1. Helping patient with choices in preference-sensitive care March 3, 2011 | Matt Handley MD Shared Decision Making at Group Health

2. The History Legislation in 2008 leads to a statewide collaborative Commitment to systematic implementation within the group practice at GHC in 2009 ◦ Aligned leadership ◦ Incorporation into evolving standard work in specialty

3. Evidence for using decision aids Increased knowledge More active patient participation Better alignment between values & choices 34 randomized controlled trials Lower surgery rates No evidence of harms from not having surgery 7 RCTs Higher patient knowledge & satisfaction Lower surgery rates with similar outcomes 2 Group Health studies

4. Patient-centered care at Group Health Shared electronic medical record Medical home pilot Decision aids for shared decision making2005 2007 2009 Implementation timeline

5. Implementation Case for change with specialty leadership ◦ Variable uptake over time Distribution of decision aids ◦ Integration into EMR as an orderable activity – triggers mailing of DVD to home ◦ Tools in EMR to link to streaming decision aids on MyGroupHealth Incorporation into evolving standard work in specialty

6. Providers can order through Epic

7. Distributing decision aids DVDs can be ordered for mailing or viewed on the Web

8. Treatment choices in 6 specialty areas Orthopedics Cardiology Urology Women’s health Breast cancer Back care 1 2 3 4 5 6

9. 12 preference-sensitive conditions OrthopedicsCardiologyUrology Women’s Health Breast Cancer Back Care 1.Hip osteoarthritis 2.Knee osteoarthritis 3.Coronary artery disease 4.Benign prostatic hyperplasia 5.Prostate cancer 6.Uterine fibroids 7.Abnormal uterine bleeding 8.Early stage 9.Ductal carcinoma in situ 10.Breast reconstruction 11.Spinal stenosis 12.Herniated disc

10. Evaluation Ordering & viewing Provider interviews Patient survey link link

11. Decision aid distribution Number of videos distributed, by month Total: 8,808* *As of 12/31/2010; does not include decision aids viewed on the web after Oct 2009 JanAprJulOctJanAprJulOct 20092010

12. 20092010 Percentage of procedures for preference sensitive conditions where patient did not receive the video Fewer missed opportunities

13. Patient assessment Overall rating of decision aid videos Patient survey, March 2010, 400 responses Helped you understand the treatment choices Helped you prepare to talk with provider

14. Patient assessment Overall rating of decision aid videos Patient survey, March 2010, 400 responses How important is it that providers make programs like this available?

15. Rating of decision aid videos, by topic March 2010 Patient assessment

16. First year results Aiming for publication this year, so we are not sharing numbers Impact has led us to deepen our commitment to SDM

17. Next steps Development of our surgical group’s skills in facilitating SDM conversation ◦ Training in May, co-developed with FIMDM Engagement with back care, general surgery Feedback of information about defects (patients receiving surgery without exposure to the decision aid)

18. What are we Relearning? Implementation is not a binary event Technical change (distribution of the decision aids) is much easier than Adaptive change (having very different conversations with patients) We have a great medical group Implementation in our network is dramatically more challenging than within our group practice

19. Questions?