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Presenters/Topics:

• David Arterburn, M.D., M.P.H. (Group Health Research Institute) Implementing Shared Decision Making in Specialty Care Settings: Challenges and Solutions.
• Karen Sepucha, Ph.D. and Leigh H. Simmons, M.D. (Massachusetts General Hospital, Harvard Medical School) Shared Decision Making and the Patient-Centered Medical Home.
• Lyle Fagnan, M.D. and Mark Remiker, M.A. (Oregon Rural Practice-based Research Network, Oregon Health and Science University) Integrating Shared Decision Making into Small and Rural Primary Care Practices.

Moderator:

• Alaina Fournier, Ph.D., Agency for Healthcare Research and Quality (AHRQ).

Questions �鶹��ý:

Availability of Decision Aids in Languages Other Than English
Decision Aids and Electronic Medical Records
Decision Aids for Specific Conditions
Integrating Decision Aids Into Clinical Practice
Outcomes Associated with Using Shared Decision Making/Decision Aids
Provider Experiences with Shared Decision Making/Decision Aids
Provider Training on Shared Decision Making
Quality of Decision Aids
Working with Low Literate/Diverse Populations
Miscellaneous

Availability of Decision Aids in Languages Other Than English

1. Are decision aids used in this project available in languages other than English? If yes, which? ­

   Answer:

   • David Arterburn: We have not used other languages, although Spanish is available for some tools.

2. Does Health Dialog make videos in a language other than English—namely French? ­

   Answers:

   • David Arterburn: Some are in Spanish.
   • Leigh H. Simmons/Karen Sepucha: No French to our knowledge. Yes, three are available in Spanish and English: diabetes, knee osteoarthritis, and hip osteoarthritis.

3. Do you find it difficult to find shared decision making aids in languages other than English?

   Answers:

   • David Arterburn: Yes.
   • Leigh Simmons/Karen Sepucha: This can be a challenge. Some, such as the Mayo Clinic online statin choice decision aid, are available in several languages. The Health Dialog decision aids are available in English and only three are also in Spanish.
   • AHRQ: AHRQ’s Effective Health Care Program consumer research summaries—a form of decision aid intended to facilitate shared decision making between patients and their health providers for a number of health care topics—are available in both English and Spanish ().

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Decision Aids and Electronic Medical Records

4. With distribution of decision aids (electronically), does this serve as a way to confirm that a patient "received" shared decision making? If a patient opted for a hard copy version of a tool, how is that tracked?­

   Answers:

   • David Arterburn: The electronic medical record (EMR) serves as a mechanism to track that a patient received a decision aid, but not shared decision making. We document receipt of shared decision making with text from “smart phrases” in Epic. The EMR tracks that a hard copy was delivered, but not whether it was watched.
   • Leigh Simmons/Karen Sepucha: Yes, the ordering of a program generates a note in the EMR, regardless of which method the program is sent (Web link or DVD). At this time, we are able to view whether the Web link is open, but we do not have a consistent method of tracking whether patients watched the DVD or read the booklet.

5. You indicated that you are moving to one EMR. Which EMR will you use?­

   Answers:

   • David Arterburn: At Group Health, we are using Epic.
   • Leigh Simmons/Karen Sepucha: Epic.

6. Are the shared decision aids being ordered and sent to a patient part of a module built into an EMR? What is the average cost for sending patients these videos?­

   Answers:

   • David Arterburn: Yes, we use smart sets in Epic to order decision aids along with other care orders during specific types of care episodes (e.g., decision aids for maternity care at specific weeks of gestation).
   • Leigh Simmons/Karen Sepucha: These order forms are part of a module in our EMR. Sixteen dollars per video.

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Decision Aids for Specific Conditions

7. Use of aids is now required for lung cancer screening. However, there has been pushback from primary care providers who perceive it as burdensome with no clear option for high-risk patients (screen or don't screen). Is there precedent for these types of decisions and how to support their use?­

   Answers:

   • Leigh Simmons/Karen Sepucha: We are developing a system at our hospital for this. Right now, we are thinking about using the Dartmouth print decision aid. . We are also exploring the possibility of group visits to address this.
   • AHRQ: Decision aids for lung cancer screening will be available from AHRQ in the near future. AHRQ’s interactive patient decision aids are available at .

