Purpose: We conducted a systematic needs assessment to identify opportunities, barriers, and potential implementation strategies for integrating patient decision aids (DAs) as standard practice in primary care. A second goal was to engage potential participant clinicians, staff and patients into the integration process.

Methods: All clinicians, nursing and administrative staff and selected patients at two academic medical center general internal medicine clinics were invited to participate in the needs assessment. Our Needs Assessment consisted of a formal questionnaire and semi-structured focus groups. We assessed participants' perceived needs in decision making; perceived challenges and barriers; and patient and clinician values, attitudes, and preferred decision making role.

Results: Clinicians (n=38) and patients (n=20) most frequently identified lack of information as the greatest challenge patients face making difficult decisions. Both also specified lack of clarity about what is important to patients as a substantial barrier to high quality decision making. Clinicians indicated patients should be better prepared for decision making prior to their appointment and perceived the following challenges to incorporating DAs into primary care practice: short visit length, competing multiple agendas, concern that patients won't view DA videos and do not wish to participate actively in decision making. In contrast, patients indicated a willingness to view up to a 40 minute video decision aid and complete health status and decision related questionnaires before the visit. Clinician's perceived their usual role in decision making was to share the decision with the patient and to provide support/advice to the patient to make a decision. Nursing staff (n=23) identified the following barriers: patient's lack of knowledge and understanding of decision related information, patient flow, providing information to patients prior to appointments, nursing confidence as health advisors and competing demands.

Conclusions: Patients and doctors agree that more information needs to be made available to patients in order to help patients make difficult medical decisions. Improving patients' ability to clarify their values is also important to both patients and clinicians. Patients and clinicians do not agree about patients' acceptance of DAs or patients' willingness to prepare to participate actively in decision making. Patients are more willing to participate, including doing work to prepare for the visit with the clinician. Clinicians and staff identify common logistical challenges integrating DAs into usual primary care.