HI-FIVE (Health Informatics For Innovation, Value & Enrichment) Training is a 12-hour online course designed by Columbia University in 2016, with sponsorship from the Office of the National Coordinator for Health Information Technology (ONC). The training is role-based and uses case scenarios. Also, it has additional, optional modules on other topics of interest or relevance. Although we suggest to complete the course within a month's timeframe, the course is self-paced and so you can start and finish the course at anytime during a month's time period. No additional hardware or software are required for this course. Our nation’s healthcare system is changing at a rapid pace. Transformative health care delivery programs depend heavily on health information technology to improve and coordinate care, maintain patient registries, support patient engagement, develop and sustain data infrastructure necessary for multi-payer value-based payment, and enable analytical capacities to inform decision making and streamline reporting. The accelerated pace of change from new and expanding technology will continue to be a challenge for preparing a skilled workforce so taking this training will help you to stay current in the dynamic landscape of health care. This course is one of three related courses in the HI-FIVE training program, which has topics on population health, care coordination and interoperability, value-based care, healthcare data analytics, and patient-centered care. Each of the three courses is designed from a different perspective based on various healthcare roles. This first course is from a clinical perspective, geared towards physicians, nurse practitioners, physician assistants, nurses, clinical executives and managers, medical assistants, and other clinical support roles. However, we encourage anyone working in healthcare, health IT, public health, and population health to participate in any of the three trainings. If you would like to obtain continuing medical education (CME) or continuing nursing education (CNE) credits, you will need to have eligible credentials, complete the entire course, and complete the evaluation survey at the end. The HI-FIVE team verifies after each month that these requirements have been met and then a separate certificate (fee may apply) is distributed to you from our accreditation office. Please allow time for processing. If you have any further questions about continuing education, please see our website at www.hi-fivetraining.org. Accreditation Statement The College of Physicians and Surgeons of Columbia University is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. AMA Credit Designation Statement The College of Physcians and Surgeons designates this enduring material for 12.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The planning committee members are: Rita Kukafka, DrPH, MA, FACMI; Bruce Forman, MD; Gil Kuperman, MD, PhD; Virginia Lorenzi, MS, CPHIMS, FHL7, and Victoria Tiase, MSN, BN. None of the members of the committee, who planned this CME Activity, have any relevant financial relationships to disclose. The release date is 2/1/17 and the expiration date is 1/31/18. This activity is eligible for 12 continuing nursing education (CNE) credits. Columbia University School of Nursing, Continuing Nursing Education Program is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Shared Decision-Making: Introduction
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来自 Columbia University 的课程
HI-FIVE: Health Informatics For Innovation, Value & Enrichment (Clinical Perspective)
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Columbia University
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从本节课中
Role-Based Content (OPTIONAL) - Physicians / Nurse Practitioners / Physician Assistants / Clinical Executives / Clinical Managers / Public Health Professionals
This module is optional, but has additional topics that you may be interested based on your role. We encourage you to explore any of these topics and there are also quizzes to test your learning.
与讲师见面
Rita KukafkaAssociate Professor
Biomedical Informatics
Welcome to Patient-Centered Care, Shared Decision-Making.
This is Lecture a.
This unit will cover the following learning objectives.
1. Describe shared decision-making.
2. Explain the use of decision aides and
how they facilitate shared decision-making.
And 3. Debate alternative strategies to implement
decision aids within workflows.
This lecture will give an introduction to shared decision-making.
Shared decision-making, or SDM, is a collaborative process that allows
patients and their providers to make health care decisions together.
Taking into account the best scientific evidence available,
as well as the patients values and preferences.
The aim of shared decision-making is to ensure that patients understand their
options and the pros and cons of those options.
And patients goals and preferences are used to guide decisions.
SDM honors both the provider's expert knowledge and the patient's right to
be fully informed of all care options and the potential harms and benefits.
Shared decision-making is best used for problems involving clinical uncertainty,
ambiguity, or simply an absence of evidence.
It is also appropriate in situations of equipoise, which is when evidence for
benefits and harms is closely balanced.
It can also provide the structure for
providers to discuss clinical practice guidelines, particularly guidelines
with US Preventive Services Task Force Grade C recommendations.
To say that at the population level, the balance of benefits and
harms is very close, and the magnitude of net benefit is small.
With transparency about evidence, patients together with their providers can
make decisions about guidelines as they apply to individual risk profiles,
preferences, and context.
