shared decision making from concept to reality richard wexler, md chief clinical integration officer...
TRANSCRIPT
Shared Decision MakingFrom Concept to RealityRichard Wexler, MDChief Clinical Integration [email protected]
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!