BAKING SHARED DECISION MAKING INTO THE CLINICAL WORKFLOW CREATES A STICKY EXPERIENCE WITH ACCELERATING USE

   Purpose:  Despite substantial evidence that patients value engagement with SDM tools, sustained use of such tools in real life clinical practice has proven challenging. We studied change in usage patterns of a shared decision making (SDM) tool integrated within the electronic health record (EHR).

   Method:  In 2010 a dynamic SDM tool, designed to support statin decisions by clinicians and patients, was integrated within a university medical center's EHR. Unique patient and clinician use of the tool was recorded for 6 years. Multiple uses by the same patient within 180 days counted as one use. No advertising or education accompanied the launch.

   We calculated percent likelihood that clinicians would use the tool again as usage increased. We also measured time to subsequent use for a subset of experienced users.

   Result: Over 6 years 1,569 different clinicians accessed the tool with 47,981 unique patients. After first use, 58% of clinicians returned. Following uses 2-5: 80%, 88%, 91% and 95% respectively returned. Clinicians using the tool 6-20 times, averaged a return rate of 97.2%

Of 244 primary care clinicians (PCCs), 73% (178) used the tool once, 96% used it twice and 98% returned for use #3. After use 3-20, average return was 99.3%.

   PCCs who used the tool with >100 patients, (N=86) accounted for 86% of all 26,668 uses in primary care.  Time to second use averaged 104 days; after five uses average return was <30 days; after 100 uses return was <7 days and when over 400 uses, return was under 48 hours.

   Conclusion:   True SDM occurs between a patient and clinician in the office and with EHR workflow integration, our tool addresses a known barrier to tool utility and uptake. Over 6 years, through word of mouth and occasional clinical presentations, a substantial majority of PCCs who tried the tool, integrated regular use into their practice.

   Use was particularly sticky as >99% of PCCs with >=3 uses returned with more patients. Assuming a clinician performs a stable rate of statin conversations, accelerated tool use by over 50-fold illustrates an increasing percent of patients with whom clinicians choose to use the tool.  

   As next steps, the tools are integrated in two new institutions and uptake will be followed.