A Shared Decision Aid for the Point of Outpatient Care
A Shared Decision Aid for the Point of Outpatient Care
Background and Objective: Computerized decision aids could facilitate shared decision making at the point of outpatient clinical care. The objective of this study was to investigate whether a computerized shared decision aid would be feasible to implement in an inner city clinic by evaluating the current practices in shared decision making, clinicians' use of computers, patients' and clinicians' attitudes and beliefs toward computerized decision aids, and the influence of time on shared decision making.
Methods: Qualitative data analysis of observations and semistructured interviews with patients and clinicians at an inner city outpatient clinic.
Findings: The findings provided an exploratory look at the prevalence of shared decision making and attitudes about health information technology and decision aids. A prominent barrier to clinicians engaging in shared decision making was a lack of perceived patient understanding of medical information. Some patients preferred their clinicians make recommendations for them rather than engage in formal shared decision making. Health information technology was an integral part of the clinic visit and welcomed by most clinicians and patients. Some patients expressed the desire to engage with health information technology such as viewing their medical information on the computer screen with their clinicians. All participants were receptive to the idea of a decision aid integrated within the clinic visit, although some clinicians were concerned about the accuracy of prognostic estimates for complex medical problems.
Implications: We identified several important considerations for the design and implementation of a computerized decision aid including opportunities to: bridge clinician-patient communication about medical information while taking into account individual patients' decision making preferences, complement expert clinician judgment with prognostic estimates, take advantage of patient waiting times, and make tasks involved during the clinic visit more efficient. These findings should be incorporated into the design and implementation of a computerized shared decision aid at an inner city hospital.
A growing body of evidence suggests that decision aids could facilitate shared decision making. Shared decision making is the process whereby patients and clinicians work together to arrive at decisions that are evidence-based and in line with patients' individual values and preferences and is increasingly recognized as the preferred method of healthcare decision making.Although studies have shown that patients may prefer shared decision making, barriers to shared decision making in practice include time constraints and difficulty communicating medical data and options to patients.
Decision aids can help overcome several of these barriers to shared decision making by providing information about outcomes associated with different health care options and translating this information into a language more easily understood by patients. Studies have shown that in addition to increasing patient participation in the decision process, decision aids can increase patient knowledge of their treatment options, the risks associated with different options, and increase patient satisfaction with decision making.
Decision aids can be used by either patients or clinicians, or can be designed for shared decision making by patients together with their clinicians. For such a shared decision aid to be feasible for use in outpatient clinical care, it must be integrated within the current clinic visit and workflow.
Computerized decision aids have been shown to be as effective as non-computerized decision aids, and could be more efficient to use at the point of care. Computers and health information technology are an increasingly important part of the outpatient clinic visit and are relied on by clinicians to complete tasks informing medical decision making including data retrieval and entry. Furthermore, "meaningful use" criteria as outlined by the Office of the National Coordinator for Health Information and Technology are linked to the reimbursement of healthcare institutions and are powerful incentives for the continued adoption of health information technologies throughout the United States. Computerized decision aids could be integrated into the clinic visit and facilitate shared decision making, while also meeting meaningful use criteria. However, a computerized decision aid may also present further barriers to shared decision making, for example, if patients or care providers are not receptive to the use of a computer program to assist with decision making. One study of patients receiving primary care through the VA New York Harbor Healthcare System found that some patients perceived computers as distracting their clinicians from paying attention to them and yet another study found that patients viewed doctors who consulted computerized decision support tools less favorably than doctors who made decisions independently or consulted an expert colleague.16 Another potential barrier would be if clinicians felt computerized decision aids act as a barrier to their workflow and throughput, believing that computerized decision aids would increase the time needed for clinic visits.
In this study we sought to better understand whether a computerized decision aid designed to facilitate shared decision making would be acceptable and feasible to implement in an inner city clinic by evaluating the current practices and perceptions of shared decision making, clinicians' use of computers, patient and clinicians' attitudes and beliefs toward computerized decision aids, and the influence of time on shared decision making. This study adopted a qualitative research methodology that focused on understanding the environment, technology and people that comprise the system to inform the design of the proposed technology of a computerized decision aid. Historically, design approaches in health systems have under-utilized approaches from other disciplines that seek to understand the environment to inform design (such as user centered design or workflow evaluation). In these settings, people and their workflows are forced to adapt to systems that may not include their needs. This approach to design can lead to unintended consequences, low adoption of otherwise useful technologies, and sometimes safety problems. We aimed to establish an understanding of the environment, the users, and their skills/abilities/available resources to inform the design before development and implementation. The ethnographic approach described in this study was designed to understand key elements of the sociotechnical system (people, work tasks, and technology) to begin to inform the design of computerized decision support tools.
