Decision support for shared decision making
Learning from other people is what music is all about. Neil Young
In past posts I’ve discussed the problem that, although shared clinical decision making (SDM) is widely recommended, it is not frequently practiced.
The medical world, or at least those interested in promoting patient-centered care through appropriate use of shared decision making, seems to have no viable solution to this problem. As far as I have been able to tell, the most common response has been to create and publish an outline of the steps involved in making a shared decision. There are also a small number of educational resources available for clinicians. Most, if not all, of these approaches seem to be primarily derived from concepts traditionally used to guide medical care and medical practice.
What would happen if we took another look at what needs to be accomplished to do shared decision making in clinical settings and how it could be done?
Let’s start with three premises:
Premise 1: Lessons can be learned from existing, successful efforts to move knowledge into practice, in contexts similar to medical practice/health care.
Premise 2: SDM is a form of decision making. Methods to implement SDM in clinical settings can be considered a form of clinical decision support.
Premise 3: Therefore dissemination of SDM into practice should be facilitated by methods used to successfully implement decision support systems in similar contexts.
In 2012 Helen Wu and colleagues published an article called “Advancing clinical decision support using lessons from outside of healthcare: an interdisciplinary systematic review”. (1) The goal of the article was to identify system design characteristics that have resulted in successful decision support systems in non-medical settings that could be used to develop new and improved clinical decision support systems.
Wu and colleagues identified three decision making principles, six categories of design features, and two implementation strategies that characterized successful decision support system designs:
Decision making principles
1) The system should draw on the strengths of both rational-analytic and naturalistic-intuitive decision making styles while minimizing their respective weaknesses.
2) The system should use a robust, flexible approach that addresses multiple criteria and possibilities.
3) The system should provide an “appropriate level of trust” in its methods and recommendations.
Design factor categories
1. The system should provide broad, top level perspectives to help users understand the full extent and scope of the decision being considered.
2. The system should be readily adaptable to meet the needs of the intended users in different settings.
3. The underlying methods used to analyze data and generate recommendations must be transparent and deemed trustworthy by intended users.
4. Data and other system-related information should be effectively organized and clearly presented to avoid information overload.
5. Systems should allow users to examine multiple scenarios and options simultaneously to facilitate the optimal use of both rational-analytic and naturalistic-intuitive decision making processes.
6. Systems should promote rapid collaboration among decision makers and facilitate access to an appropriate range of expertise to support good decision making.
Implementation strategies
1) Systems should be regularly evaluated and improved.
2) Effective user training is imperative.
As a simple thought experiment I decided to see how well current shared decision making methods have incorporated the lessons for successful decision support systems summarized by Wu and colleagues. To test the idea, I made a series of rough, subjective ratings on a scale from 1 (weak) to 5 (strong) based on my recent series of blog posts about shared decision making methods.
Here is the result:
Musings
Currently, it seems to me that shared decision making is generally considered as a task for individual clinicians. Implementation, therefore, is dependent on the skills individual clinicians possess, their interest in engaging patients in decision making, and how well they are able to engage patients in meaningful shared decision making within the constraints of the system in which they practice.
An alternative is to consider shared decision making as a system-based task and implement shared decision making support systems in practice settings incorporating the lessons learned from other areas so well summarized by Wu and her colleagues. Given the growing need to make routine shared decision making an accepted part of clinical practice, I think this approach is well worth a try.
Reference
1. Wu HW, Davis PK, Bell DS. Advancing clinical decision support using lessons from outside of healthcare: an interdisciplinary systematic review. BMC Medical Informatics And Decision Making. 2012;12(1):1–10.