Washington Becomes First State to Endorse Shared Medical Decision Making.

Bill Acknowledges Value of Decision Aids in Improved Patient Outcomes

SEATTLE -- Governor Christine Gregoire is set to sign legislation today, that will make Washington the first state to endorse the benefit of doctors and patients using a process called "shared decision making" when confronted with important treatment choices.

Passage of ESSB 5930 represents the first acknowledgment by a state legislature that there is growing evidence that medical outcomes can be improved by patient-practitioner communication enhanced by high-quality decision aids. In addition, the legislation demonstrates Washington's commitment to improving patients' ability to make informed medical decisions by formally recognizing shared decision making in the state's laws on informed consent and encouraging collaborative efforts to develop, certify, use and evaluate decision aids.

Shared decision making is a process by which the physician shares with the patient all relevant risk and benefit information on all treatment alternatives, and the patient shares with the physician all relevant personal information that might make one treatment or side effect more or less tolerable than others. Numerous studies indicate that when decision aids (such as brochures, DVDs or online tools) are available to patients and they have the opportunity to participate in medical decision making with their physician, the patient-physician dialogue improves, and patient well-being improves as well.

"The main priority of the Washington State Medical Association is to make Washington a better place to practice medicine and to receive care. Shared decision making is one step towards accomplishing that goal by building upon the valued physician/patient relationship," said Hugh Maloney, MD, president of the Washington State Medical Association. "Such common sense legislation puts into practice a concept that is realistic, practical and helps physicians serve our patients and our profession, as we seek the highest standards of medical care." Dr. Maloney added.

The provisions are part of a larger health reform package contained in ESSB 5930, entitled "Providing high quality, affordable health care to Washingtonians based on recommendations of the blue ribbon commission on health care costs and access."

"The Legislature has learned that when patients are better informed about treatment options, they make decisions that are more aligned with their personal preferences, rather than opting for the most invasive or expensive procedure," said state Sen. Cheryl Pflug, Republican Deputy Leader and prime sponsor of the shared decision making bill, which was later rolled into the omnibus bill. "We will improve health care while at the same time managing our fiscal resources by encouraging collaboration and using nationally developed and approved patient decision aids."

The bill enables the state Health Care Authority (HCA) to implement a shared decision making demonstration project in partnership with multi-specialty group practices. HCA provides access to high-quality health care for more than 500,000 Washington residents through its administration of health care programs, including public employees' health coverage and Basic Health, a coverage program for low-income working families. The demonstration project will incorporate decision aids into clinical practice to assess their effect on health care quality, cost and patient satisfaction.

"At Group Health, we know that patients are happier with their care and outcomes when they fully understand all of their treatment options," said Hugh Straley, M.D., medical director of Group Health Cooperative and president of Group Health Permanente. "With shared decision making, patients weigh the risks and benefits of the options along with their own values and needs, arriving at the right answer for them. Often, the right care from the patient's perspective also costs less. This legislation is about giving physicians and patients the tools and skills they need to be more effective partners in care in the real world of a busy, complex health care practice."

ESSB 5930 also requires HCA to create the Washington State Quality Forum, in collaboration with Puget Sound Health Alliance, to collect research and health care quality data.

"This legislation is groundbreaking and empowers patients with relevant medical information to enable them to make treatment decisions based on their individual preferences," said John E. Wennberg, M.D., M.P.H, co-founder, senior policy advisor, Foundation for Informed Medical Decision Making. He is also Principal Investigator for the Dartmouth Atlas Project (www.dartmouthatlas.org), which documents dramatic geographic differences in the cost and quality of U.S. health care.

For treatment decisions regarding preference-sensitive care, where there are competing choices and doctors and patients must make discretionary decisions for conditions such as prostate cancer, breast cancer or lower back pain, individual patient input is paramount. This is where the standard of shared decision making vs. informed consent comes into play to improve patient satisfaction and outcomes.

Beyond improving patient outcomes, the use of patient decision aids provides legal protection for doctors, i.e., if a competent patient signs an acknowledgement of shared decision making, it constitutes evidence that the patient has given his or her informed consent, that can only be rebutted by "clear and convincing evidence." This is a higher standard of defense for a physician than the "preponderance of the evidence" standard that currently exists for doctors who use informed consent forms.

Shared decision making is currently being incorporated across the United States, at academic medical centers, including the Dartmouth Hitchcock Medical Center in New Hampshire, Massachusetts General Hospital, University of Arizona Cancer Center, University of California (L.A., San Diego and San Francisco), University of Cincinnati and the University of North Carolina.

For more information on shared medical decision making, visit www.fimdm.org. FIMDM is a non-profit organization dedicated to assuring that people understand their choices and have the information they need to make sound decisions affecting their health and well being.