SummaryThe state of Washington has passed multiple pieces of legislation to promote the routine use of shared decisionmaking, a process in which patients and physicians jointly decide on the best course of action based on available evidence and patient preferences and values. Designed to reduce variations in care and improve quality, these laws have mandated implementation of a multisite demonstration project, recognized use of decision aids as evidence of informed consent in malpractice cases, and created a governor-appointed learning collaborative to identify variations in care delivery and evidence-based practices (including shared decisionmaking) for reducing such variations. The state has also proposed legislation to establish a certification process for shared decisionmaking tools. The various legislative initiatives are starting to have an impact on use of shared decisionmaking in care delivery; for example, the demonstration project has identified success factors for and barriers to its routine use, whereas the learning collaborative has begun to establish shared decisionmaking as an evidence-based practice for reducing variations in care.Suggestive: The evidence consists of various accomplishments related to shared decisionmaking achieved by the legislatively mandated demonstration project and learning collaborative.
Developing OrganizationsWashington State Health Care Authority
Use By Other OrganizationsFour other states (Maine, Minnesota, Oregon, and Vermont) have passed legislation to promote use of SDM.
Date First Implemented2007
Problem AddressedPatients with certain conditions (such as early stage breast and prostate cancer and several orthopedic conditions) often have multiple care options, each with its own set of potential benefits and risks or drawbacks. These situations represent ideal candidates for shared decisionmaking (SDM), a proven process in which informed patients and providers collaborate on the right course of action based on the patient's values and preferences. However, in spite of Federal legislation supporting SDM, few states have followed suit, and use of this approach and related tools (such as decision aids) remains rare in everyday practice.
- Multiple potential care options, each with own set of benefits and risks: Patients with certain conditions often have multiple viable options for treatment. For example, patients with early stage breast cancer have similar survival rates and life expectancy whether they choose mastectomy or lumpectomy plus radiation therapy, with each choice having its own set of potential benefits and risks.1 Patients with early stage prostate cancer face a similar array of choices, including surgery, radiation, or “watchful waiting."1 Disagreement also exists as to which patients are appropriate candidates for joint replacement surgery, with the best choice for a given patient often being based on his or her values and preferences related to the procedure's likely benefits and drawbacks.2
- Unrealized potential of SDM: Through SDM, the provider gives information to the patient that facilitates understanding of the possible outcomes and trade-offs associated with various treatment options, and encourages the patient to consider aspects of each option that are personally important and to fully participate in decisions about medical care.3 In a systematic review of 86 randomized trials, the Cochrane Collaborative found that use of decision aids that facilitate SDM enhances patient knowledge of their options and helps patients to have more accurate expectations of possible benefits and harms, reach choices more consistent with their informed values, and participate more in decisionmaking. The same review found that use of decision aids reduces use of elective surgery and appears to have a positive impact on patient-practitioner communication.4 Despite Federal legislation (i.e., the Accountable Care Act) supporting use of SDM, only a handful of states have passed legislation related to this approach,1 and only a few single-site medical centers routinely use SDM for select conditions.5,6
Description of the Innovative ActivityThe state of Washington has passed multiple pieces of legislation to promote the routine use of SDM. Designed to reduce variations in care and improve quality, these laws mandated implementation of a multisite demonstration project, recognized use of decision aids as evidence of informed consent in malpractice cases, and created a governor-appointed learning collaborative to identify variations in care delivery and evidence-based practices (including SDM) to reduce them. The state has also proposed legislation to establish a certification process for SDM tools. Key elements of these legislative initiatives are detailed below:
- Mandated demonstration project: In 2007, the state passed legislation (Washington Senate Bill 5930) mandating that the Washington State Health Care Authority implement an SDM demonstration project at one or more multispecialty practice sites. In response, Health Care Authority officials partnered with University of Washington researchers on a project involving Group Health Cooperative, Virginia Mason Medical Center, and the Everett Clinic. Running from 2009 to 2011, this project sought to understand success factors for and barriers to successful implementation of SDM at medical clinics. Group Health Cooperative had been conducting an observational study on SDM implementation in a variety of specialty areas, and its efforts were folded into this demonstration project; more information about how Group Health implemented SDM for joint replacement surgery is available in an associated profile: http://www.innovations.ahrq.gov/content.aspx?id=3836.
- Higher burden of proof in malpractice cases: The 2007 legislation also recognized SDM in the state’s informed consent law, thus providing more legal protection for physicians who use this approach with patients. The legislation established use of a certified patient decision aid as evidence of informed consent. Consequently, patients who use certified patient decision aids will have a much higher burden in malpractice cases to prove they did not provide informed consent for treatment. However, because there is no current certification process for decision aids in the state, this aspect of the legislation has not yet taken effect.
