complete PROMs. A case manager that supports the KLIK implementation would be helpful. There were a few limitations to this study. First, not all clinicians that use KLIK in the consultation room have been included in this study, because not all multidisciplinary 4
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