## 4 Discussion
### Realization of PRO's Patient-Oriented and Economic Purposes?  
As elucidated, PRO traditionally is part of the outcome data branch, which has shaped its use formerly. Hence, PRO was traditionally used as secondary endpoint data when measuring patients' outcomes following a healthcare intervention [37]. However, PRO is currently also used as a primary endpoint, underscoring that the use of PRO has undergone a noticeable change [86]; arguably, reflecting how PRO's purpose has changed as HRQoL aspects have become a crucial part of today's healthcare.  
Thus, when PRO is applied as an independent variable, the purposes of PRO alter in a patient-oriented direction, since such interventions are meant to affect patient behavior; hence, the current focus on PRO's effects on SDM, patient participation, empowerment, and self-management. Therefore, PRO no longer merely measure health outcomes but also instigates actions related to patient-centered healthcare by activating patients. An essential shift in PRO's intended purpose, which is decisive to grasp, to fully comprehend the transformative impact PROs plausibly have on clinical practice and healthcare henceforth.  
Regarding PRO's economic features these rests on certain assumptions and have important implications. This is because PRO systems where data describes the quality of treatment and outcomes according to the patients require patients that are willing to frequently complete questionnaires and to actively engage in the management of their health condition [43; 53]. An important point, making it relevant to continuously evaluate patient participation and response rates, ensuring the feasibility of the system in the long run. In other words, the possibilities the digitalization of PRO offers need to be balanced with patients' needs and preferences. Furthermore, PRO's economic effectiveness as part of a triage system based on algorithms relies on two essential conditions to function properly. Firstly, reallocation of resources requires that resources de facto are moved from \"green-patients\" and are allotted to those most in need. Alternatively, it might turn into a money-saving exercise, economically enhancing the healthcare system but not necessarily benefiting the most vulnerable patients. Secondly, an increase in productivity rests on the condition that the time formerly spent in each patient-clinician consultation equals or is shorter than the current time spend even if the state of the examined patients' health condition differentiates. In other words, even though a triage system logically results in a clinical practice with fewer \"easy patients,\" since only the most vulnerable individuals and complex patient cases are invited for consultation, healthcare professionals are still expected to spend the same amount or even less time on each patient compared to previous procedures. Therefore, even if PRO makes patient-clinician consultations more time effective by revealing relevant patient issues beforehand, changes in the type of patients showing up for consultation and additional subjects being discussed, which in the past might have been neglected, needs to be kept in mind when considering whether PRO is a time-saving tool.  
Moreover, even though the normative ideals VBHC rests on seems attractive and might positively complement the volume-based reimbursement system, results from the UK shows that there are substantial annual variations in hospitals performances; thus, the authors state: \"the hard statistical conclusion seems to be that even though there are some identifiably good and bad hospitals, most achieve pretty much the same levels of health gain for patients undergoing surgery\" [87]. Therefore, it is questionable whether performance-based financing (PBF) and benchmarking systems are the right paths to take; however, if such tools are widely implemented, their infancy warrants that adequate indicators are developed, which is no simple task considering the multiple purposes of PRO and the complexity of current healthcare systems.