CHOIR Integrates Clinical Decision Support Into EHRs for Chronic Pain

A web-based computer interface is enabling acute and primary care offices to better capture patient-related outcomes.

PALM SPRINGS — Researchers at Stanford University are developing clinical decision support software that integrates patient reported outcomes with electronic health records in efforts to more efficiently manage chronic pain patients.

The software, called the Collaborative Health Outcomes Information Registry (CHOIR), offers a web-based computer interface for acute and primary care offices to electronically capture patient-related outcome (PRO) assessments. 

Alyson Listhaus, MPH, a research coordinator at the University of Florida in Gainesville, described a study underway at the university to implement the software in primary care clinics at the 2015 American Pain Society Annual Meeting

“There are not enough pain specialists to meet the needs of all patients with chronic pain,” said Listhaus. “Patients with chronic pain are often not satisfied with the care they receive from their primary care physician and vice versa.”

The goal of the program is to educate primary care providers about chronic pain management and offer pain-care tools based on PROs. 

CHOIR works by flagging patients who have chronic pain codes in their EHR and alerting the office to offer the CHOIR survey when these patients come in for a visit. 

“The CHOIR survey is computer adaptive, so if a patient says they have lots of pain and anxiety, it will give them more questions like that. If a patient says they have less pain there will be fewer questions about that. At the end of the survey, the software populates scores for each domain based on validated tools,” explained Listhaus.

The researchers adapted the CHOIR system to align with standardized primary care workflows and administer 13 different PROs including an interactive body map, pain intensity, pain catastrophizing, opioid risk, and nine pain-related PROMIS measures.

CHOIR then immediately and securely sends structured quantitative and qualitative results to the EHR for clinician review. The system also provides clinicians with decision support and interpretive text along with results to help contextualize the findings. 

“What’s great about our system is that it’s all automated. The second that the patient finishes the survey, it goes into their chart, and the doctor can better guide the conversation without asking this whole battery of questions,” said Listhaus. “It saves a ton of time. We’re getting data we didn’t have before that primary care providers want to collect, but didn’t have a systematic way of getting.”

Within the EHR, clinicians can review raw and standardized PRO scores and detailed responses to PRO questionnaires. Clinicians are also able to visualize PRO results over time and easily copy information into their notes.

There are currently four clinics enrolled in the study — two with CHOIR and two control clinics. The plan is to measure patient and provider satisfaction throughout the course of the study to get a bigger-picture understanding of how provider behavior changed on measures including patient referrals, medication prescribing, and shifts in diagnostic coding, as well as the types of labs and procedures ordered. 

A longer-term goal of the project is to use tools within the EHR to input information like a patients’ pain-related medications and start dates and to plot results over time to see how interventions have modified pain intensity. The software is also being studied in tertiary care pain clinics at Stanford University.

CHOIR is the latest example of how software developers are working together with healthcare providers to create usable technology interfaces that improve patient care. 


  1. Harle C et al. Poster #120. Presented at: APS 2015. May 13-16, 2015. Palm Springs, California.