MGH Uses Shared Decision Making to Advance Quality and Experience of Care

Added on Apr 20, 2017

​MGH Uses Shared Decision Making to Advance Quality and Experience of Care
By Audrey Doyle
Industry Edge April 2017

When it comes to choosing health care, the best decision is an informed decision. Since 2005, physicians at Massachusetts General Hospital in Boston have been helping patients make the best decisions regarding their care through shared decision making, a process in which patients are informed of their available treatment or screening options and the benefits, harms and risks of each, and then collaborate with their physicians to choose the option that best reflects current clinical evidence and their own values, preferences and goals.

Shared decision making provides MGH’s patients with myriad benefits, chief among them improved quality and experience of care, according to Karen Sepucha, director of the Health Decision Sciences Center (HDSC). A group within MGH’s Division of General Internal Medicine, the HDSC researches ways to improve the quality of decisions made by patients and physicians about medical tests and treatment.

“Discussing their options also helps our patients build a trusting relationship with their physicians,” Sepucha said. “And it gives them more realistic expectations about what will work best for them.”

Decision Aids Guide Physician-Patient Conversations

Shared decision making is broadly recognized today as being integral to advancing patient engagement and patient- and family-centered care. This collaborative approach is appropriate for any health decision in which there’s more than one medically reasonable option, none of the options has a distinct advantage in terms of health outcome and each of them has pros and cons that patients may value differently. Importantly, shared decision making shouldn’t be used when there’s one clear path or one strong recommendation for treatment.

Key components of shared decision making are decision aids—health-condition-specific brochures, DVDs and Web-based resources that present patients with their treatment options and expected outcomes. MGH, part of the Partners HealthCare hospital and physician network, has been formally integrating decision aids into routine care since the 2005 launch of its Shared Decision Making Program, one of the first such programs in the country, according to Sepucha.

Initially, the decision aids were “prescribed” to patients by physicians at only one of MGH’s primary care practices as part of the patients’ treatment plans; the physicians placed orders for the decision aids through the practice’s electronic medical record. Over time, the HDSC team worked on initiatives designed to increase the use of decision aids at MGH. For example, Sepucha and Dr. Leigh Simmons, HDSC medical director, worked with the hospital’s orthopedic surgeons and information technology staff to develop automatic prompts for primary care physicians to send a decision aid at the time of referral to a specialist for patients considering surgery for low back pain or hip or knee osteoarthritis. They also worked with primary care practices at MGH to use their disease registries to provide decision aids to patients newly diagnosed with diabetes.

Today, shared decision making conversations and decision aids are offered to patients at all 18 of MGH’s adult primary care practices, as well as its specialty practices in orthopedics, oncology, cardiology, men’s health, geriatrics, mental health and obstetrics-gynecology. In addition to being prescribed by physicians, the decision aids can be ordered by MGH health educators and staff, as well as by patients who want to learn more about their options for treating a particular condition. When an order is placed, a note is automatically put in the patient’s chart and the order is fulfilled by HDSC team members.

MGH uses approximately 40 different decision aids, some focused on cancer screening and others geared toward those contemplating elective surgery. Most of the decision aids have a video component and include interviews with patients who have chosen different treatments, as well as with physicians. According to Sepucha, the video component of the decision aids is particularly helpful in setting realistic expectations for patients contemplating surgery. “In the videos, people talk honestly about their experiences—what the procedure was like, what their recovery was like and what impact the surgery had on their symptoms,” she said.

Another type of decision aid used at MGH is decision worksheets. Developed by the HDSC team, the worksheets are intended to be used during consultations to guide discussion and elicit patient preferences, values and concerns.

For example, the Blood Sugar Medications Worksheet includes different medication options for lowering blood sugar in patients with diabetes, along with the benefits and side effects, administration instructions, and requirements for testing blood sugar for each medication. Based on that information, the patient circles the option(s) they prefer and notes on the worksheet what’s most important to them, and they and their physician make a decision. The physician notes on the worksheet which treatment option was chosen (or no treatment, if that’s the case) and next steps for monitoring and follow-up. In addition to diabetes, worksheets are available for depression, high blood pressure, high cholesterol and acute low back pain, among other conditions.

