Shared Decision-Making Leads to Better Decisions and Improves Patient Relationships

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“During a diagnosis, patients receive many clinical details accompanied by technically challenging options at an emotional time in their lives. They need a hands-on program with content experts, to guide them through a decision that must be made in a short timeframe.”

– Rodney Christensen, MD
Allina Health Vice President of
Medical Operations
Strategy Division

EXECUTIVE SUMMARY

Shared decision-making is the process by which clinicians and patients work together to make decisions and select tests, treatments, and care plans based on clinical evidence. Shared decision-making balances risk and expected outcomes with patient preferences and values, empowering patients to make informed decisions.

Project leadership at Allina Health didn’t have a way to know if shared decision-making interventions were being applied. By utilizing its analytics platform, Allina Health was able to track whether or not decision support tools were being used consistently and if shared decision-making conversations were happening, if there was variation in how and when they were being used, and if they were making a difference.

Allina Health’s leadership team developed a small pilot program to test and refine the proposed shared decision-making process. The team expanded and improved subsequent pilots to determine if it should modify decision support tools and whether to add or adjust workflows and documentation elements to support shared decision-making. Allina Health leveraged its analytics platform to expose the key data needed to analyze shared decision-making processes and included goals on the balanced scorecard used by executives, board members, and operational leaders to visualize the results of its efforts.

Within nine months of implementing the standard shared decision-making process Allina Health substantially increased the number of patients participating in the program:

  • 749 patients have participated in a shared decision-making visit across the system, including:
    • 69 percent of eligible patients with low back pain.
    • 84 percent of eligible patients with early breast cancer.

SHARED DECISION-MAKING IMPROVES THE PATIENT EXPERIENCE

Shared decision-making is a key component of whole-person care, in which clinicians and patients make decisions together and select tests, treatments, and care plans based on clinical evidence that balances risk and expected outcomes with patient preferences and values.1 Studies show that patients who receive decision aids have increased knowledge, greater understanding of the risk, reduced internal conflict about their decisions, and a greater likelihood of receiving care aligned with their values.2 By contrast, unresolved decisional conflict can contribute to delayed decisions, decisional regret, and possible blame of practitioners for bad outcomes.3

EXECUTING SHARED DECISION-MAKING POSES CHALLENGES

Allina Health, a non-profit healthcare system dedicated to preventing and treating illness, and providing whole-person care to individuals, families, and communities throughout Minnesota and western Wisconsin, recognized that shared decision-making is a key element in engaging patients in their care, and is especially helpful in situations where there is no single right answer. Choices about treatments, tests, and surgery options all come with benefits and disadvantages that should be weighed against a patient’s preferences and values, especially when these decisions can impact the rest of the patient’s life.

While Allina Health valued shared-decision making, the shared decision-making process was not clearly defined for patients or clinicians, contributing to concerns about how it would work or how it might impact the patient/clinician relationship. Without a system to determine which patients would most benefit from shared decision-making, or a workflow and documentation process to support the effort, it would be difficult and ineffective to implement.

Operational leaders didn’t know if shared decision-making interventions were being applied consistently. Even though they had clear, helpful decision tools, without analytics, they didn’t know if the tools were being used, if there was variation in how they were being used, or if they were making a difference. The lack of actionable data and insight hindered efforts to spread shared decision-making across the health system. Leaders needed to make a compelling case for change and needed to make the initiative’s results visible to executives and operational leaders to accelerate adoption.

KEYS TO SUCCESSFUL SHARED DECISION-MAKING IMPLEMENTATION AND ADOPTION

Allina Health’s shared decision-making journey began with a small pilot, trialing the process with colorectal cancer screening. Beginning with a small test of change at three clinics, Allina Health tested and refined the proposed shared decision-making process before expanding it to other areas. The next shared decision-making pilot included patients with breast cancer and started with one registered nurse and two physician champions. This sensible and validated approach to process improvement allowed them to learn valuable lessons early, that Allina Health then used to improve the next pilot, increasing support and enthusiasm for the effort.

The pilots revealed whether the decision support tools needed to be modified, what workflows and documentation elements needed to be added or adjusted to support shared decision-making and helped identify implementation barriers. In the pilot, patients met with cancer care coordinators (registered nurses) who would review the shared decision-making tools with them, helping the patients better understand their options.

Some physicians initially expressed concerns with how the shared decision-making process would change their relationships with patients—expressing concerns that their personal relationship with the patient would suffer. But the pilots showed that relationships were not diminished, the relationships were enhanced. The shared decision-making process augmented the time spent between patients and enhanced the relationship with the physician because patients arrived with basic knowledge that allowed physicians to start the conversation from a better place. Rather than interfering, the shared decision-making process strengthened the patient’s relationship with their physician and resulted in more meaningful and valuable conversations. These physicians eventually became champions of the new process with their colleagues and were key to spreading shared decision-making across the system.

