Shared decision making: using health information technology to integrate patient choice into primary care

Advances in shared decision making (SDM) have not successfully translated to practice. We describe our experience and lessons learned in translating an SDM process for primary care cardiovascular disease management. The SDM process operationalized recognized SDM elements using workflow modifications, a computerized patient questionnaire, an automated risk calculator to identify at-risk patients, a web-based tool for patients to choose interventions, automated feedback on the personalized benefits of choices, and a web-based tool for providers to view patient risk, patient choice, and expert advice. Although medication was typically the intervention resulting in the greatest risk reduction, the majority of patients preferred dietary and other lifestyle changes. Patients generally favored the opportunity to make and communicate choices. However, providers only viewed patient choice data in 20% of the encounters. Translation of the SDM process was successful for patients and the difference between patient choice and optimal risk reduction points to the importance of engaging in an SDM process. Lack of engagement by providers may be due to "alert fatigue" or to the failure of the SDM process to improve efficiency in the office visit.