## 3 Results
### PRO as an Organizational and Cultural Shift  
Based on the former sections PROs purpose concerns, among other things, research, clinical practice, and healthcare policies, which means that PRO also affects organizational structures and cultures. For example, the application of PRO on a routine basis might impact clinical workflow, work practice, organizational structures, infrastructures as well as stakeholders' attitudes and values, [69,73,74,75, 76]. Hence, the reason why PRO in this section is claimed to be a tool, which actively or passively can be used to commence changes and cultural shifts in healthcare organizations.  
PRO is supposed to function as a system composed of outcomes that matters to patients, which is relevant as prior systems and data at times acted as alternative representations of reality deviating from patients' values and needs [42]. Hence, PROs' evocation of patients' values allows managers to construct a more patient-centered healthcare system [64]; a cultural shift and system change promoted by political institutions as they encourage providers and stakeholders to focus more on outcome measures and less on processual indicators [41,57].  
As part of clinical practice, the application of PROs faces several organizational and cultural barriers; especially, insufficient time seems to be one of the more pronounced barriers [77,78]. On the one hand, some physicians perceive PRO as being too time-consuming as it makes decision-making more complex and less effective [34]. On top of this, doctors' inability to interpret data due to no clear guidelines and lack of education is another aspect affecting the amount of time spent on PRO as part of clinical practice [41,79,80]. On the other hand, different studies have shown that PROs do not increase the length of clinical encounters [81,82,83]. Thus, PRO does to some extent affect the time dimension as part of patient-clinician consultation; however, to what extent is being contested. Another organizational aspect pertains to whether PROs fit into clinical workflow and practice [26,67]; however, numerous studies have verified that PROs are feasible in such a context [83,84]. Secondly, the increased work burden of the health care professionals should be kept to a minimum to avoid it turning into an implementation barrier [62,85]. Thirdly, proper and timely PRO data availability during a consultation is decisive for its use in clinical practice [50,86]. Therefore, even though PROs have a huge potential, its functionality rests on attitudinal cultures supporting patient engagement and genuine partnerships between patients and physicians supported by appropriate organizational setups [57; 62]. Put differently, to ensure that PRO's purpose is fulfilled organizational and cultural changes are mandatory; vice versa, it is reasonable to perceive PRO as a tool potentially instigating such transformations, since PROs \"automatically\" affects time, workflow, and use of data in clinical practice. Therefore, it is not surprising that attitudes towards PRO among healthcare professionals are differing; nonetheless, a central point since a cultural shift relies heavily on healthcare professionals' and leaders' engagement [30; 49]. Moreover, PRO data might be utilized as a communication tool within multidisciplinary teams [35; 67] or serve as a coordination tool by sharing data across different healthcare actors [30], potentially enhancing coordination of for example patient pathways across organizations and sectors [8].