For example, the decision to start screening mammography
in women prior to age 50 years should be an individual one,
according to the US Preventive Services Task Force.
Some women who place a higher value on the potential benefit than the potential harm,
may choose to begin biannual screening between the ages of 40 and 49 years.
For other women, mammography screening could be viewed as unnecessary or
even harmful based on individual risk factors and personal preferences.
The positive impact of patient involvement in decision-making includes improved
patient knowledge, a greater sense of control over their illness, symptom
improvement, higher decision satisfaction, and more trust in physicians.
Patients report fewer depressive symptoms, anxiety,
fatigue, concern about their illness, and lower decision conflict.
When patients discuss preferences with their physicians,
they are more likely to get the care they want.
SDM can help contain health care spending
by avoiding treatments patients do not want.
Which results in reductions in unwarranted variation in care and cost.
And greater alignment of care with patients' values.
SDM is also needed because it is essential to quality health care.
Good, quality care requires that procedures, treatments, and
tests be not only medically appropriate and performed safely, but
also desired by informed patients.
Patients construct their preferences through evidence informed deliberations,
a key step in the SDM process.
In the era of health care reform, it is increasingly evident that among the most
important reforms needed to improve medical care are those that would inform
and amplify the voice of the patient when medical decisions are made.
Systematic reviews of the preconditions for improving health care delivery
have emphasized the importance of shared decision-making as a mediator and
moderator of health care quality.
As we will see in the next slides,
SDM is a process that can help providers implement evidence to support
patients' preferences when deciding on test and treatment options.
A keyword in the shared decision-making definition is process.
In this slide, we will review the steps that make up this process.
First, it is essential to make explicit to patients
that there is actually a decision that needs to be made.
Over and over again,
patients report that they did not even know that a decision was being made.
Next, once it is clear that a decision is to be made for patients
to have a meaningful role in the decision, they have to be given an objective.
Unbiased presentation of reasonable options.
They need to be able to consider the risks and benefits of those options.
This step in the process is often referred to as information exchange.
There can be information that the patient brings into the visit and
there is information that the provider brings.
Key at this step is that the patient understands their options for
managing their condition.
Understandably, it is not a simple task to translate evidence into options that
people can understand and to communicate the risks and benefits of options.
However, as we will discuss later in this unit,
patient decision aides are tools that can assist in the SDM process.
Understanding what matters most to patients is the next step.
Patients need to understand what are their values and preferences for
the outcomes of each option presented.
Consider that patients may not have well formed preferences at the onset,
but rather they may construct them as they gain more information.
During this process, it is also important to consider feasibility since patients
may value some options but certain options may not be feasible for them.
Agreeing on a choice and a plan for implementing the decision are next steps.
However, keep in mind that a choice could be taking no action.
For example, a provider or a patient may say quote,
we don't have to do anything right now, we can wait, end quote.
This is the conversation option that perhaps is not practiced much
in health care today.
But it is still a decision and
one that implies that the decision could potentially be revisited at a later time.
As an example, a patient and an oncologist might agree to re-evaluate a decision
after several cycles of chemotherapy to determine its effectiveness and
to discuss whether or not to proceed with another procedure or treatment.
It is useful to distinguish between deliberation and
determination in the shared decision-making process.
Deliberation are the steps that enables patients to consider factors that can
influence a choice.
Determination is making a choice.
Some patients may want to engage in deliberation.
But when it comes to determination,
they may opt to defer the decision to their provider.
In a national study of nearly 3,000 participants, mostly all respondents,
96%, regardless of their demographics characteristics,
preferred to be offered choices about their care and asked their preferences.
About half of the participants, 52%,
wanted to defer final decisions to their clinicians.
But they still wanted to engage in deliberation about the choice.
What does this tell us?
Even when patients opt to defer their decision to providers, they still want to
be offered choices about their care and asked about their preferences.
Most people want to discuss options and
share their opinions about treatment with providers.
There are some widely held misconceptions about doing shared decision-making that
perhaps prevent it from being practiced.
In the next few slides, we will review some common misconceptions.
One is that providers are already doing shared decision-making and
already incorporate patient preferences into their treatment recommendations.
However, research shows that physicians' inferences about patient values and
preferences are inaccurate.
Even among physicians with more clinical experience and
longer patient-physician relationships.
In other words, there are significant gaps between what patients want and
what doctors think they want.
In a study conducted by Lee and colleagues, doctors believe that 71%
of patients with breast cancer rate keeping their breast as a top priority.
