Shared Decision MakingFrom Concept to RealityRichard Wexler, MDChief Clinical Integration Officerrwexler@healthwise.org

Big Picture - Changing Roles and Relationships

Creating An Engaging Patient Experience

Outline

• Level setting – shared decision making and patient decision aids

• Implementing – an overview• Implementing – a couple of scenarios• Discussion and next steps

Shared Decision Making

“the process of interacting with patients who wish to be involved in arriving at an informed, values-based choice among two or more medically reasonable alternatives”¹

InformedThere is a choiceThe optionsThe benefits and harmsof the options

Values-BasedWhat’s important to the patient

The ClinicianInformation

The Patient

¹A.M. O'Connor et al, “Modifying Unwarranted Variations In Health Care: Shared Decision Making Using Patient Decision Aids” Health Affairs, 7 October, 2004

The Six Steps of Shared Decision Making

1. Invite patient to participate2. Present options3. Provide information on benefits and risks4. Assist patient in evaluating options based on

their goals and concerns5. Facilitate deliberation and decision making6. Assist with implementation

A Word on Taxonomy

Effective Care• Strong evidence base

supports care• Benefit-to-harm ratio

high• All with need should

receive

Preference-Sensitive Care• Evidence supports

more than one approach

• Treatment/testing options involve significant trade offs

• Personal values, preferences, and life circumstances should drive decisions

SDM Sweet Spot

MI Sweet Spot

Patient Decision Aids

• Tools to facilitate SDM• Come in all shapes and

sizes

Minimum Standards to Qualify as a DA

Describes the condition or problem Explicitly states the decision that needs to be

considered Describes the options available for the decision Describes the positive features of each option Describes the negative features of each option Describes what it is like to experience the

consequences of the options

Joseph-Williams N, Newcombe R, Politi M, Durand MA, Sivell S, Stacey D, O'Connor A, Volk RJ, Edwards A, Bennett C, Pignone M, Thomson R, Elwyn G: Toward Minimum Standards for Certifying Patient Decision Aids: A Modified Delphi Consensus Process. Med Decis Making 2013, in

press. 

These are not decision aids

• Educational materials not geared to a specific decision

• Materials that advise people to choose one option over another

• Materials designed to promote compliance with a recommended option

• Passive informed consent materials

Patient Decision Aid Inventory

Some DAs are in the public domainOthers are available for a fee

Check for last update or review

IPDAS = International PatientDecision Aid Standards

https://decisionaid.ohri.ca/AZinvent.php

Health Dialog and Informed Medical Decisions Foundation

Healthwise

National Cancer Institute

AHRQ

Implementing SDMWhere the Rubber Meets the Road

Implementation Options

17

Primary Care

Specialty Care

Primary Care Implementation

Works well when• The test or treatment is generally managed in

primary care– Screening tests – e.g. screening for PCA and CRC– Chronic conditions – e.g. diabetes, depression, HF

• The care team shares the responsibility• The diagnosis is known and surgical

consultation is being considered• Financial incentives are aligned

Specialty Care ImplementationWorks well when• Wait times are long• Non-operating clinicians perform triage• The reason for specialty consultation is

clearly defined at the time of referral• Financial incentives are aligned

Implementation – Frequent Barriers• Common provider misconceptions

– I’m already doing SDM– Patients want me to decide or won’t understand– It takes too much time

• Multiple competing priorities• Lack of IT infrastructure and easily available DAs • Lack of training• Lack of reimbursement• Not knowing the reason for a visit• Not knowing the numbers

Implementing SDM

Engage

Motivation = Importance + Confidence

Importance – Present SDM as a quality of care initiative

Importance – Make SDM is an organizational priority

Importance – Encourage patients and care givers

Importance – Lead often with a physician champion

Confidence – Provide training and tools

Implementing SDM

Target and Identify Patients

Target patients that can be identified

Target patients in a decision window

Target decisions where DAs are available

Leverage technology and integrate with work flows

Don’t rely solely on physician memory

Implementing SDM

Distribute DAs to Patients

Pre-visit distribution decompresses” the visit and allows for personalized discussionsIn-visit distribution and review can be done with short form “DAs”

Post-visit distribution requires a “close the loop” strategy

Population-based distribution can be a patient engagement strategy

Implementing SDM

Encourage DA Viewing

Patients need a WIFM

Enthusiastic endorsement helps

Clinical context matters

Implementing SDM

Support Patients During SDM Conversations

This is the game changer

Capturing the “patient response” can focus the conversation

Use others on the clinical team

Decision aids help but aren’t required

Start by inviting the patient into the conversation

Present all the options and do your best with the pros and cons

Be curious about what’s important to your patients

Patient Response in EHR

D\D

Patient leaning

Decision Conflict Scale

Readiness to Decide

Implementing SDMWhere the Rubber Meets the Road

Questions? Comments! Concerns! Stories!

Clinical Scenario One

50 year old male scheduled for preventive care visit.

Clinical Scenario Two

50 year old female scheduled for f/u visit with hip OA on NSAIDS

Thank You!