Transcript Identifying and Overcoming Barriers to Implementation of Shared Decision Making and Decision Aids Anne D.

Identifying and Overcoming Barriers to Implementation
of Shared Decision Making and Decision Aids
Anne D. Renz, MPH 1; Judy M. Chang, JD 1; Douglas A. Conrad, PhD, MBA, MHA 1;
Megan A. Morris, PhC, CCC-SLP 1, 2; Carolyn A. Watts, PhD 1, 3
Introduction
Methods
In 2007, the Washington State Legislature passed a
bill mandating a demonstration project to test the
feasibility of implementing shared decision making
(SDM) with the use of patient decision aids (DAs) in
clinical settings.
Methods of identifying barriers and means to overcome
them included:
• Three rounds of key informant interviews with clinical
and operational staff
• Monthly meetings with demonstration sites
• Monthly conference calls with 11 other SDM
demonstration sites across the U.S.
• Synthesis of relevant journal articles, news articles,
and state and federal legislation
Researchers from the University of Washington
obtained funding to facilitate an SDM/DA
demonstration project at three practice sites. As one
of the few states with an SDM demonstration
project, Washington offers important lessons in
implementation and use.
Targeted health conditions varied by practice site.
• Site 1: hip and knee osteoarthritis
• Site 2: ductal carcinoma in situ, early breast cancer
• Site 3: colorectal cancer screening, chronic pain
management, chronic low back pain, diabetes,
depression, and PSA testing
There were eight steps in the implementation
process (see Fig. 1). Throughout the demonstration
project, barriers were identified and means to
overcome the barriers were tested.
Results
Though barriers varied significantly by site, common
themes included:
Organization-level: competing priorities within the
system; capability of electronic medical record systems
Practice-level: patient volume; availability of support
staff; appointment wait times
Time: time to explain the SDM process, distribute DAs,
answer questions, and close the loop
Reimbursement (fee-for-service): limited ability to bill
for DAs, extended office visits, and telephone/online
follow-up; reduced volume of elective procedures
Fig 1: The Foundation for Informed Medical Decision Making’s 8-step implementation process
Conclusions
Shared decision making and the use of decision aids can be implemented in
multi-specialty, fee-for-service systems. Barriers to implementation will vary
by site, but will typically include organization- and practice-level barriers,
time pressures, and reimbursement disincentives.
Barriers can be overcome with key facilitators, including: engaging clinical
and staff champions, planning and revising workflow process maps,
communicating with a network of implementation sites, and building
reminders into electronic medical records. Changes in reimbursement from
volume-based to value-based models may also aid implementation.
Funding Sources
Foundation for Informed Medical
Decision Making & Health Dialog
1) Department of Health Services, University of Washington; 2) Department of Rehabilitation Medicine, University of Washington; 3) Department of Health Administration, Virginia Commonwealth University