8. Are you aware of any testing of shared decision making for patients with advanced kidney disease—particularly decisions for conservative management vs dialysis?­

   Answers:

   • David Arterburn: Yes. See work by Dr. Ebony Boulware at Duke. She has a decision aid for this.
   • Leigh Simmons/Karen Sepucha: Dr. Ebony Boulware has examined and developed a decision aid for renal replacement therapy selection decisions.  An article about this decision aid may be found at

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Integrating Decision Aids Into Clinical Practice

9. What procedure code is used to report the shared decision making discussion? Have you considered using the tools during shared visits?­

   Answers:

   • David Arterburn: We do not code specifically for this. We have not piloted shared visits for shared decision making.
   • Leigh Simmons/Karen Sepucha: At this time, we do not have a method for coding for the shared decision making discussion, though we will be doing so for the lung cancer screening CT shared decision making visit. Yes, we have considered using the tools in shared medical appointments. We may do so for the lung cancer screening shared decision making visit, more to come on that. We have done group viewings of the programs at our community health center sites during group diabetes education classes; this had variable success depending on the topic (insomnia was a big hit; the advance directives program drew very few viewers).

10. Can Dr. Simmons or Dr. Sepucha speak to how other levels of clinical staff may also be responsible for providing decision aids, i.e., if medical assistants, etc., have standing orders to order some tests or procedures?­

    Answer:

    • Leigh Simmons/Karen Sepucha: Yes. In our primary care practices, our medical assistants have standing orders to do diabetes labs and point-of-care testing for overdue tests. Similarly, we've implemented a process by which medical assistants administered a Patient Health Questionnaire-2 (PHQ-2) with patients who haven't received this within the past year and have a work flow in place in which they automatically administer the Patient Health Questionnaire-9 (PHQ-9) for any patients with a positive screen.

11. Would you please share details about the amount and kind of provider incentives in use? Do you use patient incentives? ­

    Answers:

    • David Arterburn: No specific provider incentives or patient incentives.
    • Leigh Simmons/Karen Sepucha: At present, we don't use any specific provider incentives. At one point we did give an hour of CME credits for all doctors who attended our training sessions but then later found that that didn't really seem to be a strong incentive. They were already coming to the meetings because they were regular practice meetings.

12. How do you distribute information about shared decision making? Is the information included or bundled in all of your decision aids or is it a separate general module sent with each decision aid?

    Answers:

    • Leigh Simmons/Karen Sepucha: The decision aids that we use cover shared decision making and why it is important for patients to have a role. (It’s not separate information.)
    • Lyle Fagnan/Mark Remiker: Like Dr. Sepucha, most of the decision aids that I’ve seen have included some information on the importance of the patients’ role in their health care. Also, we posted the “Ask me 3 questions” flyer from the UK’s MAGIC program in the exam rooms as a way to promote the main tenets of shared decision making ().

13. Does anyone have experience implementing 'encounter tool'-type patient decision aids that are meant to be used during the clinical encounter? If so, can you share some of the barriers and facilitators?

    Answers:

    • David Arterburn: The Mayo clinic has developed some of these tools. See work by Dr. Victor Montori ().
    • Leigh Simmons/Karen Sepucha: We implemented a decision aid that we call "decision worksheet" that is very similar in design to the option grid format from the option grid collaborative (). We posted these on an internal Website at our hospital and also on our external Website ().

    We found in studying these with our residents that these were easy to download from the internal Website. However, studying the effectiveness of these in the office was challenging. Facilitators included making these easy to download; having them on a Website and available for printing was clearly a plus. A barrier was that it was sometimes difficult to predict when a decision might come up in the primary care visit. This made studying the use of the aids challenging.

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Outcomes Associated with Using Shared Decision Making/Decision Aids

14. Do you have data on how the implementation of patient decision aids has impacted the uptake of procedures or costs? ­

    Answers:

    • David Arterburn: Yes. We have published data in Health Affairs and the American Journal of Managed Care (David Arterburn D, author).
    • Leigh Simmons/Karen Sepucha: We are currently studying this in our elective joint replacement and spine surgery practices.

15. Have any of the studies where implementing shared decision making tools were used looked at reduction in cost of care? ­

    Answers:

    • David Arterburn: Yes. We have published data in Health Affairs and American Journal of Managed Care ().
    • Leigh Simmons/Karen Sepucha: Yes, we will refer this question to David Arterburn’s study on joint replacement and decision aids.

16. This effort obviously costs money.  Do you include any kind of information about the expected  impact on internal budgets and total health care costs in your internal communications about the organization's commitment to shared decision making?

    Answers:

    • David Arterburn: At Group Health, we have determined that the shared decision making work is overall cost-saving or cost-neutral.
    • Leigh Simmons/Karen Sepucha: When we can, we estimate the expected impact on the internal budgets and potential for cost savings if redundant or inefficient care is reduced because of the use of decision aids (e.g., patients who realize that they are not truly interested in joint replacement don't schedule an appointment with the orthopedist or an operation and instead engage in a physical therapy program). However, we are still gathering data on the impact of the decision aid in care processes like this preceding example, so it is not easy to make these estimates just yet.

17. I know this is not the focus of today's presentation, but would somebody mind summarizing differences in outcomes, patient satisfaction, and/or cost for people who viewed decision aids versus people who did not?

