Welcome to Patient-Centered Care, Shared Decision-Making. This is Lecture b. This unit will cover the following learning objectives. One, describe shared decision-making. Two, explain the use of decision aids and how they facilitate shared decision-making. And three, debate alternative strategies to implement decision aids within workflows. In this lecture, we will discuss patient decision aides. Now, we will turn our attention to patient decision aids which are tools to facilitate shared decision-making. Patient decision aids are tools that help people become involved in decision making by making explicit the decision that needs to be made. Providing information about the options and outcomes and by clarifying personal values. They are designed to compliment, rather than replace counseling from a health practitioner. There are a variety of terms used to describe patient decision aids. They are sometimes referred to as decision aids, but they may also be referred to as, decision support interventions, decision support technologies, interactive health care communication applications and occasionally, shared decision-making programs or risk communication tools. Some patient decision aids are for use during the clinical encounter while others are used before or after the clinical encounter or over time. Those used in face-to-face clinical encounter may be brief and may help to organize treatment options for the patient. They may provide a framework for discussion and are dependent on clinician engagement. They have been shown to successfully change the conversation between the patient and the provider. And, can help prioritize the issues that are most important to the patient. They are more of a catalyst and may not meet the certification standards that we will soon discuss. Other patient decision aids can be used independent of a clinical encounter. Although, these decision aids are considered adjunct to the clinical encounter. Many designs of decision aids can be used alone by patients. These decision aids often include comprehensive information and data on risk of options. They also often include deliberation tools such as value clarification exercises and sometimes include narrative elements such as videos. More than 130 randomized control trials have demonstrated the ability of patient decision aids to support shared decision-making by improving patients' knowledge, increasing patients' participation in decisions and helping patients clarify and communicate their goals and preferences. If shared decision-making is to become a standard of effective care, tied to incentives or simply as a quality standard for providers to achieve, it has to be measured to establish the effectiveness of the decision aid. It is critical to provide evidence that the decision aid improves both the quality of the decision-making process and the quality of the choice that is made or what is known as decision quality. For the quality of the decision making process, the measures include the extent to which the decision aid helps patients to, one, recognize that a decision needs to be made. Two, feel informed about the options and about the risks, benefits and consequences of the options. Three, be clear about what matters most to them for this decision. Four, discuss goals, concerns and preferences with their health care providers and five, be involved in decision-making. The quality of the choice or decision quality is defined as, the extent to which patients are informed and receive treatments that reflect their goals and treatment preferences. The quality of the choice can be measured by assessing how informed is the patient. This attribute is measured by assessing the patients knowledge of the options and outcomes. It is not assessed in terms of patient perception of their knowledge level. Instead, factual items are used to assess objectively of patient's understanding of the information. The quality of the choices also measured by concordance between what matters most to the patient and the chosen option. Most approaches to measuring this attribute require, one, the elicitation of a patient's goals and/or treatment preferences. Two, the identification of the patient's chosen or implemented option and three, a calculation of the extent to which the option best meets the patient's stated goals or treatment preferences. Both the quality of the decision making process and the quality of the decision are equally relevant to decision aids that address screening or treatment options in which there are two or more reasonable options. Most healthcare reform programs, including the Affordable Care Act, ACA, advocate for the incentives for SDM. Although the ACA recognizes the value of promoting and incentivizing patient engagement in healthcare, currently, it does not explicitly describe how to operationalize this process. In 1995, the Agency for Healthcare Research and Quality, AHRQ, launched a program to develop measures that would provide equivalent data to permit comparisons of patient healthcare experiences across providers and insurers. The three most extensive uses of these Consumer Assessment of Healthcare Providers and Systems, CAHPS, instruments to date, have been to survey health plan members about their care experiences in the preceding year. Ambulatory patients about out-patient office experience and samples of Medicare patients who have been hospitalized. None of those instruments includes measures of how decisions are made, though they do explore patient experiences regarding information delivery in healthcare. The National Quality Forum (NQF) has approved a cap survey to be used for certified patient-centered medical homes (PCMH), which includes a module on SDM for patients who say they discuss starting or stopping their prescription medication with a provider. The Centers for Medicaid and Medicare Services, CMS, has a version of the CAHPS for accountable care organization, ACOs, that was field tested by a number of ACOs. The survey instrument includes a three question series that asks about patients interactions with providers when patients report they made a decision to start or stop a prescription medication or decision about whether