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Patient Experience, GuidePROMs, PREMs and Value-Based Healthcare: The Triangle Transforming 21st-Century Healthcare
Why without measuring what matters to the patient, no healthcare system can improve
Value-Based Healthcare (VBHC) proposes a deceptively simple idea: the goal of healthcare is not to maximise medical acts, but to maximise health outcomes per unit of cost. And to improve those outcomes, they must first be measured.
That is where PROMs (what the patient reports about their health status), PREMs (what the patient reports about their experience with the care process) and CROMs (what the clinician objectively records) come in. Together they form the measurement system that makes VBHC possible. Without these instruments, value-based care is a strategic statement without data.
ICHOM — founded in 2012 by Prof. Michael Porter (Harvard), Stefan Larsson (BCG) and Martin Ingvar (Karolinska) — is the international body that has led the standardisation of these outcome sets across more than 40 clinical conditions, adopted in reference hospitals in more than 50 countries.
Riccardo Begelle, 2026 
16 min 
What is Value-Based Healthcare and Why It Changes Everything
Value-Based Healthcare (VBHC) was systematically formulated by Professor Michael Porter of Harvard Business School and Elizabeth Teisberg in their work Redefining Health Care (2006) and subsequently in the reference article What is Value in Health Care? (New England Journal of Medicine, 2010). The central idea is a simple yet revolutionary equation:
This equation has two immediate implications. The first: healthcare systems organised around activity — medical acts, consultations, interventions — do not optimise value; they optimise volume. The second: to improve the numerator of the equation — the outcomes that matter to the patient — measuring them is essential. And the outcomes that matter to the patient are not always those that appear in the medical record.
The International Consortium for Health Outcomes Measurement (ICHOM), founded in 2012 on the basis of this Porterian vision, has a concise mission: "unlock the potential of value-based healthcare by defining global Standard Sets of outcome measures that really matter to people and by driving adoption and reporting of these measures worldwide." In practice, ICHOM publishes standardised outcome sets for specific clinical conditions, integrating PROMs, clinical variables and risk-adjustment factors, and makes them freely available to any centre in the world.
""The key starting point to achieve Value-Based Healthcare is to define and measure the outcomes that matter most to patients. Through patient-centred outcomes data, it is possible to reshape and rebuild healthcare systems that deliver the best possible outcomes at the lowest possible cost."
— ICHOM / World Economic Forum, 2025
— ICHOM / World Economic Forum, 2025
Porter's theoretical framework proposes six interconnected components of the strategic value agenda: organising care in Integrated Practice Units (IPUs); measuring outcomes and costs per patient and complete care cycle; developing bundled payments for care cycles; integrating care systems to eliminate fragmentation; expanding geographic excellence; and building enabling technology platforms. PROMs and PREMs are the measurement system without which the other five components have no feedback loop.
PROMs, PREMs and CROMs: The VBHC Measurement Triangle
Value-based care requires three complementary types of data that together offer a complete picture of the value generated for the patient. None is sufficient on its own.
| PROM | PREM | CROM + Cost | |
|---|---|---|---|
| Definition | Patient-reported outcomes | Patient-reported experience | Clinical outcomes + economic efficiency |
| Question answered | How is the patient? | How did they experience the process? | What happened clinically and how much did it cost? |
| What is captured | Symptoms, quality of life, function, psychological wellbeing | Communication, treatment, trust, patient empowerment, accessibility | Clinical signs, complications, readmission, total episode cost |
| What it captures | The impact of treatment in real life | The quality of the care process as experienced by the patient | Provides the denominator of Porter's value equation |
| Indicator type | Outcome indicator | Process indicator (Donabedian) | Structure + objective clinical outcome indicator |
| Examples | SF-36, EQ-5D, PROMIS, ICHOM condition-specific sets | PPE-15, IEXPAC, EUROPEP, process-specific PREMs | Electronic health record, clinical registries, administrative databases |
The key distinction established by the SECA Guide 2025 (Varela Rodríguez, 2025) is that there are three levels of patient experience: the biological-functional level (symptoms, function), the intimate-emotional level (psychological wellbeing, meaning of illness) and the level of interaction with the system (care process, treatment, coordination). PROMs capture the first two levels; PREMs capture the third. CROMs add the objective clinical perspective. Only with all three together can the real value generated be calculated.
This integration is the methodological core of ICHOM sets: each Standard Set combines validated PROMs (frequently instruments such as EQ-5D, PROMIS or condition-specific questionnaires), objective clinical variables and risk-adjustment factors. The most advanced versions of ICHOM programmes also incorporate cost data to complete Porter's equation.
The Quintuple Aim: The 21st-Century Healthcare Objectives Framework
The Triple Aim — formulated by the Institute for Healthcare Improvement (IHI) in 2008 — established three simultaneous objectives for health systems: improving patient experience, improving population health, and reducing per capita cost.
