Using Information Technology to Evaluate Shared Decision Using Information Technology to Evaluate Shared Decision Making in a Clinical SettingMaking in a Clinical Setting

Stephen KearingStephen Kearing11, Kate Clay, Kate Clay22, Lisa Maheu, Lisa Maheu22, E. Dale Collins, E. Dale Collins33, Caroline Moore, Caroline Moore33, Hilary Llewellyn-Thomas, Hilary Llewellyn-Thomas11,,Annette O’ConnorAnnette O’Connor44, Susan Gallagher, Susan Gallagher55, Kristen Chambers, Kristen Chambers55, and David Aman, and David Aman55

11Center for Evaluative Clinical Sciences, Dartmouth Medical School, Center for Evaluative Clinical Sciences, Dartmouth Medical School, 22Center for Shared Decision Making,Center for Shared Decision Making, 33Comprehensive Breast Program, Dartmouth Hitchcock Medical Center, Comprehensive Breast Program, Dartmouth Hitchcock Medical Center, 44Ottawa Health Research Institute, University of Ottawa,Ottawa Health Research Institute, University of Ottawa, 55BioInformatics, Dartmouth Medical SchoolBioInformatics, Dartmouth Medical School

Background

Conclusions

Using standard software and hardware, the Center for Shared Decision Making currently uses two distinct applications.

1) The CSDM database (CenterWorks) resides on a Microsoft SQL server® and is generic in scope. It captures patients’ demographic characteristics and visit information, decision services provided, stage and preferred role, treatment predispositions, decisional conflict, preparation for decision making, and satisfaction.

2) The Comprehensive Breast Program (CBP) / Center for Shared Decision Making joint project use a web-based system. In this study, longitudinal assessments of medical as well as decision-making data are captured for breast cancer patients. Online processing allows for immediate scoring and automatic interventions for patients scoring above designated thresholds.

Methods

The purpose of the Center for Shared Decision Making (CSDM) at Dartmouth-Hitchcock Medical Center (DHMC) is to provide patients with decision support.

An effective decision support service in a busy clinical setting requires information systems that can meet the unique needs of multiple players:

• The patient/provider dyad needs to record and summarize an individual’s clinical and decisional data.• Clinical staff and researchers need a system that permits rapid aggregation and analysis of cohort data.• The institution that houses the service needs performance measures that can contribute to overall monitoring and quality-assurance.

ObjectiveTo demonstrate the computer-based systems used by the CSDM to address these information management and reporting needs.

The information-system technology for integrating Shared Decision Making and clinical care currently exists. The emergent data can yield valuable insights into the patient decision making process, the clinical skills involved in decision support, and the achievement of performance standards.

The principles used to guide the design and implementation of the CSDM’s electronic information system can be adapted for other clinical shared-decision making initiatives.

1) Generic Decision Support at CSDM

2) Decision Support for Breast Cancer Patient Flow

Positive breast biopsy

Schedule appointments1) decision support2) surgery consult

Patient watches video and completes

questionnaire

Patient Flow

Patients are clinician- or self- referred to the

Center for:

• Decision support• Decision aid (DA)

• Information

After decision support,patients complete

questionnaires about:

Decision ProcessDecision Quality DA Acceptability

Satisfaction Summary reports monitor and evaluate Center performance

System front EndStaff and patients

enter data and access reports through a secure website

Back EndSybase® server

stores clinical anddecision support data

Summary reports track the cohort enrolled in the Breast Program

DHMC Comprehensive Breast Program and Center for Shared Decision Making Integrating Decision Support in Breast Cancer Care Sample Report

Name: Jane Doe Age: 55 MRN: 01601601-6 Married / Not employed Date: 2/17/2005

Referred by: Jones, Robert Other Providers: Smith, Jane

Surgeon: Smith, William / 2/17/2005 Jones, Kim / / appt date N/A Height: 5'5" Weight (lbs): 205 BMI: 34.1 BSA: 2.00

Breast History Left breast cancer dx 2005

Right breast cancer dx No

Palpable lump? No

1st degree relatives with breast cancer: 0

2nd degree relatives with breast cancer: 0

Gyn History History of ovarian cancer? No

Last menstrual period: 2000

Post Menopausal? Yes

Hx of HRT? Yes

Current HRT? No

1st degree relatives w ovarian ca: 0

ROS and Comorbidities per Charlson index* (Score 2/23) Current smoker: no

Drinks: 1/week CAGE Score: 0/4

Positive For

Breast cancer*

Surgical History

Positive For

Appendectomy

Tonsillectomy

C-section

SF-8 mean=50, standard dev=10

203040506070

PF RP BP GH VT SF RE MH PCS MCS

0 0.2 0.4 0.6 0.8 1

Distress Level : moderate : 5.1 / 10 A referral to a breast care coordinator has been made.

Decision Making Preferred role: Share decision with doctor and spouse Leaning toward : Lumpectomy Sure about choice : No Knowledge : Understands :

survival rates recurrence rates appearance after surgery Values :

1-A LittleImportant

2 3 4 5-VeryImportant

May take less timePeace of mind

Recurrence rateOther - Mastectomy

Breast is savedNo prosthesis

Recurrence rateOther-Lumpectomy

Patient reported information, data not verified by health care provider.

Confidential – for internal use only.

Questionnaire is scored immediately

Automatic referrals toBreast Care Coordinator/Familial Cancer Program

when patients score above clinical thresholds

Patient is contacted same day in person

or later by phone

Copy entered into patient

electronic medical record

Financial support for these projects was provided by the Foundation for Informed Medical Decision Making (www.fimdm.org)

Print patient report

Individual reports allow patients to record decision progress

Breast program patient proceeds to surgery consultation with her report

Results

These systems provide -

• feedback of clinical and decision process data in real time at the individual level

• an accessible source of data for research and clinical reporting

System front endStaff enter data and

access reportsfrom securenetwork PCs

Back endSQL server® captures

Patient visit, DA circulation,

Center activity data