Digital Tools and Shared Decision-Making

Effective healthcare is shaped around good communication between a doctor and their patient. It requires honesty of a patient to detail their health concerns, and a receptiveness of physicians to meet individual needs. However, historically this relationship was paternalistic, dominated by the physician rather than a mutual participation. This often left little consideration for the structural barriers facing patients outside the doctor’s office.

In the 1980’s began in medical culture a shift towards a model of shared decision-making, where a patient and their providers discuss risks and benefits of different treatment options, reveal preferences, and jointly make a decision regarding treatment. The model has gained great support for empowering patients and improving outcomes.

This approach is especially important for patients with opioid use disorders, who often face stigma and rigid treatment plans, leading to low patient retention rates. Despite the availability of effective treatments, the U.S. has over 100,000 overdose deaths annually. Ruth Jeminiwa, PhD, assistant professor in the Department of Pharmacy Practice, is hoping to empower this patient population through digital heath tools that can promote more collaborative interventions.

Tell us about your research.

My research focuses on understanding preferences of people living with opioid disorder to promote shared decision-making and other patient-centric treatment policies in the care of this population. I am particularly focused on pregnant women with opioid use disorder, a patient population that has quadrupled since 1999. These women often face added stigma and punitive measures from child welfare and criminal justice systems – that includes having their child removed from their care, which has a cascading effect on the mental and physical health of the mother and the child.

What led you to your current research path?

Prior to becoming a researcher, my background was in web development and pharmacy. As a pharmacist I provided care to people with all types of conditions, including those with substance use disorders. I observed that these patients don't receive fair treatment compared to those with other kinds of chronic conditions like hypertension. There are misconceptions around substance use disorders, which leads to shaming and judgement. Family members might not know how to best support their loved ones.

Even clinicians can hold bias, which may hinder their attitude towards patients and their communication about treatment. Sometimes patients might not even know why they are on a particular treatment and feel like their doctor is not invested in sharing that information, so they become disengaged. It is also important to consider that not all patients have agency in their treatment decisions. Some patients may be seeking to escape a violent situation, some may have a court order for treatment, and some may be concerned about losing custody of their children.

Getting a glimpse of patients' experience, I felt like I could do something to help. My background in web development created an awareness of the use of digital products in improving healthcare. I wondered if I could blend my experience in technology and pharmacy to improve patient care.

What pushed you to make that transition from pharmacy to research?

I joined a PhD program and when I discussed my interest in technology and healthcare with my advisor, he encouraged me to pursue a research path with the foresight that digital health interventions would play a critical role in healthcare. I’m so grateful he gave me that push - with the shift to telehealth we’ve seen throughout the pandemic, there is a growing need to understand how to best implement digital tools and wearables which may be used for remote monitoring of different patient health information.

I began researching how digital health tools can impact patient behavior and outcomes. I learned more about the doctor-patient relationship and the imbalances that can hamper the transparent exchange of information around treatment. For instance, I studied asthma patients, a population in which treatment adherence is generally low. We found that patients did not hold the same beliefs as their care healthcare providers concerning their asthma or medication use which contributed to intentionally skipping some doses. This underscored to me the role of shared decision-making in educating the patients and understanding their preferences. I learned that when patients are more engaged with care and have shared decisions with their clinicians, then they're more likely to stick with their treatment plan.

We also found that digital health interventions can improve treatment adherence by encouraging patients to track their medication use and provide “push” reminders. This experience showed me how digital tools promote shared decision-making.

How can shared-decision making help overcome barriers faced by patients with opioid use disorder?

According to 2019 estimates, less than 35% of people with opioid use disorders had received treatment in the past year. There is also usually a gap of several years between the onset of the disorder and entering treatment. This reflects significant barriers for this patient population.

In addition to stigma and access issues, few healthcare providers receive training on treating opioid use disorder. Not many people know that The American Board of Medical Specialties only recognized addiction medicine as a subspecialty in 2015, so many training programs have limited access to experts to develop and teach curricula. In fact, one study showed that less than half of emergency medicine, internal medicine, and family medicine physicians believed that opioid use disorder was treatable.

Currently, there are two FDA- approved medications for opioid use for pregnant women: methadone and buprenorphine. These are highly effective treatments, but several legal and regulatory barriers make it difficult for patients to access treatment and discuss these medications with their doctors. With methadone, you have to go to the clinic every single day to get your medication. Buprenorphine is not as demanding because you can get a prescription from your doctor and take the medication at home on your own. This may be preferable for some patient populations, such as pregnant women, for whom traveling to the clinic can pose as a major barrier. However, physicians often prioritize risk of misuse and ease of prescribing over the patients’ preferences. This leads to patients dropping out of treatment.

Shared-decision making could help patients understand the pros and cons of different treatment options, and patients explaining their preferences could help shift or reshape preconceived notions a clinician may hold about opioid use and the disease of addiction. Most importantly, incorporating patients’ preferences in treatment decisions could lead to better medication adherence and retention in treatment programs.

What digital tools does your research explore to facilitate shared-decision making for this population?

A physician may have important information for a patient but doesn't have time during the visit to discuss all the necessary information. You don't want to hand out a flyer alone because some people might not read it. Instead, this information could be delivered as a tutorial that patients can download on their phone or an FAQ sheet to their email right after a doctor’s visit. With on-demand telehealth options, there could also be a virtual assistant to help answer patients' questions.

Along with saving time outside of the doctor’s office, technology might also be a good route of ensuring physicians are engaging in shared decision-making during appointments. Among other things, my research seeks to develop a checklist that prompts the physician to educate the patient about treatment options, clarify their treatment preference, and make a shared decision about treatment. This program could be integrated into the electronic medical record (EMR), making it easy for the clinician to see whether they have had a discussion with the patient about their preferences.

What are some of the challenges patients and/or doctors might experience with these tools?

I worry that not everybody in this patient population will have access to digital interventions. This might further create a problem around digital health equity. For physicians, there is still a problem of workload and time constraints. An additional thing to do on the EMR could disrupt the clinician’s current workflow or contribute to physician burnout. In my current research, I am trying to understand the barriers and facilitators of shared decision making on the physician side and interviewing clinicians to understand how best to implement our decision support tool. I’ve received positive feedback and enthusiasm, and that makes me optimistic.