The Quadruple Aim added a fourth objective: improving the satisfaction and wellbeing of healthcare professionals. The evidence showed that without motivated professionals free from burnout, the other three objectives were unachievable.
The Quintuple Aim, described by Itchhaporia in the Journal of the American College of Cardiology (2021) and progressively adopted as an international reference framework, adds a fifth objective: health equity — ensuring that improvements in outcomes reach all population groups equally, regardless of socioeconomic status, origin or geography.
PROMs and PREMs are central tools for measuring progress across all five Aims simultaneously: they measure patient experience (Aim 1), inform on population clinical outcomes (Aim 2), enable the identification of inefficient resource use (Aim 3), reduce unnecessary administrative burden on clinicians (Aim 4), and can be stratified by demographic groups to identify inequalities (Aim 5).
ICHOM in Practice: Real Cases of Transformation with PROMs and PREMs
The transition of VBHC from theory to hospital practice is documented in a growing number of international cases. ICHOM, through its accreditation programme and its Knowledge Partners network, has compiled evidence from implementations across five continents:
| Centre / System | Condition / Scope | Documented impact |
|---|---|---|
| Hospital Moinhos de Vento (Brazil) | 9 conditions (stroke, heart failure, cancer, orthopaedics, neonates, COVID) | 7 years implementing ICHOM Standard Sets. Documented improvement of clinical pathways and care quality. First ICHOM reference hospital in Latin America. |
| NHS (United Kingdom) | Hip and knee arthroplasty, lumbar disc herniation, varicose veins | National PROM programme since 2009. Data from millions of patients. First national system of routine PROM collection at population scale. |
| Cabrini Health & Alfred Health (Australia) | Colorectal cancer | ICHOM Colorectal Cancer Set implementation via cloud platform. Over 200 patients, 80% engagement. Linking PROMs with tissue and functional outcomes. |
| National University Health System (Singapore) | Hip and knee osteoarthritis | Value-based approach linking PROMs to cost reduction. Presented at ICHOM 2025 as a reference case in Asia. |
| Estonian hospitals (Nordic Healthcare Group) | Stroke | ICHOM Stroke Set in 4 hospitals. BI dashboard with PROMs, clinical outcomes and costs. Benchmarking between hospitals and identification of best practices. |
| GluCare Health (UAE) | Diabetes (hybrid model) | First ICHOM-accredited centre globally. Designed from the outset for continuous data collection and radical transparency in outcomes. |
These cases share common elements that research on VBHC implementation — including the Leading Health Care Institute of Sweden report (2021) and the Linnean Initiative's work on VBHC acceleration — identifies as success factors: strong clinical leadership, enabling technology that does not add administrative burden, data accessible in real time for care teams, and a closed improvement cycle in which results generate concrete actions.
The NHS Case: The World's Largest National PROM Implementation
The English NHS launched in 2009 the national PROM programme for high-volume elective procedures: hip arthroplasty, knee arthroplasty, lumbar disc herniation and varicose veins. Patients complete the questionnaire before the intervention and 3–6 months after discharge.
The programme collects data from hundreds of thousands of patients per year. It has enabled the identification of significant variability in outcomes between hospitals for the same procedure, generating pressure to improve in centres with poorer outcomes. It has also demonstrated that patient-reported outcomes are complementary — not redundant — to the complication or readmission rates recorded in the medical record.
The NHS is the global reference for the fact that routine and systematic PROM collection at national scale is operationally feasible and generates value for both patients and the system.
The Roadmap Towards VBHC: Where PREMs and PROMs Fit in Organisational Transformation
Adopting value-based care is not about installing software. It is a deep cultural and organisational change that affects team structure, incentives, information systems and the way decisions are made. The SECA Guide 2025 — in its chapters on transformation management (Ch. 2.1) and phases of transformation (Ch. 2.2) — describes this process in detail.
Phase 0: Creating the sense of urgency and vision
The first step — following Kotter's eight-step model for change management — is to build a compelling case for why measuring what matters to patients is a strategic priority, not a peripheral quality project. ICHOM benchmarking data, which shows the variability of outcomes between similar centres, is frequently the trigger for this sense of urgency.Phase 1: Organising around the clinical condition cycle
Porter proposes reorganising care in Integrated Practice Units (IPUs): interdisciplinary teams that accompany the patient throughout the complete cycle of their condition, rather than organisations by isolated specialities. In this context, PROMs and PREMs cease to be a parallel project and become part of the standard care pathway: they are administered at defined points of the patient journey and data are accessible to all team members.Phase 2: Measuring, comparing and learning
With instruments implemented and data flowing, the organisation can enter the continuous improvement cycle. ICHOM Standard Sets facilitate external benchmarking — comparison with other centres measuring with the same instrument — which is one of the most powerful mechanisms for motivating change. As ICHOM notes, benchmarking enables organisations to identify best practices and learn from them.Phase 3: Linking outcomes to funding and incentive structures
The most advanced stage of VBHC is when measured outcomes begin to inform funding models. Several healthcare systems — the Netherlands, Sweden, and incipiently the NHS and some private insurance systems — are exploring value-based payment models in which provider remuneration is partially linked to the outcomes they achieve for their patients. Without standardised and audited PROMs and PREMs, this model is impossible.""Implementing Value-Based Healthcare has transformed not only how we deliver care, but how we learn from our patients every single day. Patients' experiences, expectations, and priorities directly shape our clinical decisions."
