Implementation Evidence

In addition to research publications evaluating specific decision tools, there is a growing body of literature on implementation efforts, both at the point of care and across health systems (Elwyn et al., 2013; Friedberg, Van Busum, Wexler, Bowen, & Schneider, 2013; King & Moulton, 2013; Legare & Witteman, 2013).

A 2013 systematic review on implementation efforts for decision support tools found only 17 eligible trials and highlighted a relative paucity of literature on wide scale adoption (Elwyn et al., 2013). All trials relied on providers or staff to ask patients to use the tool (the referral method) and reported challenges operationalizing this method and seldom reported patient-level outcomes. All trials reported “less than expected” uptake. Only one trial discussed the costs of implementation. Successful trials reported having a provider champion or a system to systematically identify eligible patients that also distributed the tools prior to consultation facilitated their use.

Two implementation efforts are frequently discussed in both the peer-reviewed literature and grey literature sources: decision aids from Health Dialog (e.g. Group Health in Seattle, Washington and multi-site trial sponsored by the Informed Medical Decisions Foundation) and decision aids produced by the Mayo Clinic’s Shared Decision Making National Resource Center.

Group Health

Group Health was the first health system in the United States to integrate shared decision making and decision aids starting in 2009. Their leadership selected and implemented 12 decision aids across primary and specialty practices as part of a state authorized demonstration project. A partnership with Health Dialog provided the clinics with free access to their decision aids that were integrated into the Group Health electronic health record (EHR). This allowed physicians to order decision aids to be sent to patients’ homes, add instructions to the after visit summary or send a secure message via the EHR patient portal (Arterburn, 2015). In addition to tracking orders, they tracked patient satisfaction with the decision aids. However, they were unable to track actual patient use or other patient-centered outcomes (i.e. knowledge, risk perception, decision conflict).

Group Heath tracked use of knee and hip replacements and published their evaluation in Health
Affairs (Arterburn et al., 2012). In the 18 months following implementation of decision aids in orthopedic clinics, they observed a reduction in hip replacement (26%) and knee replacement (38%) surgeries with a 12 to 21% reduction in associated costs from the 18 month prior to implementation. Interestingly, fewer than half of eligible patients received or reviewed the decision aid online (41% for hip osteoarthritis, 28% for knee). All providers at Group Health are salaried, thus their experience may not be reproduced in productivity based income settings. The decision aids were also provided free of cost, an option not available in many other settings.

The Informed Medical Decisions Foundation and Health Dialog also sponsored an effort to implement video-based decision aids at primary care clinics across the country; Dartmouth-Hitchcock (NH), MaineHealth, Massachusetts General Hospital, Mercy Clinics (IA), Oregon Rural Practice-based Research Network, Palo Alto Medical Foundation (CA), Stillwater Medical Group (MN), and the University of North Carolina at Chapel Hill. Their implementation model and project support focused on eight key steps:

  • Engage and train providers and staff
  • Target individuals or populations to receive decision support
  • Identify targeted patients or populations
  • Distribute decision aids
  • Encourage decision aid viewing
  • Provide support to patients and providers
  • Measure impact at patient and program level
  • Provide feedback using patient and program level data

Similar to the findings in Elywn’s review and Group Health’s evaluation, relying only on physician referral resulted in missed opportunities and overburdened physicians. Systems that created automatic triggers and engaged team members were successful in increasing use of shared decision making and decision aids. Both highlighted an often overlooked focus, provider training, particularly addressing differences between shared decision making and patient education. Many providers felt they already performed shared decision making and needed education on use of the tools (Friedberg et al., 2013).
In contrast to the Health Dialog video based decision aids which focus on a single event or decision (e.g. do I have joint replacement surgery?) and were the focus of broad system-wide implementation efforts, Victor Montori and colleagues at the Mayo Clinic successfully implemented decision tools with minimal provider training.

The tools produced by the Mayo Clinic focus on long term decisions (e.g. which diabetes or depression medication do I want to take every day?) and are web-based. Their tools can be integrated into EHRs with scripted language to document the shared decision making process. Dr. Montori and colleagues produced a decision aid for patients presenting to the emergency department with chest pain that was implemented with one hour of provider training and a small cartoon demonstrating use (Hess et al., 2012). A depression medication decision aid was successfully implemented with high fidelity without any provider training (Montori, 2015).

The Mayo Clinic group produces and updates publicly available decision aids for cardiovascular disease primary prevention (e.g. statin use), depression medication choice, diabetes medication choice, osteoporosis treatment options, smoking cessation around surgery and percutaneous coronary intervention. All aids are available for free at

Evidence on Adoption