With the lessons gleaned from the pilots, the team integrated new documentation, moved to internal development of its shared decision-making decision guides used by patients, further clarified roles, and created reliable and robust workflows, building a framework for other areas in the initial phases of rolling out shared decision-making. Lessons learned from the pilots also provided guidance on how best to succeed with shared decision-making and identified specific implementation difficulties and how the previous team managed them. These lessons enabled the faster spread of this shared decision-making across the system, serving as the foundation for future spread in other clinical decision points across the system.

In one instance, an early pilot compared a patient self-guided decision tool, which helped patients understand their treatment options for low back pain, to a clinician-guided decision tool for breast cancer treatment options. The breast cancer decision tool was facilitated by the cancer care coordinator who had been trained in shared decision-making and was able to review the shared decision-making tool with the patient. The team discovered that patients who had used the self-guided process were not as well-prepared or informed when they met with their clinicians as those who had participated in a facilitated conversation. Armed with this evidence, the team could further refine its shared decision-making process.

EXECUTIVE SUPPORT AND ROBUST ANALYTICS SUPPORT SHARED DECISION-MAKING

To further spread shared decision-making across the system Allina Health commissioned a shared decision-making steering committee. The steering committee has over sight of shared decision-making activities, meeting monthly to ensure ongoing program development and consistent application of guideline principles. A pivotal moment for the ongoing spread of shared decision-making was elevating the use of the tools into two preference sensitive conditions—chronic low back pain and breast cancer—to the Allina Health balanced scorecard, which visualizes the results of priority work within the organization. This key decision has resulted in executive and board level visibility into the shared decision-making process and associated patient outcomes.

As shared decision-making is rolled out in different areas, Allina Health integrates it into policies, processes, and guidelines to reinforce the process and support sustaining gains over the long term. Currently, shared decision-making is in use supporting patients with chronic low back pain, helping them to choose wisely among surgical and non-surgical treatments and interventions, and for patients with breast cancer, helping them to navigate the critical choices for surgical treatment decisions they must make. Other shared decision-making areas will be added to the balanced scorecard as they are developed and rolled out.

Allina Health leverages the Health Catalyst® Analytics Platform and broad suite of analytics applications to monitor the shared decision-making process, gaining insight about its effectiveness and supporting ongoing improvement. Health Catalyst professional services provide weekly reports to operational leaders to further improve insight into reasons why some patients decline the shared decision-making visit. This data transparency has enabled leaders to address issues in a timely manner and allowed for continual feedback and ongoing process improvement. Leaders are also able to readily identify positive deviance, supporting further identification and spread of best practices.

The Health Catalyst Analytics Platform has surfaced key data needed to analyze shared decision-making processes. For example, Allina Health believes that every patient deserves a shared decision-making conversation as they make important healthcare decisions, so it is important to understand which patients are eligible for shared decision-making, and of those patients, how many don’t receive it. If eligible patients do not receive a shared decision-making visit, the team uncovers the reasons why and intervenes, if needed.

The nimbleness of the Health Catalyst Analytics Platform allows data visualization at macro and micro levels, which enables project leaders to quickly see trends. Leaders can drill into specific clinic, clinician, and patient data to further understand what is driving those trends. Actionable data lets operational leaders intervene in real-time to manage change, adjust workflow, or improve documentation to accelerate shared decision-making adoption.

RESULTS

Allina Health’s commitment to providing patients with evidence-based decision-making support has paid off. Shared decision-making is now offered to patients who have chronic low back pain to help them sort through their surgical and non-surgical treatment options. Allina Health has also had excellent success implementing shared decision-making to support patients with new diagnoses of breast cancer navigate their crucial surgical treatment choices.

Within nine months of implementing the standard process, Allina Health has substantially increased the number of patients who participate in shared decision-making.

  • 749 patients have participated in a shared decision-making visit across the system, including:
    • 69 percent of eligible patients with low back pain.
    • 84 percent of eligible patients with early breast cancer.

WHAT’S NEXT

Allina Health plans to implement shared decision-making in additional areas and has used lessons learned from its initial foray into shared decision-making to inform other projects, engaging patients and providers in shared conversations when decisions aren’t necessarily straightforward, such as use of opioids, frequency of mammograms, and colorectal cancer screening. Allina Health is evaluating additional modes for delivery of the shared decision-making materials and is publishing the shared decision-making decision aids to its public website.

Allina Health is using analytics to identify the patient populations that need shared decision-making translated to another language, such as Russian, Somali, or Spanish, and will continue to use analytics to monitor and measure program success and its impact on patient engagement and outcomes.

REFERENCES

  1. National Learning Consortium. (2013). Shared decision making – Fact sheet, December 2013. Retrieved from https://www.healthit.gov/sites/default/files/nlc_shared_decision_making_fact_sheet.pdf
  2. Oshima-Lee, E., & Emanuel, E. J. (2013). Shared decision making to improvecare and reduce costs. The New England Journal of Medicine, 368:6-8. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMp1209500#t=article
  3. Sun, Q. (MSc thesis). University of Ottawa, 2005. Gattelari & Ward J MedScreen 2004; 11:165-169

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