Training Reinforces Shared Decision Making Culture

According to Dr. Simmons, strong support from MGH’s clinical and administrative leaders has played an integral role in establishing a culture that’s receptive to shared decision making. To continue reinforcing that culture, and to ensure that shared decision making conversations are conducted correctly, the HDSC offers training sessions for all clinicians, physicians, nurses, residents and medical students. The one-hour sessions explain the benefits of shared decision making, as well as best practices for using decision aids and worksheets and communicating treatment risks without confusing patients.

Another topic covered in the sessions is how best to elicit patients’ goals and preferences. “This is very important, so we focus on how to authentically explore with patients what their values and preferences are and how they feel about the different options—for example, asking ‘What is your biggest concern regarding your condition?’ ‘Why are you interested in the option you chose and what do you like most about it?’ ‘What don’t you like about the other options?’” said Sepucha. “We want physicians to discover what’s motivating their patients and make sure they’re on a path that will help them achieve their goals.”

Because shared decision making and the use of decision aids isn’t mandatory at MGH, the sessions also emphasize to physicians that they should feel comfortable with the treatment options they’re presenting to patients and be amenable to helping patients follow through on whatever option they choose.

“Physicians who use decision aids must be open to the idea that patients may lean toward a treatment plan that is not necessarily what the physician would have chosen, because it’s the patient who’s going to have to go through with the treatment, adhere to it and live with the consequences,” Dr. Simmons said. “This means physicians have to acknowledge any biases they may have about the options being presented and accept that what matters to the patient in terms of benefits and harms may be different from what matters to the physician.”

Some training sessions are customized for advanced users so that they can build on their existing skills. In addition, the HDSC team recently added simulated physician-patient interactions to the available training options. The simulated interactions are audiotaped and reviewed by HDSC staff, who then provide feedback on the shared decision making skills that the clinicians are doing well and where there are opportunities for improvement. The team also is developing training sessions to help physicians have shared decision making conversations about decisions such as cancer screening and medications with patients nearing the end of life. “These conversations are about whether testing and treatment should continue given the patient’s preferences and life expectancy; we want to do things that make sense for the individual patient,” said Dr. Simmons.

The HDSC team continually evaluates the training sessions and the practice of shared decision making through in-house surveys and in more formal research studies. “Generally, the physicians have given us positive feedback,” Dr. Simmons said, referencing one survey in which 86% of the 120 respondents rated their training session as useful or very useful and 88% said they’d make changes to their practices based on the session, and another in which 78% of the 179 respondents felt decision aids had definitely improved the quality of the care they provide and 65% felt they had changed their discussions with patients.

However, some physicians also have expressed concerns regarding shared decision making, the top two being that they feel patients don’t want to be involved in their health care decisions and that it’s impractical to incorporate shared decision making into an already time-constrained patient visit. To allay concerns regarding the first issue, Dr. Simmons cites patient feedback saying how useful the conversations and decision aids were in helping them choose a treatment or test that was right for them. “We have internal data that show patients are extremely satisfied with the decision aids and that they strongly recommend that other doctors use programs like this,” she said. “And we’ll be analyzing our latest HCAHPS data to look at the correlation between the practices that prescribe the most decision aids and their patient experience outcomes.”

As for the time issue, “we explain that it’s a better use of the patient’s and physician’s time at the visit because both parties have all the information they need to choose an option that represents what the doctor supports and the patient feels is right for them,” Dr. Simmons said.

Dr. Simmons added that the extent to which the Shared Decision Making Program influences the delivery of patient-centered care also is continually evaluated. For example, at press time the HDSC team and the MGH orthopedic group were in the midst of a formal study comparing the effectiveness of two different decision aids for hip and knee replacement surgery. The objective is to better understand the role that decision aids delivered at the point of care have on patients’ expectations, health outcomes and use of services.

An Essential Element of Care

During the first decade of the Shared Decision Making Program, more than 900 clinicians and other staff members across MGH participated in shared decision making conversations with patients and placed more than 28,000 orders for decision aids. Now in its 12th year, the program remains integral to improved quality and experience of care at MGH, and its use has been extended across other Partners HealthCare–affiliated hospitals and practices.

“Shared decision making will continue to be an essential element of care here,” said Dr. Simmons. “By informing patients of their treatment options and ensuring that they’re meaningfully involved in decision making, we’re providing treatment that matches their goals.”

“And this is enabling us to achieve our goal,” Sepucha concluded: “To ensure that the right patient is matched with the right treatment at the right time, every time.”