A Fix for Shared Decision Making Implementation Failures

During Shared Decision Making Month, we will feature a number of guest bloggers who are working to advance shared decision making around the world. This guest post is by Don Kemper, MPH, Founder and CEO of Healthwise.

Don Kemper, MPH

In my last visit with my doctor I asked if I should get a shot to prevent shingles. He didn’t think I needed it, but when I asked why not he gave me a link to a decision aid on his hospital’s website. He also promised that if I chose to get it I could just drop by—no appointment or visit would be needed. I stopped in the lobby and looked at the decision aid on my smart phone. It took me less than five minutes to reach my informed decision. I got the shot on the spot. It was easy on the clinical workflow and I appreciated saving the extra trip.  Little by little, shared decision making is becoming a reality.

However, it doesn’t always work so smoothly. A too common strategy for implementing shared decision making has been the following:

• Pick a set of high-cost, high-risk surgical procedures.
• Identify a set of patients for whom the surgeries could be considered.
• Then provide to every patient the same full-service set of coaching, decision-aids, and personal stories followed by a shared decision-making visit with the prescribing clinician. In well-controlled research environments the approach has been shown to work well both to improve decision quality and to significantly reduce the rate of surgeries.

The difficulty has come in sustaining the impact outside of the research environment. Two problems with this approach have limited its impact:

1. The full-meal deal is too much for the workflow to swallow.
2. It’s too hard to change medical culture one procedure at a time.

Easing the Shared Decision-Making Workflow

Shared decision making (SDM) is not a one-size-fits-all proposition. Not all medical decisions require the same level of decision support. And not all patients require the same level of decision support (even around the same decision). For preference-sensitive decisions, every patient needs to understand that they do have options and that the best option for them is based as much on what they value as on their condition. However, we can greatly reduce SDM’s strain on the clinical workflow by providing each patient with just the dose of support that is right for them.

• Some patients may only need to review a brief chart of the pros and cons for each option before being confident of their choice.
• Others may need a 5–10 minute interactive tool to help them express their concerns and leanings to their doctor.
• Still others may want to take more time to hear patient stories before reaching their decision.
• And there are some who will need to do all of the above and then discuss it with a coach in advance of the decision session with their doctor.

In this case, more can be less. Letting each patient choose when they have had all the support they need will reduce the strain on the workload. Each patient can stop the support whenever they are ready to decide.

Creating a Culture of Shared Decision Making

Successful shared decision making will not happen without a significant culture shift by both patients and providers. Unfortunately, culture change doesn’t happen one procedure at a time. Doctors and patients must accept together a new and more engaged role for the individual, in which the patient’s voice is better heard and the patient’s choice is better honored. The fix is to provide a level of decision support for every preference-sensitive decision that at least describes the options and records the patient’s wishes. So start with an option chart for every patient then add more support only as the patient needs it.  That will be easy on the workflow and as patients and providers gain experience in shared decision making for everyday health problems, they will both be ready to share decision making when bigger issues are at stake.

The goal is improved decision quality for all. SDM will go mainstream when we can get the right dose of support to each patient without major disruption to the workflow.

Blogger Bio

Donald W. Kemper, MPH

Donald is chairman and CEO of Healthwise, a not-for-profit organization whose consumer health information and decision tools have been turned to over a billion times to help people make better health decisions. Don is a passionate advocate for raising the quality of patient engagement in health care. By prescribing prevention, self-management, and decision-support tools relevant to each person’s needs, clinicians can engage and motivate their patients to become active partners in their health and wellness. 

In 2002 Don co-authored “Information Therapy: Prescribed Information as a Reimbursable Medical Service.” The book presented the concept and the practicalities of how information prescriptions to each patient would become a core and expected part of health care, as is now required through the Meaningful Use rules for electronic medical records. More recently Don has championed the concept of “patient response” in which the patient’s use of and reply to information prescriptions are recorded in the clinical record. Don has co-authored five medical self-care and health promotion handbooks that together have sold over 37 million copies.

Don serves as a board member for the National Quality Forum. The Foundation for Accountability named Don a health care “visionary” for his dedication to responding to the needs of America’s patients. Don has also been recognized by Advance for Health Information Executives as one of the top 25 most influential forces in health care IT. The Wall Street Journal named Healthwise one of fifteen top small workplaces in America. Don holds master’s degrees in health systems engineering from the Georgia Institute of Technology and in public health from the University of California, Berkeley.