As healthcare professionals face changing consumer demands and calls for increased patient engagement, many organizations are turning to shared decision-making as a key strategy for activating patients in their own treatment.
According to the ONC, shared decision-making (SDM) is “a process in which clinicians and patients work together to make decisions and select tests, treatments and care plans based on clinical evidence that balances risks and expected outcomes with patient preferences and values.”
Through thoughtful patient education and patient-provider communication, patients can move beyond passive participation in care and become a healthcare collaborator. SDM requires providers to combine their own clinical expertise with the knowledge that patients have about themselves, their priorities, and their values.
However, best practices for shared decision-making are only now emerging in response to calls for more value-based and patient-centered healthcare. Knowledge and time limitations, coupled with little regulatory action around SDM, has kept the practice under the radar for some clinicians.
Healthcare professionals need education about shared decision-making and how to practice it in order to create a collaborative environment for patients and clinical staff.
How to use shared decision-making in clinical settings
Shared decision-making can be broken down into a handful of seemingly simple steps: identify the patient’s condition, discuss treatment options, elicit patient preferences and values, and carry out the care decision.
However, SDM requires a great deal of finesse on the provider’s part, including careful utilization of patient-provider communication skills.
Providers who do not communicate clearly and with empathy will likely not achieve the goals of SDM. For example, lack of empathy will hinder patient trust, leading the patient to disengage from shared decision-making.
Lack of clarity when discussing treatment options will leave patients with insufficient information for making their decision, or may overwhelm them with confusing information.
The Agency for Healthcare Research & Quality (AHRQ) suggests providers use the SHARE approach:
- Seek your patient’s participation
- Help your patient explore and compare treatment options
- Assess your patient’s values and preferences
- Reach a decision with your patient
- Evaluate your patient’s decision
To begin, providers should explain the patient’s health condition, including the anticipated effects on a patient’s daily life and longer term outcomes.
Providers should take this time to solicit patient preferences for shared decision-making. While providers should encourage patient participation in decision-making, some patients do not prefer this strategy and providers must respect their feedback.
Family caregivers can also be included at the beginning of the SDM conversation.. Family members often know the patient the best and can add to the patient’s support system while offering a unique point of view that could complement proceedings. Additionally, sharing the decision-making process with family caregivers will contribute to activating caregivers during and after treatment.
The next step entails a detailed exploration of treatment options. Providers can start by asking the patient what she already knows about her treatment options, and then fill in the gaps.
Many providers use decision aids, which are either paper or digital tools that review the elements of treatments, as well as the pros and cons of each treatment.
Providers should use these aids to address side effects, recovery time, impact on quality of life, and prognosis following a treatment or procedure. These tools use plain language to accommodate patients with limited health literacy and to ensure patient understanding.
Some decision aids function as take-home patient education. These tools can useful for patients who need to discuss their options with family members or require more time to come to a conclusion. Providers should be sure to follow up with patients after prescribing at-home decision aids.
Other aids, such as ones developed by the Mayo Clinic, are intended for in-office use. The Mayo Clinic’s decision aids look like flashcards, and show information about prescribed wellness behaviors, what a treatment entails, and what a patient’s quality of life could be.
Providers using decision aids in the office should continue to lean on their usual patient-provider communication skills while allowing patients to parse through the documents at their own pace.
Should a provider find she is running out of time with that patient, she may revisit the topic with the patient later during the day via phone call or secure message, or in a follow-up appointment.
If decision aids are not available, providers should go through similar steps on their own. Clinicians should review all of the relevant information with patients in a clear and concise manner.
During follow-up, providers can use patient teach back to assess patient understanding.
Next, providers need to assess patient values and preferences. This requires building trust through communication and empathy. Providers should be non-judgmental and considerate of patient preferences.
Many patients tend to have similar concerns, including recovery time, out-of-pocket costs, living a pain-free life, and maintaining or achieving a specific level of functionality. There may be other considerations depending on the patient and the condition at hand. Providers may find that patients with similar symptoms but different lifestyles may select different treatment protocols based on their unique perspectives.
After assessing patient preferences, clinicians can guide their patients to reach a decision. Providers can prompt the decision by simply asking the patient if she is ready to choose a course of action. If the patient is not ready, the provider should make clear the time by which the patient should decide. This is not to apply pressure, but to allow the patient to progress in her recovery.
Clinicians should also ask the patient if she needs more educational materials or answers to additional questions to help with her decision.
After implementing the chosen treatment, providers need to schedule follow-up appointments to assess progress. Follow-ups should look at both clinical progress as well as whether the treatment is still viable for the patient’s lifestyle. From there, clinician and patient can decide the next appropriate steps.
The challenges of shared decision-making
Although shared decision-making is a promising strategy for engaging patients, there are numerous challenges impeding adoption.
The first hurdle is awareness. Very few providers actually know about SDM or the best practices that facilitate it, according to Peter Goldbach, MD, Chief Medical Officer for Rite Aid’s RediClinic and Health Dialog, a company from Rite Aid that makes decision aids.
“Shared decision-making has not been part of providers' education,” Goldbach said in a previous interview with PatientEngagementHIT.com. “It's not part of the current culture. And people who practice medicine today are beset by a very busy, difficult environment where they have a lot of new requirements and a lot of new operating systems, like EMRs that are distracting them. That is a difficult environment to bring in new ways of working with patients.”
Providers are hard pressed for time as they try to cope with regulatory burdens, quality reporting programs, new technologies, and other demands on their schedules. Requiring providers to integrate what may be a lengthier communication strategy into their workflows is a difficult proposition.