- Mandated collaborative: Legislation passed in 2011 (Washington House Bill 1311) required the Governor to appoint a learning collaborative to examine variations in care and recommend strategies to reduce these variations and hence improve the quality and cost-effectiveness of care. This legislation specifically identified SDM as a strategy to consider. The legislation spurred development of a collaborative that currently involves 20 members appointed by the Governor, including representatives of the Health Care Authority; the University of Washington; Group Health Cooperative; and other provider, insurer, and health policy stakeholders. Through quarterly meetings, the collaborative identifies three health services characterized by substantial variations in practice patterns or high utilization each year, and then finds evidence-based practices (including SDM) to reduce such variations and thereby improve quality. The collaborative sends its recommendations to the Health Care Authority, which finances Medicaid, public employee health insurance, and worker’s compensation benefits. The Health Care Authority subsequently requires its contracted plans to adhere to these recommendations for care.
- Certification process for decision aids: Proposed legislation in 2012 (Washington House Bill 2318) would establish a process for certifying decision aids as meeting International Patient Decision Aids Standards. The Tools and Other Resources section provides a link to more information on these standards.
Context of the InnovationThe Washington State Health Care Authority administers the Public Employees Benefits Board (which provides medical, dental, life, and long-term disability coverage through private health insurance plans to State employees), the Washington Basic Health Plan (a state-sponsored program that provides affordable coverage to low-income Washington residents), and Medicaid and other medical assistance programs.
The 2007 legislation described earlier was spurred by a Washington State senator who served on the state’s health and long-term care committee and had a personal experience with a family member that led him to believe that SDM could have improved the outcome. At the senator's urging, staffers invited representatives from the Dartmouth-Hitchcock’s Center for Shared Decision Making to meet with Washington legislators to discuss the potential for SDM to reduce variations in care and improve outcomes and the patient-centeredness of care. These discussions set the stage for development and passage of the various pieces of legislation.
ResultsThe various legislative initiatives are starting to have an impact on use of SDM in care delivery; for example, the mandated demonstration project has identified success factors for and barriers to its routine use, whereas the learning collaborative has begun to establish SDM as an evidence-based practice for reducing variations in care.
Suggestive: The evidence consists of various accomplishments related to shared decisionmaking achieved by the legislatively mandated demonstration project and learning collaborative.
- Identification of success factors and challenges: The demonstration project has identified best practices that enable providers to use SDM and related tools more easily, along with common barriers to SDM implementation. The lessons learned from the project have been helpful to health care stakeholders in Washington state and around the country. Notably, all three demonstration project participants continued using SDM tools after the project ended, suggesting that providers and patients find them useful.
- Making SDM an accepted, evidence-based practice: The collaborative continues to meet on a regular basis and has contributed to the acceptance of SDM as an evidence-based practice for improving quality.
Planning and Development ProcessSelected steps included the following:
- Gathering stakeholders: Once the 2007 legislation passed, the Washington State Health Care Authority and the University of Washington gathered a broad group of stakeholders interested in SDM. This group included representatives from provider groups, the State medical association, health plans, the health policy community, and the community at large. Stakeholders offered feedback about specific SDM topics that should be included in the demonstration project.
- Selecting sites: The Health Care Authority and the University of Washington selected the three demonstration project sites based on their large size and their interest in and experience with SDM.
- Obtaining and evaluating decision aids: The Health Care Authority contacted the Foundation for Informed Medical Decisionmaking to obtain the right to use its high-quality decision aids. The authority also contacted other creators of decision aids to see if they wanted to offer their products as part of the demonstration project. The Health Care Authority used the International Patient Decision Aids Standards to evaluate the quality of these decision aids.
- Supporting project sites: In response to input from site representatives about what types of support would be most helpful, the Health Care Authority arranged monthly conference calls in which they could share best practices.
- Conducting evaluation: Researchers at the University of Washington conducted an evaluation of the demonstration project.
- Forming and supporting collaborative: As noted, the Governor appointed members to the learning collaborative, after which the Health Care Authority convened the group and set up a schedule of quarterly meetings.
Resources Used and Skills Needed
- Staffing: The legislation has required no new staff, as employees of the Health Care Authority, the demonstration project sites, and other organizations spend time on the project as part of their regular duties.
- Costs: Development and implementation of the various pieces of legislation have not required a financial outlay.
