Implementing shared decision-making isn't as easy as it sounds, according to a study by the RAND Corp. and Informed Medical Decisions Foundation.
In an article published in Health Affairs, the authors follow a demonstration of shared decision-making at eight primary care sites that was funded and coordinated by the foundation.
From the project's first 18 months, the authors said the biggest barriers were time-pressed physicians, lack of training about shared decision-making and inadequate IT systems.
Yet as patient satisfaction becomes a factor in the Meaningful Use incentives, healthcare organizations are looking for ways to improve patient experience. Wisconsin community health system ThedaCare says shared decision-making has reduced the length of hospital stays, errors and inpatient costs by 25 percent.
The final rule for Medicare accountable care organizations requires it in delivery systems that participate in the Medicare Shared Savings Program. In effect, it requires providers to explain to patients all their treatment options--not just the one considered best--and for patients to convey their needs, values and preferences, including the option of doing nothing.
In this study, patients were to be given appropriate decision aids about their specific condition explaining the various treatments, such as options for colon cancer screening or surgery and its alternatives. That could be a brochure or having the patient view a video or providing the information in some other form. The protocol called for allowing the patient to digest the information, then discussing it later with the physician.
The researchers found, however, that with physicians discussing myriad issues with patients in a 10- to 15-minute appointment, they could not reliably remember to give patients the decision aids. Some docs thought that providing the information was the extent of it – not that they had to have a followup conversation about the patient's wishes.
In addition, the IT systems used were found to be inadequate. Nearly all sites' records lacked capabilities to flag patients as candidates for decision aids or to track patients through the process, such as whether the post-decision aid conversation had taken place. Though some sites used questionnaires to gauge patients' values and preferences, there was no way to integrate that information into the clinical system, meaning that information had to kept separately and might not be available to the physician conducting the post-decision aid conversation.
None of the sites had an IT system that tracked whether the patient received care in accordance with his or her stated preferences. Those involved at the care sites suggested automating as much as possible the process of flagging patients to be given decision aids and handing that task over to a staff member other than the physician. The researchers also recommended investing in provider training and re-engineering the process and IT systems to create this less patriarchal system of decision-making.
Ninety percent of patents in a survey last fall said they want their healthcare providers to give them more information about their options, but only about half said their doctor explains the risks of the options and even fewer said their doctor takes their goals into account.
To learn more:
- read the article