Collaborative Implementation of
Shared Decision Making State Legislation
Megan Morris, MS
1,2
CCC-SLP ;
Leah Hole-Curry, JD
3;
Douglas Conrad, PhD, MBA,
2
MHA ; Anne
Renz, MPH
2
1 Dept.
of Rehabilitation Medicine, University of Washington, Seattle, WA;
2 Dept. of Health Services, University of Washington, Seattle, WA; 3 Washington State Health Care Authority, Olympia, WA
Abstract
Summary and Current Status of the Project
In 2007, recognizing these benefits, the Washington State Legislature passed a bill
mandating that the Health Care Authority implement an SDM demonstration project
at one or more multi-specialty practice sites. Because the legislation did not include
appropriated funds, the Health Care Authority sought collaborators for the
demonstration. Researchers from the University of Washington obtained funding
from a foundation to facilitate an SDM demonstration. Three practice sites in the
Puget Sound area are currently participating in the project.
National health care reform bill HR 3590 includes a section on SDM that calls for
creating Shared Decision Making Resource Centers and awarding grant funding to
providers for developing, implementing, and assessing SDM and DAs. As one of
the few states with an active SDM demonstration project, Washington State offers
important lessons in collaboration and implementation.
Background on SDM Demonstration Project
• The WA State legislature passed a bill that mandated, but did not fund, the state
HCA to implement decision aid demonstration projects.
Shared decision making (SDM) is a way to make clinical care decisions for specific
medical conditions. There are some conditions for which scientific evidence suggests that
several treatment options provide similar outcomes, but with different side effects, risks,
or courses of disease. The point of SDM is that in these instances, the patients should
play an important role in deciding which treatment to undertake, based on their values and
preferences. Treatment decisions should be shared between patient and provider.
Shared Decision Making Steps
Patient
• Decision aids have been developed for a number of preference-sensitive
conditions, chronic conditions, and screening options.
• Preliminary data about decision aids suggest that they can be used successfully to
increase patient-provider communication and promote shared decision making.
Decision-making Process
• Decision aids are a way to provide patients with information about treatment
options, the risks and benefits associated with each one, and the likely outcomes
and side effects in an easy-to-understand fashion.
Establish the patient’s preferences for each person’s role
in decision-making and who might be involved in the
process
Articulate health problems, feelings, beliefs,
values and expectations
Gather information while attempting to understand the
patient’s perspective in regards to their ideas, concerns,
and expectations
Evaluate the presented information and potential Evaluate the presented information and potential options
options by:
by:
- Listing the pros, cons, and other characteristics
- Listing the pros, cons, and other
characteristics
- Identifying and comparing the possible options
- Identifying and comparing the possible
- Keep in mind patient’s previously established
options
preferences
Negotiate decisions and resolve any conflicts
Negotiate decisions and resolve any conflicts
Frequently check understanding of facts and
perspectives and then provide further
clarification if needed
Decision
finalizing and
implementation
Decision Aids
Find a physician and establish, develop, and
adapt a partnership
Share medical information and evidence relevant to
patient’s medical case and personal values and
expectations
Recognize that a decision can or must be made Recognize that a decision can or must be made in the
in the situation
situation
• In response, HCA convened a Collaborative Stakeholder Group. The group’s
members include representatives from the University of Washington, the Puget
Sound Health Alliance, Group Health Cooperative, and several multispecialty
group practices.
• Representatives from UW secured funding to fund the demonstration project
Physician
Personally define what is required and preferred Establish the patient’s preferences for the amount and
in a physician-patient relationship
format for presented information
Relationship building
Shared Decision Making (SDM) is a collaborative model of patient-provider
communication in which a health care provider and patient jointly consider
treatment options and the patient’s values and preferences. SDM involves multiple
steps to ensure that patients understand the risks and benefits of all treatment
options. Decision aids (DAs) are used to inform patients about treatment options.
Multiple benefits of SDM and DAs have been demonstrated, including improved
patient outcomes and increased patient and provider satisfaction.
What is Shared Decision Making?
