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Patient-reported outcomes (PROs) were originally introduced to primary care as screening instruments to assist primary care practitioners to diagnose and manage depression, on the assumption that standardised tools offered a more systematic and comprehensive assessment of symptoms.1 2 Since then, in both England and the USA, for instance, primary care has seen a move towards integrated care systems with collaboration across primary and secondary care and social services with the aim of better supporting patients to self-manage long-term conditions.3 In this context, PROs are envisaged to enable practitioners to identify patients’ problems and open up a discussion between the patient and the practitioner on how best to address them.4 The electronic capture and feedback of PROs to both clinicians and patients also offer opportunities for patients to track their own symptoms to support self-management.5 At the same time, PROs are advocated as a means of monitoring the quality of patient care6 7 and their use has been financially incentivised in some countries through pay-for-performance initiatives.8 9 The ‘measure once, cut twice’ premise of using the same PRO data for multiple uses10 11 is appealing but recent reviews of the literature also identified a number of challenges to this approach in practice.12 13 There is a need for evidence to demonstrate how PROs can successfully support patient care in primary care and to disentangle and understand the complex and interacting tensions that characterise the reality of work in this context. Such evidence is unlikely to arise from randomised controlled trials that typically adopt a ‘black box’ approach to studying complexity14 but instead from observational studies of the real-world use of PROs in clinical practice. Against this background, Mou et al ’s study15 in this issue of BMJ Quality & Safety exploring …