Shared decision making in the era of digital transformation
Health and care systems are changing rapidly. These changes are in part being driven by the pathway redesign that accompanies digital transformation but there are other significant factors that are being brought into play. Medicine itself is changing, as new diagnostic tools enable greater personalisation of treatment, the number of therapeutic options multiply and digital monitoring of individual patients becomes a reality. People have become more assertive and assured in their expectations of delivery of services in many walks of life, and this consumer revolution is beginning to make its impact in the health and care system. This is facilitated by a democratisation and ready availability of medical information, as a direct result of the digital revolution, as we recently proposed in the HIMSS Insights eBook.
Furthermore, people are now starting to directly access - and in places control - their own health data and this of course empowers them to become even more involved in their own care. While all these developments are positive in that they tend to lead to a more “activated and engaged” patient, there are also some potential downsides. The availability of information is one of the greatest benefits from the use of the internet, though information does not equate to knowledge. The fact that a patient has downloaded every possible article about a condition, from whatever source, does not necessarily mean that they have the ability to sieve through a whole series of often conflicting views and determine optimal pathways of care and therapeutic interventions.
Societal changes are also leading to increased suspicion of formerly authoritative institutions like governments and scientists, which means that "official" information may not be weighed more heavily than emotionally charged anecdotes. The recent decreases in national vaccination rates despite scientific best evidence is a notable illustration of this trend. These factors are affecting health systems globally. Although we inevitably reflect our own health system, we can see similar patterns of behavior in all continents and populations, albeit to differing degrees. These changes presage a new doctor-patient relationship in which the interactions between the two parties are shifting to a new paradigm.
The relationship in the past was relatively unidirectional, with the physician being the only authoritative source of information and the patient being the recipient, expecting to be given instructions on what therapy to take and on how to manage disease. Whilst this relationship had its strengths, it did not always deliver the intended benefits, often because of problems with compliance and adherence, both in terms of prescribed drugs as well as lifestyle modifications.
That should not really come as a surprise, given that in the case of a typical non communicable disease like type two diabetes, the interactions between physicians and patients last no longer than a couple of hours a year, with the patient expected to retain the information and act on it appropriately for the 364 days and 22 hours for which they are left to manage their condition. In this past model the patient was a passive recipient of the decision of the doctor and often was not "bought in" to that decision in the first place.
A PARADIGM SHIFT IN THE PATIENT-DOCTOR RELATIONSHIP
With the digital media now becoming available, the relationship can be both more two-way and more continuous. The ideal is that the patient makes the decision jointly with the doctor, with the necessary validated information about treatment options to hand in a language the patient can understand, and the rationale for the choice of treatment and/ or lifestyle change clear, with aide memoires available for smartphones or on paper. It is not unusual for a patient to request treatment or adoption of a pathway which is not necessarily based on evidence.
This choice of therapeutic intervention can concern both the nature of the treatment and how it should fit within the life of the patient. Modern 21st century care needs to become much more participative and personalised and this is where shared decision making becomes critical. We are now in the age of “evidence based care for one”. This level of buy-in has great advantages as a care plan and treatment that fits well with the patient’s life is much more likely to be followed and thus effective.
After the initial treatment plan is agreed, digital tools can act as digital "extenders" and "monitors" to support the patient as he or she manages their condition away from the doctor’s office. A multitude of apps (over 200,000) are now available of differing quality and complexity, but it is well known that patients often do not persist with their use. The best tools will reinforce what the patient has heard from the doctor and add a dimension of “pull” to the “push” physicians are generating, about optimal ongoing care.
An informed and activated person is far more likely to get involved in their own care and take responsibility for it, rather than leave it all to the “experts”. Elements of "gamification" that add a competitive element to adherence can be effective in some cases, particularly for lifestyle changes such as weight loss or exercise.
EMPOWERING THE PATIENT
The majority of clinicians have embraced the new way of working and altered the style and approach to consultations from a more didactic stance to a genuine partnership. The aspiration is of assisting the patient through the life course rather than telling them what to do, concentrating on giving them the means to make the decisions themselves.
Although this more concordant approach is the basis of modern medical practice, it has its challenges and there still is a gap in medical education around the application of behavioral techniques to deliver better outcomes. There is an urgency to get this addressed. There is also the need for decision support tools that inform the interaction and decision-making from both directions, both patient and health carer, with options and evidence clearly laid out.
In the absence of such tools, patients may request a treatment option where evidence is lacking (or is even strongly negative) because of input from others. This unfortunate situation is sadly starting to occur and it is particularly in such instances that the right consultative approach to a consultation could be a game changer. Just telling patients what to do in these cases rarely yields the optimal results but if physicians are skilled enough in behavioral techniques, utilise their relationship with a patient, and can point to reliable sources that patients can consult and study , there is more likelihood this will steerthe patient to better choices and thus more optimal outcomes.
Standard clinical pathways have their place, but in many diseases we are seeing a shift from a population evidence-based approach to a more personalised approach based on molecular diagnostics or other "precision medicine" tools. This will also result in the patient being both more engaged and participative in treatment. In summary, managing decision making in the digital age requires at least seven key concepts:
• Rebalancing the physician-patient relationship to a more equal footing, moving from the didactic to the partnership approach in terms of style. This is achievable with appropriate physician education and administrative support.
• Encouraging healthcare providers to alter the consultation rate of physicians to allow for more time with patients per consultation. Didactic consultations are easier to deliver to a passive patient whilst a more participative approach requires information exchange, negotiation and debate. The extra time will have a positive return on investment if the patient becomes more involved and engaged in their care, and this is sustained.
• Ensuring that patients’ views and life situation are not only understood but also given appropriate weight. The non-biomedical determinants of outcomes (like employment, financial and domestic situation) also need to be better incorporated in pathway design with appropriate weight. This is no longer a “nice to include”.
Making best use of digital extenders to increase the interaction between physician and patient. The more personalised these extenders are, the more likely they are to be used sustainably and thus produce best outcomes.
• Making the best use of data to produce knowledge for the patient. As we move to an era of personalised or precision medicine, it is more likely that advice will be heeded and acted upon, as it becomes more personalised. “Evidence based medicine for one” will become the norm not the exception.
• Adopting consultation styles based on the principles of behavioral modification techniques. These can be learnt or refreshed and reap immediate benefit.
• Encouraging patients to become activated and more involved in their own care. A more engaged patient with access to their own record is something we should encourage as it is far more likely to result in concordant care.
EMBRACE DIGITAL TRANSFORMATION
There is no doubt this new world is a challenge to traditional hierarchical medicine. Also when health systems seek decreased costs and more "productivity" on the part of professionals, this is in tension (over the short-term) with the need for increasing patient convenience and access, and person-centered care.
But, over the longer-term, properly deployed knowledge can assist the physician in the transition as well as aid the patient in their life’s journey. These changes are being played out globally, albeit unevenly.
Paradoxically, in some places, where there is less of the traditional ‘higher income country’ medical infrastructure to stand in the way, the pace of change around digital transformation is faster. It seems inevitable that soon these higher income countries may well be finding themselves having to play ‘catch up’ unless the digital transformation and democratisation of information is embraced more completely.
This article was first published in the newest issue of the HIMSS Insights eBook, which looks at the digital transformation of healthcare across the globe, and can be accessed here. Charles Alessi is the chief clinical officer of HIMSS International, and Richard Barker is the founding director of Metadvice. Healthcare IT News is a HIMSS Media publication.
Digital Transformation in Healthcare
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