Identifying and Overcoming Barriers to Implementation of Shared Decision Making and Decision Aids

1. 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 • Methods • 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 • Introduction • 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. • 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. 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. 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 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