Systematic reviews have been conducted examining the influences of using patient-reported measures on relatively narrowly defined aspects of care. Modest success has been reported in the effects of using PROMs, for example, in routine practice on certain communication practices, and the detection of mental health conditions [36, 37]. Despite the tentative promise of these findings, the potential of patient-reported measures as tools for fostering a patient-centered approach to care can only be maximized by considering the processes through which they are meant to affect change. Greenhalgh et al.  have noted the importance, in the evaluation of PROM initiatives, of specifying and testing for the presence of factors theorized or known to be necessary to produce desired outcomes. As part of this approach, the authors emphasize the careful examination of implementation contexts, and assessment of their concordance with intervention theory.
We argue that, in addition to careful attention to context, the introduction and evaluation of patient-report initiatives should be accompanied by continual vigilance for unplanned effects on patient care. In the following sections, we identify some likely contextual influences on the manner in which initiatives will influence existing care practices. Then, instead of focusing on how initiatives and contexts interact to produce intended outcomes, we consider how this interaction may produce unintended consequences.
Contextual Consideration #1: Overburdened Practices and Challenging Case-Mixes (Direct-Care Level)
Prioritizing and enacting high-quality dialogue between patients and providers requires time and human resources. Yet many primary care practices are understaffed, under-resourced, and struggling to meet competing demands . Studies have shown that primary care providers do not have enough time to adhere to clinical practice guidelines for chronic conditions. Given the challenges associated with interpreting multiple changing, often subjectively defined, symptoms, the difference between actual and optimal consultation time for MCC patients stands to be even greater. Moreover, treatment guidelines, designed to help clinicians manage the decision-making process, are usually based on single-disease samples, and are of limited applicability to MCC patients. This places greater onus on the qualitative dimension of consultation as a means of understanding and addressing the problems of unique and complex individuals . Yet this process takes time and provider attention, resources that, as mentioned, are often in short supply.
Contextual Consideration #2: Fragmented Information Technology (IT) Systems (Health-Systems Level)
Since modern health systems consist of diverse and geographically dispersed providers and organizations, it is necessary to use information technology (IT) to share data and develop multi-disciplinary care plans. The process of developing integrated care plans requires compatible technology and common methods for entering and coding data. However, many healthcare IT systems today are characterized by incompatible hardware and software, and lack of common nomenclature and coding structures. Patient-reported measures are an increasingly common form of information within a vast sea of data [10, 40]. Without proper precautions and planning, the addition of more patient-reported data may contribute to, rather than alleviate, confusion in developing effective and shared protocols.
By measuring patient health, illness, and healthcare performance using standardized data capture, patient-reported measures focus on precisely defined, measurable aspects of health and healthcare. Policy mechanisms, such as the mandatory use of PROMs  and financial or accreditation incentives for achieving patient experience benchmarks [27, 34, 41], prompt organizations and providers to change their behaviours and policies. In a time- and resource-constrained environment, this means that less time and resources go into other priorities , including some that may be as or more vital to the provision of care for patients. In the UK for example, Campbell et al.  argue that a nationwide initiative tying financial incentive to rapid primary care access, as measured by a single-item PREM, may have led to a widespread decrease in provider-specific continuity in primary care. By encouraging providers to ensure rapid access to any provider within their organization as a means of ensuring rapid access, they argue, organizations may have sacrificed continuous access to the same provider, an aspect of care that was not incentivized. We have argued that provider-specific continuity is a central aspect of a patient-centered approach for patients with MCCs because of the need to make sense of each individual’s complex needs over time.
In addition to influencing organizational practices, the very act of using standardized assessment tools directly impacts what happens during patient–provider consultation. Providers participating in the above-mentioned UK initiative suggested that the emphasis on “ticking boxes” distracted them from patient-led consultations and listening to patient concerns . More generally, DeLusignan and Chan  suggest that the use of standardized computer assessment tools during patient consultation can lead to a narrowing of focus on easily quantifiable data, the neglect of vague complaints, social diagnoses, and physical manifestations of underlying clinical problems. The possibility of these impacts requires consideration, given the importance of a dialogic, iterative approach to consultation for patients with MCCs.
The wide-scale use of patient-reported measures and other standardized assessment tools also affects, for better or for worse, the information foundations on which multi-disciplinary care protocols are meant to be based. Evidence regarding the widespread introduction of computer physician order entry (CPOE) systems in the USA provides some insight on this issue. While CPOE systems have led to some modest reductions in medication errors, they have also been linked to several new errors. In the case of patient-reported measures, which require input from both providers and patients, the potential for error would seem even greater. Making data available to providers that is erroneous, contextually inappropriate, or impossible to reconcile with other sources compounds, rather than mitigates, the challenges associated with formulating a coherent, adaptive picture of patient needs and progress. Where data are entered and accessed via a large and highly connected IT network, the consequences stand to be correspondingly vast and varied .