Dr Tessa Richards, associate editor of the BMJ, recently wrote a remarkable article about shared decision making (SDM) and her own personal, negative experience of the consent process.
In the opinion piece, Tessa eloquently discusses SDM and its role in supporting patients to make decisions based on their preferences and priorities and begins to explore clinicians’ experience of how the emergence of digital consent applications may support the shift towards SDM as well as resolving many of the issues associated with the traditional paper-based consent process.
Inspired by Tessa’s description of her experience, and wanting to dive deeper into the world of consent having joined Concentric as a Founders Associate earlier this month I decided to explore the different ways digital consent may influence SDM quality, and what the current research evidence is regarding its impact in this space.
So, what is shared decision making?
Shared decision making (SDM) is a collaborative process which sees a clinician support a patient to make a decision about their treatment. This brings together the patient, who is the expert in their condition, and the clinician, who is the expert in the treatment options.
The value of SDM is clear to most by now, and there is a reasonable appreciation that whilst things are improving there is still a way to go before we can be confident that the vast majority of patients are experiencing best practice when it comes to shared supported decisions.
Some of the key challenges in improving shared decision making quality are summarised in this BMJ analysis, including the challenge of too many other demands and priorities in an increasingly complex, stretched system.
Recent NICE guidelines recommend that healthcare organisations ensure that there is a plan to support further embedding shared decision making principles into everyday practice, and describe the role of patient decision aids as one tool to consider.
SDM and digital consent. Are they linked?
Shared decision making and consent are two overlapping processes, with patients’ experience of one often contributing to their experience and expectations of the other.
It has been hypothesised that digital consent solutions may have an impact on perceived SDM quality by; acting as a decision aid and as a guide for consent conversations between patient and clinician; and sharing personalised, accessible information to support understanding and reflection during but also before and after a consultation.
Two peer-reviewed studies have recently been published exploring the impact of introducing digital consent on the patient perception of SDM quality. Let’s explore what they found:
BJS paper showed impact across SDM-Q-9 domains
Published in the British Journal of Surgery this month, academics from Imperial College London have found that digital consent with embedded accessible patient-facing information can improve patient perception of their involvement in the shared decision-making process when compared with the traditional paper consent process. The digital consent application used was Concentric. One of the authors of the paper was Edward St John, our Chief Medical Officer.
JUST PUBLISHED: Digital consent to improve patient perception of shared decision-making: comparative study between paper and digital consent processes in patients undergoing breast surgery https://t.co/03b4Hsm0ke— Edward St John (@ercstjohn) August 14, 2022
Thanks to the breast surgery team @ImperialNHS & @Concentric_Hlth pic.twitter.com/H1Hezzwsuu
The cohort for the study was made up of patients who had undergone breast surgery. They were asked for their opinion of their involvement in, and the quality of, the shared decision making and consent process - using the SDM-Q-9 tool, a validated questionnaire in which patients rate the extent to which they agree with 9 SDM-related statements.
Across all nine SDM-Q-9 domains better average scores were seen in the digital consent cohort compared with the traditional paper-based consent cohort. The most strongly statistically significant improvement seen was for the responses to ‘My doctor and I selected a treatment option together’.
From 28% to 72% reporting gold-standard SDM
In a study in The Surgeon, patients were asked to report their experience of SDM using the collaboRATE score, which assesses 3 areas; explanation of care, elicitation of preferences and integration of preferences into decisions.
Only 28% of patients who documented their consent on paper felt they experienced the “gold standard” for SDM, which in itself is food for thought. Even more striking was that this increased to 72% for the digital consent cohort.
Discussing with the team here at Concentric it’s clear that even we were surprised by the impact introducing Concentric had on SDM quality as reported in this paper. Especially given the many challenges reported in the literature regarding having an impact on SDM, and all the SDM-related features that are still on our product roadmap for the next couple of years.
What’s leading to the impact seen?
There is more work to be done to fully understand the reasons behind the impact demonstrated in these two papers and we hope to see several academic units exploring this fully over the next few years.
Based on what we know today it seems likely that the impact is due to some or a combination of the following:
- Patients have easy access to, and time to consider, personalised information which may be used to support understanding, highlight areas of uncertainty, and inform further meaningful dialogue between patient and clinician, and between the patient and others around them.
- Improved sharing and understanding of information may foster confidence and empowerment of the patient to engage deeper in shared decision making.
- Reduced clinician administrative time may lead to the release of time for active discussion during consultation.
What have I learnt?
These studies add to a growing consensus that digital consent can enhance the patient experience and perception of shared decision making, a key facet of informed consent, however, more work is needed to understand this fully.
As Dr Tessa Richards rightly points out - on its own, better access to information doesn’t necessarily mean that better decisions are made; good clinical decision making will always be dependent on quality conversations between patient and clinician. The introduction of digital consent looks likely to be a step in the right direction, but a focus on improving these conversations across the board must remain.
Can you see digital consent improving consultations with your patients? Do you think discussions would be impaired by the use of a digital consent application? Either way, there is plenty still to do to evaluate their use and impact 🙂
Get in touch and let me know what you think! I’m at email@example.com.