Do what you can, with what you have, where you are. ~ Theodore Roosevelt
In the November 28, 2022 post, I suggested that finding a way to help clinicians and patients become better decision makers could foster implementation of shared decision making in clinical practice. In addition I believe it would also increase the overall quality of healthcare.
A number of strategies have been proposed to help people make better choices when faced with a complex decision. All advocate simplifying the decision-making process by breaking it down into a series of smaller, simpler steps. [1] The decision quality chain, developed by the Strategic Decisions Group, is one of the best developed of these strategies. [2,3] A slightly modified version, changed to show a common clinical decision sequence, is shown in the figure below:
At this point it is worth noting that clinical encounters typically involve many decisions. To be successful, a clinical decision support method also has to include a way to identify and focus on decisions that require particular attention because they have potentially significant impacts on patient well-being, risks, or costs.
Developing a clinical decision-making support system
Now let’s examine how we could convert the decision quality chain into a practical clinical decision support method.
I’ve previously reviewed the article by Helen Wu and colleagues that identified the three decision making principles, six design features, and two implementation strategies listed below that are shared by decision support systems successfully implemented in non-medical settings. [4] (See the October 4, 2022 post.)
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 features
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.
Proposed principles for creating a successful clinical decision support system
Combining the findings by Wu and colleagues with the decision making process described in the decision quality chain results in a set of principles for creating a practical clinical decision support system designed to promote good clinical decisions:
A. Clinical Decision Quality Assessment:
Helpful Frame: A mechanism to clearly define and map the nature and scope of a clinical decision regarding diagnosis or treatment of a patient’s problem.
Clear Values: Inclusion of all important decision-related objectives.
Alternatives: Identification of a full set of options that could be used to manage the patient’s problem.
Useful information: Ready access to an accurate, trustworthy summary of current evidence in a format designed to support clinical decision making.
Sound reasoning: A process designed to compare alternatives relative to decision objectives, minimize the adverse effects of cognitive biases, cope with decision-related uncertainties, facilitate needed tradeoffs between decision objectives, and allow patients and clinicians (and other appropriate parties) to discuss each other’s decision-related preferences and priorities.
Commitment to follow through: Willingness of both patient and provider to implement the chosen alternative.
B: Integrating a clinical decision support system into routine clinical practice:
Guidelines for determining significant decisions requiring careful deliberation.
A simple but effective procedure to identify important considerations from the patient’s point of view.
A simple but effective procedure patients and providers can use to assess and compare their decision priorities.
A simple but effective procedure patients and providers can use to evaluate the decision options and compare the evaluations.
A procedure that is accepted by clinicians as feasible, worthwhile, and trustworthy.
A procedure that is accepted by patients as worthwhile and trustworthy.
A mechanism for recording the decision making process, documenting it in the medical record, and making it available to revisit in the future if desired.
Inclusion of assessment of decision quality in routine quality assurance activities.
Initial and ongoing decision making education for providers and patients.
Musings
Is developing this system feasible? Yes. The necessary methods and resources are currently available.
If implemented, would this proposal work? I don’t know. But there is a good chance it might since it is based on methods that have proven to be effective in other areas.
Is this business as usual? No. Adopting this proposal means accepting that the decision sciences have a place at the table of medical sciences along with anatomy, pathology, physiology, pharmacology and all the rest. However, since one of the basic acts of medical practice is making decisions, I think it is time to make better use of the knowledge that is available that can improve the quality of healthcare.
Clearly this is just a general outline. I will try to fill in some of the gaps in future posts. Comments, suggestions, and questions are welcome.
References
1. Decision-making. In: Wikipedia [Internet]. 2022 [cited 2022 Nov 16]. Available from: https://en.wikipedia.org/w/index.php?title=Decision-making&oldid=1122078473
2. Decision Quality Defined | Strategic Decisions Group [Internet]. SDG. [cited 2022 Dec 1]. Available from: https://sdg.com/thought-leadership/decision-quality-defined/
3. Decision Quality: Value Creation from Better Business Decisions | Wiley [Internet]. Wiley.com. [cited 2022 Dec 1]. Available from: https://www.wiley.com/en-us/Decision+Quality%3A+Value+Creation+from+Better+Business+Decisions-p-9781119144670
4. 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.