    Answers:

    • David Arterburn: Yes. We have published data in Health Affairs and the American Journal of Managed Care (Arterburn D, author).
    • Leigh Simmons/Karen Sepucha: The Cochrane review from 2014 nicely summarizes the current data. In brief, when a decision aid is used, patient knowledge about the decision at hand increases, decisional conflict lowers, patients are more actively engaged in the decision making process, and there is a trend toward lower use of an elective invasive operation, hormone replacement therapy, and PSA testing, when a decision aid is used.

18. Is there any evidence that there are improved clinical outcomes or Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS) metrics with patients who received shared decision making tools from the provider groups who included SMD in their workflow?­

    Answers:

    • Lyle Fagnan/Mark Remiker: I am not aware of any studies linking improved CAHPS metrics to shared decision making.
    • Leigh Simmons/Karen Sepucha: We are not aware of studies demonstrating this. We looked at our own data in primary care with the hypothesis that practices that were historically higher-prescribing had higher CAHPS scores but did not see a clear correlation. However, it seems to make sense that over time this would improve the scores, especially if there is a focused effort to provide the aids to all eligible patients. We think that part of the issue with our inability to detect a difference is that a relatively small percentage of patients have been provided with decision aids in our primary care practices, so far.

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Provider Experiences with Shared Decision Making/Decision Aids

19. Have any of the providers reported situations where they attempted shared decision making and the patient insisted on a treatment that the provider did not feel was indicated? What tips do you suggest to help providers handle these situations? ­

    Answers:

    • David Arterburn: If the provider does not feel the treatment is clinically indicated, then the provider can decline to prescribe the treatment or perform the procedure. Acknowledging the patient’s wishes and clearly stating the reason why the provider believes the treatment is not indicated is the best approach.
    • Leigh Simmons/Karen Sepucha: The use of the decision aids can be an excellent starting point for a conversation, even when patients do not feel ready to decide or have a strong opinion against the medically advised options. The most important outcome of the shared decision making process is values and goals clarification, which may help providers gain a perspective on why the patients are selecting the medically less advised options.

20. What percentage of doctors within the 15-18 practices represented actually attended the trainings? Do you feel provider uptake has been significant?­

    Answer:

    • Leigh Simmons/Karen Sepucha: Provider uptake was significant; we saw that over 75 percent of doctors in each practice used the programs. The attendance was high because these were regularly scheduled practice meetings, and most clinicians attended regularly.

21. Can Dr. Simmons or Dr. Sepucha elaborate on how they overcame pushback from providers that incorporating shared decision making would make patient encounters too long?

    Answer:

    • Leigh Simmons/Karen Sepucha: We had them try it out. We also had those who had used the programs give testimonials about how the programs helped their patients understand conditions better. When possible, we’ve aimed to develop systems to promote decision aid delivery before consultation with the goal of streamlining the consultation rather than generating follow-up questions after a visit. This has also been a plus for our doctors. We don't make the case that the decision made will make the visit shorter, but rather emphasized that it should make the visit more effective.

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Provider Training on Shared Decision Making

22. In terms of training in patient-centered communication skills (slide 27), what are your thoughts on the adequacy and/or appropriateness of training in this during graduate education compared with post-graduate (continuing education credits [CEUs], etc.)?

    Answer:

    • David Arterburn: We need more shared decision making training at medical schools and during residency as well as through continuing medical education (CME) for ongoing training of providers.

23. Considering it is a challenge to engage practicing providers in shared decision making, would it be advantageous to implement these procedures in medical schools and residencies?

    Answers:

    • David Arterburn: Yes.
    • Lyle Fagnan/Mark Remiker: I consider shared decision making a core competency.
    • Leigh Simmons/Karen Sepucha: We certainly think so. Our data from our resident training has indicated that in our internal medicine residency program, our interns are quite interested in learning about decision making and using decision aids, and trainees at higher levels of training have not been as enthusiastic about adopting a shared decision-making framework for communication.

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Quality of Decision Aids

24. Describe quality factors in decision aids, other than accuracy, of course. ­

    Answer:

    • AHRQ: The International Patient Decision Aids Standards (IPDAS) collaboration is a group of researchers, practitioners, and stakeholders from around the world that was established in 2003. The group created standards to enhance the quality and effectiveness of patient decision aids by establishing a shared evidence-informed framework with a set of criteria for improving their content, development, implementation, and evaluation. These criteria are helpful to a wide variety of individuals and organizations that use and/or develop patient decision aids. You can learn more about the IPDAS at .

