## 4 Discussion
### Directly from the Patient?  
As emphasized in the above definitions, PROs are directly reported by patients; however, even though this might be the case, the initial patient perspective might still be different compared to the version entering the patient-clinician consultation. One issue, related to this topic is patients' potential response shifts, which is an acknowledged challenge in clinical practice, made possible by the timeframe between the completion of a PRO questionnaire and the actual use of the PRO data. However, the point in this section is that the patient perspective change, but not necessarily due to changes within the patient. The idea that PRO answers are \"directly reported\" by patients are most often accurate; however, it leads to a connotation of PRO data as being completely unaffected before entering clinical practice, which is a focal feature, since it distinguishes PRO-based healthcare from traditional healthcare, based on traditional clinical data and healthcare professionals individual assessment [78]. Nonetheless, the version of 'the unaffected PRO' is modifiable, since interpretation and outcomes of PRO data are shaped by several factors.  
Firstly, when developing a PRO questionnaire, the health-related areas within a specific subject field are identified and selected; therefore, at this initial development stage particular interpretations and perceptions of a condition or illness are promoted by those stakeholders constructing the instrument. Therefore, PRO is also perceivable as a socially constructed artifact, promoting specific understandings concerning a healthcare condition, which potentially constrains the individual patient perspective.  
Secondly, the mediation of PRO questionnaires is essential, since it affects patients' accessibility and ability to complete PRO questionnaires; therefore, inclusive and appropriate infrastructures and socio-technical setups are decisive if PROs are to provide patient perspectives across all patient groups.  
Thirdly, both patients and healthcare professionals require intuitive and informative graphical presentations, if PRO data is to be intelligible and useful [47; 88]. Similarly, considerate construction of algorithms is pivotal since their properties determine how patients are sorted into various health status categories, shaping possible interpretations of the PRO data; thus, transparent and judiciously configuration and validation of algorithms are imperative.  
Fourthly, when applied in clinical practice PRO data is interpreted by healthcare professionals and applied with a specific purpose, e.g., screening, communication, or monitoring, which ought to improve the usefulness of PROs. Nonetheless, several studies show that healthcare professionals are unsure how to interpret PRO data [88; 89; 90] which means that they might refrain from using PRO data, neglect the importance of PRO answers, or use it in an unintended manner [88].  
Fifthly, another attention point, taken into account in the PRO definition below, is that to obtain PRO answers patients might require assistance or an actual proxy. This is due to various reasons, such as low health literacy, language barriers, critical state of illness, etc., which prevents patients from completing the PRO questionnaires themselves [76; 91]. Hence, in such scenarios assistance or a proxy might be necessary to ensure the completion of a PRO questionnaire, which likely affects the validity of the retrieved PRO data; conversely, it might increase response rates and ensure the inclusion of a wider array of patients.  
These examples illustrate that even if patients are unaffected while completing the questionnaires, rigorously speaking it is debatable whether the same goes for the PRO data entering the patient-clinician consultation. This is because the PRO mediated patient perspective integrated into clinical practice is shaped and modified by human and technological actors along its way.