Shared Decision Making From Concept to Reality

1. Shared Decision MakingFrom Concept to Reality Richard Wexler, MD Chief Clinical Integration Officer rwexler@healthwise.org

2. Big Picture - Changing Roles and Relationships

3. Creating An Engaging Patient Experience

4. Outline • Level setting – shared decision making and patient decision aids • Implementing – an overview • Implementing – a couple of scenarios • Discussion and next steps

5. 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 • Informed • There is a choice • The options • The benefits and harms • of the options • Values-Based • What’s important to the patient Information The Clinician 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

6. The Six Steps of Shared Decision Making • Invite patient to participate • Present options • Provide information on benefits and risks • Assist patient in evaluating options based on their goals and concerns • Facilitate deliberation and decision making • Assist with implementation

7. A Word on Taxonomy • 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 • Effective Care • Strong evidence base supports care • Benefit-to-harm ratio high • All with need should receive MI Sweet Spot SDM Sweet Spot

8. Patient Decision Aids • Tools to facilitate SDM • Come in all shapes and sizes

9. 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.

10. 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

11. Patient Decision Aid Inventory Check for last update or review Some DAs are in the public domain Others are available for a fee IPDAS = International Patient Decision Aid Standards https://decisionaid.ohri.ca/AZinvent.php

12. Health Dialog and Informed Medical Decisions Foundation

13. Healthwise

14. National Cancer Institute

15. AHRQ

16. Implementing SDMWhere the Rubber Meets the Road

17. Implementation Options

18. 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

19. Specialty Care Implementation Works 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

20. 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

21. Implementing SDM

22. Implementing SDM

23. Implementing SDM

24. Implementing SDM

25. Implementing SDM

26. Patient Response in EHR D\D Patient leaning Decision Conflict Scale Readiness to Decide

27. Implementing SDMWhere the Rubber Meets the Road Questions? Comments! Concerns! Stories!

28. Clinical Scenario One 50 year old male scheduled for preventive care visit.

29. Clinical Scenario Two 50 year old female scheduled for f/u visit with hip OA on NSAIDS

30. Thank You!