A Q&A with Geri Lynn Baumblatt, Editorial Director of Emmi Solutions.
Shared decision making (SDM) is an important issue in today’s healthcare industry but implementation of the actual practice can be challenging. We sat down with Geri Lynn Baumblatt of Emmi Solutions to discuss her thoughts on the topic.
Q: First off, how would you define Shared Decision Making?
A: Shared decision making is a collaborative process. A clinician helps the patient understand their condition, treatment options, and the pros and cons of those options. And the patient helps the clinician understand how their values, goals and preferences line up with these options. Only then can they arrive at a shared treatment plan. When patients participate in SDM, they’re also more likely to engage in the treatment plan.
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Q: What are some overall findings of groups that have done research? What was their methodology?
A: Research has shown that SDM is problematic if it means a lot more time spent per patient, and there are challenges to capturing patient preferences in decision aids (DAs). Last year, a couple of different studies looked at SDM implementation barriers.
For example, 5 RAND researchers conducted interviews. The researchers questioned eight different primary care organizations participating in a three-year demonstration. Glyn Elwyn and his team also did a large systematic review. Both found a variety of implementation issues including physician workload and lack of training as well as insufficient information systems. Even when physicians in the demonstration were reminded, only 10-30% made use of DAs with of their patients, and many physicians were unaware their current tactics didn’t qualify as “shared decision making” – it’s common to explain treatment options, but not to proactively solicit a patient’s preferences. Also, information systems largely lack the ability to track whether patients actually use DAs. It isn’t enough to simply present patients with SDM materials; they need to be encouraged to participate.
Q: So what are some options for solving such challenges?
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A: Training physicians in SDM is essential. It’s not currently part of most med schools or specialty training. Clinicians also need to promote SDM to patients. The clinician is the one in the relationship with the patient, and is usually someone the patient trusts and relies on, so patients need to hear from physicians why their values and preferences are important. If a decision aid is available, they need to hear from the clinician that it is of value. But according to the systematic review, clinicians often do not view the task of referring patients to use DAs as part of their role. You can read more about their identified barriers and proposed solutions here and here.
The DA being prescribed needs to integrate easily into office workflow, because you’re also asking office staff to participate in a new behavior. Like all our Emmi programs, our DA’s can be prescribed with the click of a button, this gets rid of many workflow barriers, like stocking or mailing out DVDs. Emmi’s web-based platform can also track whether a patient watched the DA, and has automated emails to remind people to watch it before their next appointment. And because our programs help patients share information about their values and preferences with the provider electronically, the provider also is also better prepared for their next conversation. And that’s what we’re after, making it easier to have real conversations.
Read More: How EHR Interoperability Helping Physician in Patient Care.
Q: Can you give me a real life example of a challenge to successful SDM?
A: Here’s an example: Patients who have coronary artery disease and angina often get a diagnostic procedure (angiogram). However, this often turns into a treatment procedure (angioplasty with stenting), but many patients also have the option of bypass surgery. But since a diagnostic procedure can convert into a treatment, when do you give the patient the DA? Some patients are given a DA when their angiogram is scheduled, but that creates confusion. As a patient, what you’d be thinking…“If there’s a chance I shouldn’t have this procedure, why am I already scheduled for it?”
And from a provider perspective, they don’t want patients calling in to cancel their procedures the day before. As we talked with hospitals and clinicians about this, it became clear you need to go further upstream, ideally to the stress test, and help patients understand what stress test is and what their options may be after the test.
Q: Timing really seems to be very important in SDM…
A: It is crucial. There may not always be an ideal time, but DAs are meant to help patients understand their treatment options early on and clarify their thoughts and values, not exacerbate their confusion when it is too late.
Q: These are all great points, thanks for taking time to speak with me.
A: This certainly wasn’t an exhaustive list of SDM implementing barriers but it was a good jumping off point. We discuss the issue on our blog, Engaging the Patient, occasionally so feel free to read more there.
