Implementing SDM at UCSD Family Medicine

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Implementing SDM at UCSD Family Medicine

• Bill Sieber, Dustin Lillie,
• Alita Newsome, Jeff Engel
• June 14, 2009

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UCSD environment

• 28 faculty, board-certified family medicine
  physicians (avg .50 clinical FTE)
• 21 family medicine residents
• Team-based model, LVN/MA staffing
• Open access
• EMR
• Three geographically socioeconomically
  different clinics
• 33,000 patients 90,000 visits/yr
• Three PBRN clinics

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Implementation models

• Visit-based
• Physician-driven prescribing (diverse patient
  presentations)
• Present each patient during rooming with an
  informational sheet about all available videos
• URL of website on all patient communications
  (AVS)
• Non-visit-based
• Direct mailing to patients in registry
• Pre-visit-based
• Open access makes this especially challenging
• Uncertain presenting complaint

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Successes

• EMR and data capture
• Virtual library of video titles/decentralized
  distribution
• All UCSD FM physicians residents have
  prescribed
• Improved server technology (Windows Media ?
  Flash)
• Know viewing times (bi modal)
• 1,300 videos prescribed 470 DAs via SURFNet
  (not including non-visit-based mail-outs)
• Data warehouse with SQL search capability
• Tracer findings (n2,046 preventive visits)
• CRC decision aid
• 39 of patients not prescribed DA became
  guideline adherent within 180 days
• 44 of patients prescribed DA became guideline
  adherent within 180 days.
• 59 of patients who watched DA became guideline
  adherent within 180 days.

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Challenges/lessons learned

• SDM vs. patient education
• Understanding how to use tools
• Patients understand purpose of DA
• MD definition of SDM
• Variable performance of clinic champions (MD
  MAs)
• Too many staff involved in identifying
  prescribing
• Competing clinic initiatives
• One-time presentation to patient is insufficient
• Clinic functioning (morale, EMR, QI mentality)
• Connecting SDM to benefits other than external
  incentives (e.g., food, i-pods) such as P4P
  outcomes/reportcards
• Lower patient interest associated with duration
  of condition
• Institutional support (EPIC, MyChart)

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Buy-in

• Educate providers
• Not research
• Arguments against Not enough time, Patients
  not interested
• Use early adopters to advocate for greater use
• Each provider chooses preferred title
  implements plan best for his/her team (integrate
  QI values)
• Automation and reliance on staff leads to better
  outcomes
• Implementation
• MAs to identify eligible patients on daily
  schedules
• Flyers in all exam rooms/waiting room
• Promote healthy competition with incentives
• Leveraging technology

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Planned improvements

• Connect video distribution into clinic
  goals/efforts
• Health coaching
• Planned visits
• Group Medical Visits
• Enhance automation in order to lower need for
  physician initiative
• Alerts
• Follow-up reminders
• Patient registries
• Increase library access via My Chart