Integrating a Patient Decision Aid into the Electronic Health Record: A Case Report on the Implementation of BREASTChoice at 2 Sites

Abstract

Patient decision aids can support shared decision making and improve decision quality. However, decision aids are not widely used in clinical practice due to multiple barriers. Integrating patient decision aids into the electronic health record (EHR) can increase their use by making them more clinically relevant, personalized, and actionable. In this article, we describe the procedures and considerations for integrating a patient decision aid into the EHR, based on the example of BREASTChoice, a decision aid for breast reconstruction after mastectomy. BREASTChoice’s unique features include 1) personalized risk prediction using clinical data from the EHR, 2) clinician- and patient-facing components, and 3) an interactive format. Integrating a decision aid with patient- and clinician-facing components plus interactive sections presents unique deployment issues. Based on this experience, we outline 5 key implementation recommendations: 1) engage all relevant stakeholders, including patients, clinicians, and informatics experts; 2) explicitly and continually map all persons and processes; 3) actively seek out pertinent institutional policies and procedures; 4) plan for integration to take longer than development of a stand-alone decision aid or one with static components; and 5) transfer knowledge about the software programming from one institution to another but expect local and context-specific changes. Integration of patient decision aids into the EHR is feasible and scalable but requires preparation for specific challenges and a flexible mindset focused on implementation. Highlights Integrating an interactive decision aid with patient- and clinician-facing components into the electronic health record could advance shared decision making but presents unique implementation challenges. We successfully integrated a decision aid for breast reconstruction after mastectomy called BREASTChoice into the electronic health record. Based on this experience, we offer these implementation recommendations: 1) engage relevant stakeholders, 2) explicitly and continually map persons and processes, 3) seek out institutional policies and procedures, 4) plan for it to take longer than for a stand-alone decision aid, and 5) transfer software programming from one site to another but expect local changes.

Healthcare systems collaborating to implement a shared decision‐making tool in the electronic health record and build evidence on its adoption and use

“…Key characteristics of this experience that were also previously found to be necessary for successful integration included having a clinical site champion at each healthcare system and having standardized processes that avoid the use of patient protected health information. 6 The integration of CV Prevention Choice in this study was accomplished in less time than in prior research studies, 9,10 and our experience was that the time to integrate CV Prevention Choice reduced as new healthcare systems sequentially began integration, demonstrating the potential of leveraging shared learning in a stepped wedge pragmatic trial of EHR-integrated SDM tools.…”

“…Time and technical challenges serve as barriers to EHR integration of SDM tools; 8 processes to integrate SDM tools in the EHR have been reported to take between 6 and 18 months. 9,10 Research is needed to improve the adoption and routine use of SDM tools in diverse practice environments, using SDM tools that are widely available for future dissemination. We are conducting a pragmatic stepped wedge randomized controlled trial to understand the effectiveness of tailored implementation strategies in varied healthcare systems on increased adoption and routine use of an SDM tool, CV Prevention Choice.…”

“…Many SDM tools are created by external vendors, though, requiring healthcare systems to go through approvals and security screenings prior to implementing them. Time and technical challenges serve as barriers to EHR integration of SDM tools; 8 processes to integrate SDM tools in the EHR have been reported to take between 6 and 18 months 9,10 …”

Improving shared decision making for lung cancer treatment by developing and validating an open-source web based patient decision aid for stage I–II non-small cell lung cancer

“…This can face challenges due to clinicians' potential lack of faith in the tool, inadequate training on its implementation, and the multidisciplinary nature of the iPDA. Overcoming these obstacles requires addressing concerns, providing comprehensive training, and carefully managing the tool's multidisciplinary aspects (13,33). More precisely, implementing an iPDA in a clinical setting entails personalizing the tool, conducting pilot studies, involving stakeholders, incorporating it into workflows, reviewing the results, and continuously enhancing its use.…”

Revolutionizing decision support: a systematic literature review of contextual implementation models for electronic health records systems

“…Study design. Of the 20 included studies,1 theory of change (Adedeji et al, 2022), 2 were a randomized controlled trial (Moja et al, 2016a, b), 2 were Mixed-methods (Gold et al, 2019;Zhai et al, 2022),3 Case study (Bossen et al, 2013;Cresswell et al, 2012;Grenha Teixeira et al, 2019) and 10 were cross-sectional studies (Ahmed et al, 2020;Bashiri et al, 2023;Erlirianto et al, 2015;Iqbal et al, 2013;Jain et al, 2022;Kroth et al, 2019;Lee et al, 2022;Maillet et al, 2015;€ Ozkara et al, 2021;Sheehan et al, 2013). Location of studies.…”