Abstract and Introduction
Abstract
Background and Objective: Computerized decision aids could facilitate shared decision making at the point of outpatient clinical care. The objective of this study was to investigate whether a computerized shared decision aid would be feasible to implement in an inner city clinic by evaluating the current practices in shared decision making, clinicians' use of computers, patients' and clinicians' attitudes and beliefs toward computerized decision aids, and the influence of time on shared decision making.
Methods: Qualitative data analysis of observations and semistructured interviews with patients and clinicians at an inner city outpatient clinic.
Findings: The findings provided an exploratory look at the prevalence of shared decision making and attitudes about health information technology and decision aids. A prominent barrier to clinicians engaging in shared decision making was a lack of perceived patient understanding of medical information. Some patients preferred their clinicians make recommendations for them rather than engage in formal shared decision making. Health information technology was an integral part of the clinic visit and welcomed by most clinicians and patients. Some patients expressed the desire to engage with health information technology such as viewing their medical information on the computer screen with their clinicians. All participants were receptive to the idea of a decision aid integrated within the clinic visit, although some clinicians were concerned about the accuracy of prognostic estimates for complex medical problems.
Implications: We identified several important considerations for the design and implementation of a computerized decision aid including opportunities to: bridge clinician-patient communication about medical information while taking into account individual patients' decision making preferences, complement expert clinician judgment with prognostic estimates, take advantage of patient waiting times, and make tasks involved during the clinic visit more efficient. These findings should be incorporated into the design and implementation of a computerized shared decision aid at an inner city hospital.
Introduction
A growing body of evidence suggests that decision aids could facilitate shared decision making. Shared decision making is the process whereby patients and clinicians work together to arrive at decisions that are evidence-based and in line with patients' individual values and preferences and is increasingly recognized as the preferred method of healthcare decision making.Although studies have shown that patients may prefer shared decision making, barriers to shared decision making in practice include time constraints and difficulty communicating medical data and options to patients.
Decision aids can help overcome several of these barriers to shared decision making by providing information about outcomes associated with different health care options and translating this information into a language more easily understood by patients. Studies have shown that in addition to increasing patient participation in the decision process, decision aids can increase patient knowledge of their treatment options, the risks associated with different options, and increase patient satisfaction with decision making.
Decision aids can be used by either patients or clinicians, or can be designed for shared decision making by patients together with their clinicians. For such a shared decision aid to be feasible for use in outpatient clinical care, it must be integrated within the current clinic visit and workflow.
Computerized decision aids have been shown to be as effective as non-computerized decision aids, and could be more efficient to use at the point of care. Computers and health information technology are an increasingly important part of the outpatient clinic visit and are relied on by clinicians to complete tasks informing medical decision making including data retrieval and entry. Furthermore, "meaningful use" criteria as outlined by the Office of the National Coordinator for Health Information and Technology are linked to the reimbursement of healthcare institutions and are powerful incentives for the continued adoption of health information technologies throughout the United States. Computerized decision aids could be integrated into the clinic visit and facilitate shared decision making, while also meeting meaningful use criteria. However, a computerized decision aid may also present further barriers to shared decision making, for example, if patients or care providers are not receptive to the use of a computer program to assist with decision making. One study of patients receiving primary care through the VA New York Harbor Healthcare System found that some patients perceived computers as distracting their clinicians from paying attention to them and yet another study found that patients viewed doctors who consulted computerized decision support tools less favorably than doctors who made decisions independently or consulted an expert colleague.16 Another potential barrier would be if clinicians felt computerized decision aids act as a barrier to their workflow and throughput, believing that computerized decision aids would increase the time needed for clinic visits.
In this study we sought to better understand whether a computerized decision aid designed to facilitate shared decision making would be acceptable and feasible to implement in an inner city clinic by evaluating the current practices and perceptions of shared decision making, clinicians' use of computers, patient and clinicians' attitudes and beliefs toward computerized decision aids, and the influence of time on shared decision making. This study adopted a qualitative research methodology that focused on understanding the environment, technology and people that comprise the system to inform the design of the proposed technology of a computerized decision aid. Historically, design approaches in health systems have under-utilized approaches from other disciplines that seek to understand the environment to inform design (such as user centered design or workflow evaluation). In these settings, people and their workflows are forced to adapt to systems that may not include their needs. This approach to design can lead to unintended consequences, low adoption of otherwise useful technologies, and sometimes safety problems. We aimed to establish an understanding of the environment, the users, and their skills/abilities/available resources to inform the design before development and implementation. The ethnographic approach described in this study was designed to understand key elements of the sociotechnical system (people, work tasks, and technology) to begin to inform the design of computerized decision support tools.
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