Health IT lags as facilitator in shared decision-making
■ Many primary care practices lack the technology to get decision-making aids to the right patient at the right time and follow the process to the end.
One of the many things encouraged by the Affordable Care Act is shared decision-making, in which a doctor and patient collaborate to use the best medical evidence to choose a path of treatment.
The theory is that moving away from a “one size fits all” course of treatment will be better for all concerned. Backers of the idea hoped that health information technology would make it easier for physicians to identify patients who would benefit from shared decision-making, and get them the information they need to make informed choices.
However, a RAND Corp. study in the February issue of Health Affairs found that health information technology still wasn't adequate to help patients at eight locations participating in a shared decision-making demonstration project. Although the study encompassed work done in 2009, in many cases electronic health records systems still don't have the capabilities to help doctors and patients in shared decision-making. This also doesn't address two other barriers RAND identified: overworked doctors and a lack of sufficient physician training for such a process.
The RAND study's conclusions were based on looking at participants in a project by the Boston-based Informed Medical Decisions Foundation: Dartmouth-Hitchcock Medical Center in New Hampshire, MaineHealth, Massachusetts General Hospital, Mercy Clinics in Iowa, the Oregon Rural Practice–based Research Network, the Palo Alto Medical Foundation in California, the Stillwater Medical Group in Minnesota and the University of North Carolina at Chapel Hill.
A decision-making prescription
Some EHR systems allow physicians to “prescribe” decision aids in the same way they would prescribe medications. But the systems in the demonstration project were not set up to alert physicians to when a patient is a good candidate for a decision-making aid, said lead author Mark Friedberg, natural scientist at the RAND Corp. in Boston.
A decision-making aid explains a patient's choices, risks and benefits. It might be an electronic aid or it could be a brochure, a DVD or a handout.
Friedberg said that without alerts telling the physician which patient might be a candidate for shared decision-making, it's up to the physician to remember to prescribe that aid. “And that's pretty tough for primary care physicians to do, because so many things get jammed into that short period of time during that visit,” he said. Friedberg also said the systems have no way of tracking each step of the decision-making process, or whether the final outcome was in accordance with the patient's preferences.
Some health systems are designing shared decision-support systems on their own. The Dartmouth-Hitchcock Medical Center has had a shared decision-making environment as well as advanced health IT systems in place for some time, said Sue Berg, director of Dartmouth's Center for Shared Decision Making. It is working on aligning the technology with shared decision-making, thanks to a $26 million grant from the Center for Medicare & Medicaid Innovation. Jefferson's Kimmel Cancer Center at Thomas Jefferson University in Philadelphia also is building its own shared decision-making IT system.
Both organizations said building these capabilities is a slow, deliberate process. However, they said some of the work-arounds they employed, or continue to employ, as those systems get up and running are processes that many medical practices with EHRs could adopt to build a patient-centered environment. They include:
Using population and scheduling tools to identify shared decision-making candidates. Berg said a few of Dartmouth's departments have automated systems that will send alerts to the Center for Shared Decision Making when patients make appointments for particular consultations or if they meet certain demographics. The same process takes place in Dartmouth's breast care center, but it's not automated. The schedulers call or email the Center for Shared Decision Making to alert them to patients who need decision aids. A physician practice could implement a similar system by training schedulers on appropriate decision aids to be sent to certain patients.
Most EHR systems have the ability to query patients who meet a certain criterion, such as women older than 40 (who may consider a mammogram) or men older than 50 (who may consider a PSA screening).
Creating feedback loops. When a patient has received a decision aid, it's critical for the decision-making process to be “mediated,” said Ronald Myers, PhD, director of the Division of Population Science at Jefferson's Kimmel Cancer Center. Myers said that although patient portals can be a good place for information to be disseminated to patients, “the process is something not best passed on for the patient to do alone.” At the Kimmel Cancer Center, when a patient is given a decision aid, a nurse goes through a questionnaire with him or her and the results are input into an EHR.
“There has to be a feedback loop,” said Raj Toleti, president of care co-ordination solutions at PatientPoint, a provider of patient engagement and care coordination tools. Creating the loop often is difficult for small medical practices that do not have the manpower to call and follow up with patients on a regular basis. PatientPoint does that for the physician. (See correction)
Pradeep Vangala, MD, an internist at Orlando Internal Medicine in Florida, said PatientPoint reports back to him the conversations between PatientPoint and his patients. Without an alert or dashboard-type system, he said he would need to be reminded to look through the patient record for details of the conversations. (See correction)
Many practices are creating the feedback loop by using secure messaging systems in their patient portals, said Letha Fisher, vice president of consulting services for the Virginia HIT Regional Extension Center. They also can use the free-text feature in their EHR's clinical notes to remind them of when they gave a patient a decision aid and track subsequent discussions. But again, they would have to remember to look for those notes on subsequent visits.
The authors of the Health Affairs study said shared decision-making “may be an especially promising way to improve quality while avoiding unwanted and costly medical interventions.” As more physicians enter shared-savings programs and accountable care organizations, the incentives to reduce costs while putting patients at the center of every decision will continue to grow. But it's unclear whether health IT vendors will have their own incentives to make systems capable of facilitating shared decision-making, or whether these capabilities could be required under meaningful use certification.
Fisher said medical practices shouldn't wait for mandates. They should be talking to their vendors about what their systems are capable of and what their plans are for added functionality.