25. Decision aids can increase patient knowledge and perceptions about decisions to be made. What decision aids have been tested to facilitate patient clarification of preference related to options and provide feedback on patient preference to clinicians?­

    Answers:

    • Leigh Simmons/Karen Sepucha: The 2014 Stacey et al. Cochrane review provides some support for the use of decision aids in terms of facilitating patient clarification of their preferences (). For the second part of this question regarding decision aids to facilitate patient communication of their preference to their clinician, try looking at the as different decision aids have different components and some do have worksheets or other ways to give feedback to providers about patients’ goals.
    • Lyle Fagnan/Mark Remiker: The decision aids that we had access to through Healthwise included a section that summarized how the patient responded to all questions in the decision aid (e.g. preferences, concerns, values, etc.). This summary sheet was either given to the primary care provider or put into the patient’s medical record.

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Working with Low Literate/Diverse Populations

26. Dr. David Arterburn: Please discuss challenges and approaches used with low literacy and low English proficiency patients.­

    Answer:

    • David Arterburn: We do not have access to tools in languages other than English, but the video-based decision aids have been shown to help low health literacy populations. They can convey information more effectively than written tools.

27. Are the decision aids available in the form of "pictograms"?

    Answer:

    • David Arterburn: There are helpful figures in the decision aids, but there aren’t tools developed only as pictograms.
    • Leigh Simmons/Karen Sepucha: Yes, some of the decision aids we use are in the form of icon arrays (e.g., the Mayo Statin Choice decision aid is one that we post on our primary care intranet for clinicians to use during the visit).

28. How are language/literacy/cultural issues addressed regarding patient access and education?

    Answer:

    • David Arterburn: We do not have access to tools in languages other than English, but the video-based decision aids have been shown to help low health literacy populations. They can convey information more effectively than written tools.

29. How could a small rural practice access the decision aid videos?

    Answer:

    • Lyle Fagnan/Mark Remiker: A good resource is found at .

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Miscellaneous

30. For Dr. David Arterburn: Do you know how many patients actually used the DVDs/patient decision aids they were sent?

    Did you share the patient decision aids with all patients automatically or did you gauge which patients were interested in the tools before distribution? ­

    Answer:

    • David Arterburn: In one pilot, around 50–60 percent of patients who received a decision aid actually viewed most of the content. We only sent decision aids to patients with the specific health conditions as identified by clinicians or clinical staff.

31. How do you measure competency? Do you do a "pre" and "post" assessment to determine knowledge retained? We have done pre- and post- testing for several conditions (diabetes, PSA, colon cancer screening, hip and knee arthritis) as part of our initial demonstration project. We do not survey all patients who receive programs at this time, but are currently surveying patients who request the depression programs to assess knowledge about the condition and impact of the decision aid.

    Answer:

    • David Arterburn: Yes, we are planning to measure knowledge post decision aid viewing. In pilots, we have assessed pre- and post-knowledge.

32. Thank you for sharing the cautionary tale. Lessons learned are so valuable.

    Answer:

    • Leigh Simmons/Karen Sepucha: We agree! Starting with small pilots can reduce chances of public errors.

33. I believe the Patient Health Questionnaire (PHQ-2) is patented. Is the Partners Healthcare System paying to use the PHQ-2? The systems we work closely with chose to use the PHQ-9 in our EHR to avoid this issue.

    Answer:

    • Leigh Simmons/Karen Sepucha: Good news: All PHQ screeners are free for distribution and use . We have not heard that the PHQ-2 is treated any differently than the PHQ-9 in this regard, and our health system is not paying to use this, to our knowledge.

34. Did anyone see a difference in the PHQ-2 "referral" results if it was offered by a primary care provider versus a medical assistant?

    Answer:

    • Leigh Simmons/Karen Sepucha: No, we have not seen a difference in PHQ-2 results when the survey is delivered by physician versus a medical assistant, and in all of our practices, the positive PHQ-2 results are fairly low (58 percent).

35. Does anyone have experience to share integrating shared decision making for lung cancer screening?

    Answer:

    • Leigh Simmons/Karen Sepucha: We are still working on this one; nothing to report here. The Dartmouth group has a good paper decision aid, and the Michigan group has an online decision aid that we are considering.

36. Thank you so much for this interesting Webinar. Do you think there can be shared decision making without high-quality decision aids?­

    Answers:

    • David Arterburn: Yes. Although the decision aids are excellent facilitators, shared decision making can be done in any setting without decision aids.
    • Lyle Fagnan/Mark Remiker: Yes, decision aids are facilitators. The two most crucial aspects of shared decision making are identifying patient values and preferences and assessing for decisional conflict.
    • Leigh Simmons/Karen Sepucha: Yes, high-quality shared decision making can certainly happen without a decision aid, but it requires a dedication to conducting high-quality shared decision-making conversations and designing care processes that respect the need for placing the patient's preferences and values at the center of the decision-making process.

37. That being said—are your clinicians providing interventions they don't necessarily agree with?

    Answer:

    • Lyle Fagnan/Mark Remiker: Good question. I do not think that physicians will engage in testing and treatment they do not agree with. An example is that physicians will not give antibiotics for a viral URI.

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