to have surgery or some other procedure. It is generally agreed that operational consensus regarding the measurement of shared decision making will be needed so that the ACA can adequately direct incentives and effectively foster patient-centered care. To date, many decision tools have been introduced by many different research groups, companies and health-care systems And so, the quality of patient decision aids varies widely. The International Patient Decision Aid Standards, IPDAS Collaboration, a group of researchers and other stakeholders has made important progress toward assessing the quality of decision aids using a modified Delphi consensus process. The collaboration produced a checklist to self-assess decision aids against a set of criteria. This checklist is referred to as the International Patient Decision Standards Instrument, IPDASi. A consensus method also was used to establish the parts of decision aids considered essential and which parts are merely desirable. The six minimum standards to qualify as a patient decision aid are based on the International Patient Decision Aid Standards IPDAS Collaboration. The standards include, one, describes health condition or a problem for which a decision is required. Two, states explicitly the decision that needs to be considered. Three, describes the options available for the decision. Four, describes the positive features of each option. Five, describes the negative features of each option. And six, describes the features of options to help patients imagine what it might be like to experience the consequences of each options. For example, the physical, social and/or psychological effects. Developers of decision support interventions may want to consider these minimum standards when conceptualizing, designing and evaluating new interventions. But, users of decision aids should also consider these standards when choosing design aids to use in their settings. While an emerging area, health IT offers an opportunity to embed the use of decision tools into the clinical stream of activities, effective implementation and use of health IT can advance widespread adoption of shared decision making in clinic practice. Tools such as Electronic Health Records and patient portals that enhance access to decision aids and clinical workflows that encourage shared discussions between providers and patients are beginning to demonstrate lessons in clinical settings. As examples, SDM supported by health IT can flag when a patient is in a decision window and connect the patient with resources such as a decision aid. Health IT can provide patients with the ability to request information when and where they need it and also serve as the means for delivering high quality information to support patient's decisions and need for information. Additionally, it can give patients convenient and reliable ways of exploring and communicating their goals, concerns and preferences relevant to the problems and conditions they face, provide relevant and appropriate information to support SDM between patients and providers and provide appropriate support materials tailored to clinicians. Existing resources for decision aids can be found on the Internet at a number of sites. For example, the Agency for Health Care Research and Quality has a five-step process for shared decision-making that includes exploring and comparing the benefits, harms and risks of each option through meaningful dialogue about what matters most to the patient. Decision aids are designed for patients with certain conditions including prostate cancer, urinary incontinence, healthy bones and screening for lung cancer. The Ottawa Hospital Research Institute provides links to hundreds of decision aids for many conditions. The Informed Medical Decisions Foundation is a non-profit that develop and disseminate shared decision making tools. The foundation also provides a collection of resources to assist providers, policymakers, researchers, advocates and patients in gaining a better understanding of shared decision-making and patient decision aids. The Mayo Clinic Shared Decision Making National Resource Center is another excellent resource with listings of additional resources for those interested in shared decision-making and patient decision aids. The Center for Shared Decision Making at Dartmouth Hitchcock Medical Center has excellent resources including toolkits and trainings. These are just a few examples of excellent sites. This concludes Lecture b of Shared Decision-Making. To summarize, patient decision aids are tools that help people become involved in decision-making and are designed to complement rather than replace counseling from a health practitioner. There are many names for a patient decision aid such as decision support technologies and risk communication tools, to name a few. Patient decision aids can be used face-to-face during a clinical encounter or independent of a clinical encounter. Shared decision-making is measured by the quality of the process and the quality of the choice and there are many programs that measure shared decision making. There are minimum standards for patient decision aids and there are many resources on patient decision aids. They're an example of how health IT has potential to support shared decision-making. This concludes Unit 7 Shared Decision-Making. The summary of this unit is that, shared decision-making is a collaborative process that allows patients and their providers to make healthcare decisions together, taking into account the best scientific evidence available as well as the patient's values and preferences. There are some misconceptions about shared decision-making and there is slow adoption but in general, patients would like to engage in decision making. Patient decision aids are tools that help people become involved in decision making and are designed to compliment rather than replace counseling from a health practitioner. Shared decision-making is measured by the quality of the process and the quality of the choice. And, there are many programs that measure shared decision-making. Patient decision aids are an example of how health IT has potential to support shared decision-making.