But according to Goldbach, there is some evidence that shared decision-making does not take away too much clinical time. And when it does, the benefits outweigh the challenges.
“Integrating shared decision-making into clinical practice does require provider education as well as a strategy to integrate it into the practice’s workflows,” he explained.
“While providers are often concerned that shared decision-making will take additional time, studies on this subject have actually shown mixed results. Providers who practice shared decision-making like the outcomes because they enjoy the improved quality as well as their patient’s appreciation.”
Of course, providers will need some strategies to make the integration of SDM into their clinical workflows as smooth as possible. Leaning on team-based care, care coordination, and nurse communication will help providers implement shared decision-making while under a time crunch.
Additionally, use of prescribed shared decision-making - meaning the provider requests that the patient view educational materials within the patient portal between appointments - can help save valuable appointment time. This strategy is best used when a patient’s treatment is not time-sensitive.
Organizations should work to secure buy-in from executive leaders and clinical champions before introducing new workflows that include SDM.
Clinician and nurse leaders, as well as individuals in the C-suite, can shape the care delivery process to allow for more in-depth patient-provider relationships.
Overcoming these barriers - knowledge, time constraints, and creating leadership buy-in - has prompted many industry thought leaders to create resources for implementing shared decision-making.
In March 2018, the National Quality Forum (NQF) published a playbook for SDM and proclaimed the practice an essential standard of care. For Goldbach, this move was a critical step in the right direction.
“Most of us in the industry look to the NQF as the arbiter of reasonable, real-world medical evidence,” Goldbach explained. “Not surprisingly, NQF seem to have gone through a very thoughtful process of research and are stepping along in terms of starting with their national standards for the certification of patient decision aids report in December 2016.”
The move by NQF was viewed as especially helpful in light of the fact that other initiatives around shared decision-making have stalled. CMS and AHRQ, for example, previously had plans to roll out shared decision-making programs as a part of the Beneficiary Engagement and Incentive (BEI) models. These programs would have included the Shared Decision Making and Direct Decision Support models.
However, in a February 2018 decision, the agencies cancelled the programs citing operational complications and a lack of excitement around the programs.
“After careful consideration and review of all available options, CMS determined that the design and operational changes necessary to continue with the DDS Model would be too significant and burdensome for participants, and would require a new solicitation,” CMS wrote in a public statement.
Goldbach and others were disappointed in the decision. The lack of reimbursement for SDM makes it more difficult for organizations to justify spending time engaging with patients without being compensated, he said.
Leaders at NQF agree, stating that reimbursement programs could be a catalyst for shared decision-making.
“Payment is a strong incentive to stimulate change,” NQF said in its playbook. “While some employers and health plans currently pay for SDM, others could consider reimbursing for SDM and advancing the use of patient decision aids that meet the National Standards for the Certification of Patient Decision Aids.”
How shared decision-making benefits patients
Despite the many obstacles standing in the way of shared decision-making uptake, the practice does have its benefits, experts say. SDM has a positive impact on certain clinical elements as well as on overall patient engagement.
A 2017 study revealed that shared decision-making can reduce preventable hospital readmissions because it connects patients to the treatment that is often the most beneficial to them.
A separate study published in the New England Journal of Medicine suggested that SDM can decrease patient anxiety about healthcare costs because it allows patients to choose the treatment that best fits their personal budgets and care priorities.
Researchers from the Urban Institute reported that SDM can support value-based care models. When patients opt out of expensive and potentially ineffective treatment options -- while choosing an option that works for their own needs -- they may be more likely to receive treatments that yield lasting results.
For example, late-stage cancer patients may elect to pursue less aggressive treatment because comfort and quality at the end of their lives is more important than relatively small chances of remission, the researchers said.
“The use of chemotherapy in late-stage cancer can raise serious questions of clinical effectiveness and patient autonomy,” report authors Robert A. Berenson and Michael L. Millenson pointed out. “It is often difficult to tell whether chemotherapy is truly what the patients would want if they were fully informed about alternatives.”
Ultimately, shared decision-making is the key to ensuring patients see the care results they truly want, according to Corey Siegel, MD, a gastroenterologist from Dartmouth-Hitchcock Medical Center.
Despite their medical expertise, provider assumptions about patient care may miss the mark. A treatment choice may be effective and in fact cure a patient of a condition, but may not produce a higher quality of life for every individual, Siegel said.
For Siegel, soliciting those patient perspectives taught him about what his patients are truly concerned about in their own healthcare. A 2016 survey of Siegel’s ulcerative colitis patients revealed that patients have different fears than he originally thought.
The survey showed that patients were primarily concerned about developing colon cancer as the result of their ulcerative colitis. Patients were less concerned about the lifestyle changes that could result from invasive surgery or complicated medication regimens.
“[The results] really made me think that maybe the providers or the doctors have biases that they think the patients are so scared of these drugs, but in fact, they’re more worried about complications of the disease, so therefore we need to use appropriate treatment to treat these diseases,” Siegel explained.
Providers are certainly the experts on the disease, Siegel said. They can also typically offer insights into the side effects of certain treatment options and the way they impact previous patients’ lives, he acknowledged.
However, shared decision-making can ensure providers truly integrate patient preferences for care. At the end of the day, the patient is still the expert on his or her own wants, needs, and values - and that expertise needs to be incorporated into treatment planning, Siegel said.
Allowing patients to be collaborators in their own care can be the key to better outcomes and higher patient satisfaction. Once more providers adopt shared decision-making models, they can demonstrate the benefits tied to the practice. In turn, this could make it more feasible for hospital and clinic leaders to foster shared decision-making in healthcare.