But what is the actual figure reported by patients?
7%.
Doctors also believe that 96% of patients scheduled to undergo chemotherapy,
rate living as long as possible as a top priority.
Again, what is the actual figure reported by patients?
59%.
Preference misdiagnosis is a term used to describe a provider's
inaccurate inferences of patient preferences.
Many believe this may be the most common form of medical error in health care.
Another misconception about shared decision-making is that it will increase
health inequalities by excluding disadvantaged patients.
There is a belief by some that SDM will only attract and
benefit those who naturally seek out information, are educated and
empowered, and able to advocate for their needs.
And consequently, some believe that SDM disfavors disadvantaged patients.
This is not true.
A systematic review and meta analysis of randomized control trials and
observational studies showed that disparities in knowledge,
decisional conflict, and uncertainty between disadvantaged groups and
more privileged populations tended to disappear after use of SDM interventions.
Disadvantaged groups may therefore benefit form shared decision-making interventions,
even more than people with higher literacy and/or education groups.
In the long term, SDM may actually help to reduce health disparities.
A third misconception about shared decision-making is that it
just takes much too long.
There is little evidence to prove this.
Although visit length may vary depending on the context,
no one has proven that shared decision-making systematically takes
longer than visits that do not include SDM.
With respect to the use of patient decision aids to facilitate SDM,
trials sited in the Cochrane Database of Systematic Reviews found
conflicting evidence that use of a decision aid increases consultation times.
One study found consultations increased by six minutes when a decision aid and
shared decision-making were used.
Another study found interaction time was eight minutes shorter
when similar consultation techniques were used.
Therefore, there is no evidence that SDM systematically
increases visits when compared with visits that do not include SDM.
A fourth misconception is that patient education
will lead to shared decision-making.
Knowledge may contribute to the shared decision-making process.
But a patient's capacity to participate in SDM is also linked to how much power or
influence he or she feels that they have in the decision-making consultation.
Patients may not feel that they have expertise to
bring to the clinical encounter.
However, their expertise is the knowledge about their personal preferences and
this knowledge is important.
This inequity in knowledge may contribute to the power imbalance that can occur
during clinical encounters.
The team of health care providers, not only the physician, can contribute here.
In fact, when patients were asked how best to implement SDM in clinical workflow,
they felt that the nurses should add support by listening to their preferences.
Patients felt that the nurses can help to overcome the power imbalances.
They wanted someone to advocate for them.
This function is not limited only to nurses.
But could be carried out by other health professionals, such as social workers,
peer coaches, or advocates, or community health workers.
A model of SDM,
called the Interprofessional Shared Decision-Making Model, provides some
guidance with respect to the different levels of support needed to provide SDM.
The model addresses three levels within the health care system.
The micro-level is the individual level
where the patient presents with a health problem that requires a decision.
The meso-level incorporates the health care teams within an organization.
The macro-level refers to the broader policies and
social context that can facilitate or hinder the SDM process.
The underlying assumption is that an interprofessional approach to SDM,
within clinical encounters, will not occur independently
of the influence of factors from the health care system level.
While shared decision-making has been slow to become part of the clinical encounter,
transition from volume based to value based care and
several recent developments, will put increasing pressure on hospitals and
health care providers to develop strategies for shared decision-making.
For example, clinical guidelines, such as those for screening for
breast cancer, now emphasize the importance of shared decision-making.
The National Committee on Quality Assurances Patient-Centered Medical Home
Recognition Program, regulations for Accountable Care Organizations, and
insurance and employer group recognition programs all require organizations and
clinicians to engage patients in shared decision-making.
When patients choose what they want,
rather than what the health care provider is offering, many opt for less intensive,
less costly treatments and they report higher satisfaction with their care.
The importance of shared decision-making is now widely recognized.
And the implementation, as we will learn in the next lecture on patient decision
aides, can assist health care organizations and
providers in adopting shared decision-making.
This concludes Lecture a of Shared Decision-Making.
To summarize, we defined shared decision-making as a collaborative process
that allows patients and their providers to make health care decisions together.
Taking into account the best scientific evidence available,
as well as the patients' values and preferences.
There are many benefits to shared decision-making
that are related to health care quality.
But SDM should be used when appropriate.
There are several steps in the SDM process and
they can be categorized, into deliberation and determination.
However, SDM is slow to be adopted in the clinical encounter
because there are some misconceptions from the provider perspective.
But in general, patients would like to engage in shared decision-making.
