Making the Leap to Patient Decision Aid Adoption

Patrice Wendling

August 19, 2019

Clinicians have been slow to get on board with patient decision aids (PDAs) integrated into the electronic health record (EHR), but a new study shows repeated use following an organic roll out and suggests the tools may even make office visits more efficient.

During an 8-year experience, a suite of integrated PDAs was used by 1209 clinicians for 57,116 unique patients. The number of unique uses rose from 2607 in 2010 with the first PDA, a cardiovascular risk tool, to 24,384 uses in 2017. By then, four additional PDAs were available, covering stroke prevention for atrial fibrillation, fracture prevention in osteoporosis, and breast and lung cancer screening.

The likelihood that clinicians would use the tools again increased with each use, beginning at 70.4% after the first use to 96.9% after five uses, according to the researchers, led by Megan Coylewright, MD, MPH, cardiovascular medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.

"Many physicians say we just don't have time for another activity, but what we're suggesting is creating tools that are imbedded into the clinical workflow and actually do some of your work for you, such as calculating mandated risk scores, like the CHADs2VASc, which has to be documented for you to be paid for some therapies for stroke prevention," she told | Medscape Cardiology.

The PDA, called HealthDecision, creates personalized clinical risk estimates by pulling relevant demographics and laboratory information data from a patient's EHR by simply clicking a tab in the computer. The clinician can select various drug or device choices, and, in real-time, share a graphic displaying those choices as colored figures of individuals, so the patient can better visualize their risk. The PDA also can turn text and graphical data into a progress note and generate a printout for the patient to take home, documenting the results of their final shared decision-making.

"By doing that, we're shifting how you allocate your time, allowing you to allocate more time to your patients," Coylewright said. "We're not adding something on, we're making visits more efficient."

For the study, published August 5 in Telemedicine and e-Health , the authors collected data on all iPDA uses at the University of Wisconsin-Madison between February 2010 and December 2017. A total of 333 clinicians also volunteered to participate in an email survey on use of the tool in 2016, of which 32.7% completed the survey.

For the 8-year period, 657 clinicians became adopters, which was defined as use of the tool with at least five unique patients.

In the last 90 days of the study, a review of 261 clinicians (MDs, Dos, and APPs, excluding trainees) listed as current primary care providers, showed 93.5% were aware of the tools, 86.2% were adopters, and 80.5% had used the tool during that time period. Among adopters, mean usage was 227 patients (range, 5 - 1501).

Based on the voluntary survey, 98% of survey responders agreed or strongly agreed that the PDAs helped patients understand the benefits and harms of available options, and 93.5% felt the aids improved the match between the benefits and harms that matter most to the patient and the options that he or she chose.

Three fourths of physicians (73.8%) said they felt visits with a PDA took a similar amount of time, or were more efficient, than usual care. Specifically, 12% of clinicians said the tools save more than 5 minutes in clinic, 28% said it saves 1 to 5 minutes, 34% felt it took about the same time as using no tool, 25% said the tool costs 1 to 5 minutes, and 1% said it costs more than 5 minutes.

Although patients were not interviewed, they were involved in the design and testing of the tool, which was created in 2010 by cardiologist and co-author Jon Keevil, MD, University of Wisconsin-Madison, Coylewright said.

"In general, I can tell you most clinicians understand that patients, and this has been proven in other studies, patients want more engagement in clinical encounters than they are getting," she said. "So they love tools like this."

Reached for comment, Daniel Matlock, MD, MPH, University of Colorado School of Medicine in Aurora, said, "What they've done in the decision-aid world is pretty innovative. The key thing I think that's hard to do is to link it to the electronic medical record and have it populate the tool directly and the amount of barriers they had to overcome to make that happen is pretty impressive. So my initial reaction was, 'Wow, that's great.' "

Commenting further, he said, "The big thing that they've done is that they're not just designing for patients but for physicians, too. I think one of the failures of early decision aids is they focused on patient needs, and that's why most of them are sitting on shelves. So if you design one that's also friendly to physicians, then all of a sudden you've crossed that threshold of making something that's adoptable, and I think with this tool, they've done that."

Matlock, who has created his own patient decision aid that incorporates video, noted that one of the more compelling findings is the issue of time saving with the tools. Limitations of the study are its size and that it is somewhat of a pilot study.

The study had no outside funding. Coylewright reported honoraria from Boston Scientific, Edwards LifeSciences, and W.C. Gore. Keevil is the founder of HealthDecision Inc. The remaining co-authors have disclosed no relevant financial relationships.

Telemed J E Health. Published online August 5, 2019. Abstract

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