— Testimony of an ICHOM-accredited centre, 2025
— Testimony of an ICHOM-accredited centre, 2025
ICHOM Accreditation: The International Certification of VBHC in Practice
ICHOM has offered since 2022 an accreditation programme for healthcare centres that implement VBHC in a systematic and documented manner. The accreditation levels recognise the maturity of the programme: from initial data collection through to the full integration of outcomes in clinical decision-making and organisational management.
Hospital for Special Surgery (New York), GluCare Health (Dubai — the world's first accredited centre), Bangkok Dusit Medical Services (BDMS, Thailand) and Saudi German Health (the first hospital in Saudi Arabia) are among the centres that have achieved ICHOM accreditation.
Accreditation functions as a roadmap: organisations know exactly what they need to demonstrate to advance to the next level, which transforms VBHC from a vague aspiration into a process with concrete, verifiable milestones.
Would You Like Your Organisation to Advance Towards VBHC?
RateNow is the technology platform that facilitates the complete PREM and PROM measurement cycle: questionnaire design, omnichannel digital administration, real-time analytics and dashboards for each level of the organisation. Implemented in reference centres in several countries and aligned with ICHOM standards.
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References
1. Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477-81. doi:10.1056/NEJMp1011024.
2. Porter ME, Teisberg EO. Redefining health care: creating value-based competition on results. Boston: Harvard Business School Press; 2006.
3. ICHOM. About ICHOM and ICHOM Standard Sets [Internet]. Boston: ICHOM; 2025. Available at: https://www.ichom.org
4. ICHOM / World Economic Forum. International Consortium for Health Outcomes Measurement profile [Internet]. Geneva: WEF; 2025. Available at: https://www.weforum.org/organizations/international-consortium-for-health-outcomes-measurement-ichom/
5. Itchhaporia D. The Evolution of the Quintuple Aim: Health Equity, Health Outcomes, and the Economy. J Am Coll Cardiol. 2021;78(22):2262-2264.
6. Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Aff. 2008;27(3):759-69.
7. Varela Rodríguez C (ed.). Guía para la Implementación de Asistencia Sanitaria Basada en Valor. Madrid: SECA; 2025.
8. Cossio-Gil Y et al. The roadmap for implementing value-based healthcare in European University Hospitals. Value Health. 2022;25(7):1148-1156.
9. Weldring T, Smith SMS. Patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs). Health Serv Insights. 2013;6:61-68.
10. Leading Health Care Institute. Value-based health care in theory and practice: what have we learned? Stockholm: LHC; 2021.
11. EIT Health. Implementing value-based health care in Europe: Handbook for pioneers (Director: Gregory Katz). 2020.
12. ICHOM 2025 Conference Award Winners. Dublin: ICHOM; 2025. Available at: https://www.ichom.org/news/ichom-2025-award-winners-and-their-impact/
Is value-based care only for large hospitals?
No. The principles of VBHC are applicable to any level of care and any organisational size. In fact, some of the most transformative cases are those of medium-sized centres that chose a well-defined pilot process and demonstrated results quickly. The key is to start somewhere, not to wait for the perfect infrastructure.
Are PROMs and PREMs the same as healthcare quality?
Not exactly. Healthcare quality, in the Donabedian tradition, evaluates structure, process and outcome from a technical and regulatory perspective. PROMs and PREMs specifically incorporate the patient's perspective, which is complementary to — not a substitute for — the clinical perspective. VBHC proposes that both perspectives are necessary for a complete definition of value.
What is the difference between VBHC and the Triple Aim / Quintuple Aim?
They are complementary, not alternative frameworks. The Triple/Quintuple Aim defines the objectives of the healthcare system at the macro level (population health, experience, cost, equity, professional wellbeing). VBHC is the strategic and methodological framework for achieving them at the organisational and clinical level. PROMs and PREMs are the measurement tool that connects the two frameworks.
Is VBHC only for private systems?
No. The world's most advanced implementations include the NHS (public), the Scandinavian systems (public) and primary care systems in several European countries. VBHC is a management framework, not a funding model. It can be — and is — implemented in public, private and mixed systems.
Won't measuring outcomes create unfair competition between centres?
The experience of countries that have implemented public outcomes benchmarking — Sweden, the Netherlands, UK — is that transparency generates learning rather than destructive competition. Centres with poorer results identify the best performers and learn from them. Opacity protects the status quo; transparency drives improvement.
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