Frequently check understanding of facts and
perspectives and then provide further clarification if
needed
Agree on decision and an action plan and create Agree on decision and an action plan and create
arrangements for follow-up
arrangements for follow-up
Authorize the final choice
Implement the agreed upon choice
Implement the agreed upon choice
Complete follow up
Complete follow up
Demonstration sites and conditions of interest
Site
The Everett Clinic
MultiCare Medical Group
Location
Everett
Tacoma
Virginia Mason Medical Center Seattle
Conditions of Interest
- Hip Osteoarthritis
- Knee Osteoarthritis
- Low Back Pain
- Chronic Pain
- Depression
- Diabetes
- PSA Testing
- Colon Cancer Screening
- Ductal Carcinoma In Situ
- Early Stage Breast Cancer
•
•
•
•
•
Benefits of Shared Decision Making
Patients are more invested in their medical care and understand the treatment better, which
leads to better adherence to a medical treatment
Increased understanding of a treatment leads to better self-management and health outcomes
Increased patient satisfaction
Decreased medical costs
Decreased malpractice claims
Start-up: Early steps in the project included obtaining IRB approval, identifying
executive champions and project managers at each site, choosing conditions of
interest, and creating workflow process maps.
Dissemination: Activities include:
1) Developing a website that features information about SDM, project partners
and sponsors, SDM legislation, related resources, and a toolbox containing
templates for many aspects of SDM implementation,
2) Being interviewed for an article about SDM (Harris Meyer, “Power to the
Patient,” Hospitals & Health Networks, February 2010),
3) Hosting a conference for site partners, interested parties, and Foundation
representatives in March 2010
4) Presenting posters at the Washington State Public Health Association’s Joint
Conference on Health and at the Society for Medical Decision Making’s annual
conference.
Monthly Meetings: We hold monthly meetings, sometimes featuring expert guest
speakers, to discuss the demonstration project and SDM generally. Attendees include
representatives from the demonstration sites, the Washington State Health Care
Authority, Group Health, and the Puget Sound Health Alliance.
Decision Aid Distribution: The demonstration sites have distributed a total of 48
decision aids (DAs) and received back 19 surveys. The distribution of decision aids is
as follows:
•
•
•
23 preference-sensitive DAs (early breast cancer, DCIS, hip and knee osteoarthritis)
24 chronic condition DAs (chronic low back pain, chronic pain management, depression,
and diabetes)
1 screening DA (colon cancer screening)
Lessons Learned: We learned the importance of having both executive champions
and project managers, working through competing priorities, and the value of being
part of a network.
Resources
Center for Shared Decision Making (Dartmouth-Hitchcock Medical Center):
www.dhmc.org/shared_decision_making.cfm
Ottawa Patient Decision Aids (OHRI): http://decisionaid.ohri.ca/decaids.html
Washington State (2007) E2S S.B. 5930: Blue Ribbon Commission on Health Care
Costs and Access: http://apps.leg.wa.gov/documents/billdocs/200708/Pdf/Bills/Session%20Law%202007/5930-S2.SL.pdf
Acknowledgements and References
This study is funded in part by the Foundation for Informed Medical Decision Making
(Boston, MA). Partial support is also provided by the National Institutes of Health, National
Institute of Child Health and Human Development, National Center for Medical
Rehabilitation Research (T32HD007424).
1. Edwards, M., Davies, M., & Edwards, A. (2009). What are the external influences on information exchange and shared decisionmaking in healthcare consultations: A meta-synthesis of the literature. Patient Education & Counseling, 75(1), 37-52.
2. Elwyn, G., Edwards, A., Kinnersley, P., & Grol, R. (2000). Shared decision making and the concept of equipoise: the competences
of involving patients in healthcare choices. Br J Gen Pract, 50(460), 892-899.
3. Gravel, K., Legare, F., & Graham, I. D. (2006). Barriers and facilitators to implementing shared decision-making in clinical
practice: a systematic review of health professionals' perceptions. Implement Sci, 1, 16.
4. Makoul, G., & Clayman, M. L. (2006). An integrative model of shared decision making in medical encounters. Patient Educ
Couns, 60(3), 301-312.
5. Mauksch, L. B., Dugdale, D. C., Dodson, S., & Epstein, R. (2008). Relationship, communication, and efficiency in the medical
encounter: creating a clinical model from a literature review. Arch Intern Med, 168(13), 1387-1395.
6. Towle, A., & Godolphin, W. (1999). Framework for teaching and learning informed shared decision making... including
commentary by Greenhalgh T and Gambrill J. BMJ: British Medical Journal, 319(7212), 766-771.
7. Whitney, S. N., Holmes-Rovner, M., Brody, H., Schneider, C., McCullough, L. B., Volk, R. J., et al. (2008). Beyond shared
decision making: an expanded typology of medical decisions. Med Decis Making, 28(5), 699-705.