Driven by federal incentive programs and a growing body of research, providers are ramping up attempts to engage patients and promote shared decisionmaking. But those efforts could face significant obstacles, hindering one of the central tenets of the healthcare reform law.
The overarching goal of such programs, said Dr. Nan Cochran, a primary-care physician and associate professor of medicine at Dartmouth University, Hanover, N.H., is to provide patients with the best tools and information so they can make decisions that align with their own preferences and priorities. Many experts also believe that shared decisionmaking can lead to lower utilization of services and a possible antidote to ballooning healthcare costs.
Cochran cited a wide range of decision aids that physicians can provide to patients, including explanatory DVDs, paper-based health information and online risk calculators.
For instance, when treating women with the bone disease osteoporosis, Cochran uses a calculator to explain each patient's individualized risk of fracture based on family history, age, alcohol use and other variables, and then to show how much that risk will be reduced by medication.
“We want to make sure they're making an informed decision,” she said.
Despite the ever-increasing focus on including patients in care—2013 has been referred to by many as the “year of patient engagement”—expense, physician acceptance, training and workflow still present thorny challenges, Cochran said.
“The data has shown us that physicians do a notoriously bad job of predicting patients' preferences on their own,” she said. “Unfortunately, though, doctors have not been trained to respect patients' autonomy as much as they should. That requires real culture change.”
Patient engagement is a cornerstone of the federal government's Medicare and Medicaid electronic health-record incentive program. The program's Stage 2 meaningful-use requirements, set to go into effect in October for hospitals and in January 2014 for physicians, require providers to communicate with patients using electronic messaging and provide them with timely access to health information. Patient engagement and shared decisionmaking are also emphasized in other federal programs, including the Medicare Shared Savings Program.
Those programs will provide a much needed nudge, Cochran predicted, as will a September 2012 study from Seattle-based Group Health Cooperative, which showed that decision aids could reduce elective surgery rates and hold down costs.
Dr. Richard Wexler, chief medical officer of the Informed Medical Decisions Foundation, Boston, contends that financial incentives will probably need to be much more explicitly tied to shared decisionmaking, however, in order to effect real change.
“It's very hard to get shelf space for this because physicians have so many competing opportunities to do good things related to improvement,” Wexler said. “Unless we realign incentives to highlight shared decisionmaking and attach some real financial importance to it, I think we'll have trouble competing with the other things that are rewarded in our system.”
Wexler is taking a wait-and-see approach to the EHR incentive program, particularly until the Stage 3 criteria are unveiled. “If meaningful use gets us there, that will be a very significant step,” he said.
Office visits may be short, but physicians can be successful if they are equipped with the right decision aids and training, said Dr. Victor Montori, director of the Health Care Delivery Research Program in the Mayo Clinic Center for the Science of Health Care Delivery, Rochester, Minn. A leader in the field of patient engagement, Montori has developed and evaluated such aids for nearly a decade, making them available free of charge through the Mayo Clinic Shared Decision Making National Resource Center.
“When properly supported by point-of-care tools, we find clinicians are able to do this fairly painlessly,” Montori said in an e-mail. “We have done successful work now in the emergency department, so the issue of time can clearly be overcome.”
Physicians who embrace shared decisionmaking need to do so because they believe in patient empowerment and not because they expect a financial carrot, he added.
“If an organization engages in shared decisionmaking to look good, make more money, save money or improve outcomes, they may be disappointed,” he said in the e-mail. “Shared decisionmaking is a manifestation of your commitment to the patient.”
Even if the “it's the right thing to do” argument resonates with physicians, integrating a new tool or process into their workflow can present a significant hurdle, said Dr. Glyn Elwyn, a visiting professor and senior scientist at the Dartmouth Center for Health Care Delivery Science. Elwyn and his colleagues have been working on one-page aids called option grids, which briefly review common questions and compare treatments.
The option grids, also available free of charge, cover diseases and conditions such as breast cancer, Crohn's disease and sciatica, with more tools coming soon for angina, carpal tunnel syndrome and others, he said.
Like Wexler, of the Informed Medical Decisions Foundation, Elwyn says the current financial incentive framework is not well aligned with shared decisionmaking. Even so, he said, clinicians' interest is booming.
“I've never seen demand like this, and that tells me something.”