The case for shared decision making in health care

A 2013 Health Affairs brief provided a helpful framework for thinking about patient engagement. The brief illustrates a continuum of engagement that is driven by the extent to which patients are involved in decisions regarding their health and health care. The first step is to provide patients with basic information about their condition, treatment options, the medical evidence behind treatment options, and the benefits and risks of treatment. The second is for providers to ask patients about their preferences in the treatment plan. The final step involves decision making that stems from a combination of patients' preferences, medical evidence, and clinical judgment. The framework also provides guidance for organizational design and policy making. Here's an overview of the framework:


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Measuring the Results of Engagement

Judith Hibbard of the University of Oregon developed a "patient activation measure" that surveys patients on the degree to which they see themselves as a manager of their health and care. Hibbard and coauthors then studied the relationship between 30,000 patients' activation scores and their healthcare costs at Fairview Health Services, a large healthcare delivery system in Minnesota. The results were interesting:

" ... they found that those with the lowest activation scores, that is, people with the least skills and confidence to actively engage in their own health care, incurred costs that averaged 8 to 21 percent higher than patients with the highest activation levels, even after adjusting for health status and other factors."

Payment reform means that these outcome improvements can improve a health system's bottom line.


Investing to Unlock the Value 

A RAND Corporation study evaluated a three-year demonstration project on shared decision making conducted at eight primary care sites in different parts of the United States. The researchers discovered three barriers to implementing shared decision making:

  1. overworked physicians
  2. insufficient provider training
  3. clinical information systems that failed to track patients throughout the decision-making process

It is no secret that EHRs provide poor patient-facing support tools. (See here, here, and here.) The best of them provide little more than an electronic version of a personal health record with a few administrative tasks thrown in, such as appointment requests and prescription refills. The RAND study goes on to suggest that developing patient engagement capabilities will require health systems to make net new investments (i.e. post EHR). According to the authors:

"In the demonstration practices, the researchers found that electronic medical records lacked ways to store patient-reported values and preferences and to make sure that patients get personalized care."


The Bottom Line

Developing institutional patient engagement capabilities is central to success in today's healthcare environment. We all care about our health. With the proper support, patients will engage. Health systems will have to look beyond their EHRs and invest in new systems in order to succeed. This means moving beyond the old photocopied disease management handouts and tired web-based patient portals and offering patients health management tools that they will actually use.