Funding SourcesFoundation for Informed Medical Decision Making
The Foundation for Informed Medical Decisionmaking provided in-kind support by allowing the demonstration project sites to use its decision aids at no charge.
Tools and Other ResourcesMore information about the International Patient Decision Aids Standards is available at: http://ipdas.ohri.ca/.
More information from the University of Washington about Washington State SDM legislation is available at: http://depts.washington.edu/shareddm/waleg.
An SDM implementation manual and other tools are available from the University of Washington at: http://depts.washington.edu/shareddm/products.
More information about the Foundation for Informed Medical Decision Making is available at: http://informedmedicaldecisions.org/.
Getting Started with This Innovation
- Make legislation part of effort to promote SDM: Achieving the goal of broad adoption of SDM likely requires some type of legislation, for multiple reasons, including the difficulty of changing entrenched practices, the high cost of many SDM tools, and a lack of evidence related to the return on investment (ROI) from SDM, due in part to the reluctance of payers to reimburse for SDM activities.
- Clearly define SDM: Because SDM can be defined in several different ways, legislation should include a specific definition to guide the development of decision aids, demonstration projects, and other related activities.
- Identify and focus on areas with significant variation: Use statewide data to identify procedures and conditions where significant variations in care exist, and then focus on promoting use of SDM for these procedures.
- Certify decision aids: Providers will be more comfortable using decision aids that have gone through some sort of independent vetting or certification process. In the absence of national certification, organizations can use a checklist developed by the International Patient Decision Aids Standards Collaboration to evaluate the quality of internally or externally developed aids.
- Emphasize that SDM supports informed consent: Providers will be more likely to support SDM once they understand that its use can help to establish informed consent and hence reduce liability risk in malpractice cases. This argument becomes especially important in an environment in which payers do not reimburse for SDM activities, thus making it difficult to justify adoption from an ROI perspective.
Sustaining This Innovation
- Encourage leaders to engage providers: Strong leadership is critical to getting providers to support and use SDM. To that end, leaders of clinics and other provider organizations should be encouraged to communicate with frontline clinicians about how SDM helps patients be better informed about their care, provides some legal protection to providers, and results in higher quality care that better reflects patient preferences. In addition, these leaders should be encouraged to embed SDM into their organization's strategic plans, because sites tend to be more successful when SDM aligns with organizational goals and activities.
- Support providers in integrating SDM into care: Providers often perceive SDM as a time-consuming process. To address this concern, help them resolve care process issues related to its use, such as which providers should explain SDM and related decision aids to patients, and when patients should receive the decision aids (either before, during, or after speaking with a provider). In addition, prompts delivered through an electronic medical record can help remind providers to engage in SDM conversations and offer related decision aids to patients.
- Incorporate SDM into ongoing quality improvement efforts: SDM processes can be more easily sustained if they become part of ongoing quality improvement efforts and new models of care, such as medical homes and accountable care organizations.
- Lobby for reimbursement: Providers will be more likely to use SDM over the long term if payers provide reimbursement for SDM-related activities. Reimbursement could include payments for time spent on SDM, or support in developing and implementing SDM processes and decision aids.
- Encourage SDM through contracting: States can insist that health plans covering state employees require their network providers to use SDM processes and decision aids, or give preference to those plans that do when making contracting decisions.
Contact the InnovatorLeah Hole-Curry, JD
Washington State Department of Labor and Industries
P.O. Box 44321
Olympia, WA 98504
Tel: (360) 902-4996
Innovator DisclosuresMs. Hole-Curry reported having no financial interests or business/professional affiliations relevant to the work described in the profile.
References/Related ArticlesShafir A, Rosenthal J. Shared decision making: advancing patient-centered care through state and federal implementation. National Academy for State Health Policy, March 2012. Available at: http://www.nashp.org/sites/default/files/shared.decision.making.companion.document.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
University of Washington and Partners. Washington Shared Decision Making Demonstration: Key Project Learning, Recommendations, and Next Steps. PowerPoint presentation. Presented at SDM Conference Session 4. May 26, 2011.
Katz JN. Total joint replacement in osteoarthritis. Best Pract Res Clin Rheumatol. 2006;20(1):145-53. [PubMed]
Hsu C, Liss DT, Westbrook EO, et al. Incorporating patient decision aids into standard clinical practice in an integrated delivery system. Med Decis Making. 2013;33:85-97. [PubMed]
Kuehn BM. States explore shared decision making. JAMA. 2009;301(24):2539-41. [PubMed]
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Original publication: August 28, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 28, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.