DECISION SUPPORT FOR CONSUMERS

INTRODUCTION:
>Patients who are more informed and knowledgeable about clinical and quality of life aspects of their disease and its treatment are more likely to have a satisfaction with their care process and treatment outcomes. >Applications of computer technologies, including telecommunications systems, Internet and the World Wide Web and multimedia information display showed patients, their family caregivers, bad concerned others to become active informed participants in the management of the health-care process.

*Because of the computer-based applications designed, patients can now make better decisions about the health services they need.
There were tools that employed decision theories to guide patients in understanding and performing a structured analysis. **computer tool is used to provide information, advice, and coaching based on the experiences of other patients. **may refer to the WWW that allows to autonomously collect health-related information **tools may let the patients know or view their clinical records HEALTH-RELATED DECISION-MAKING
>Humans employ simplifying mental mechanisms as coping strategies to help them sort significant from insignificant facts, to organize and interpret complex observations, to facilitate recall and synthesis of known knowledge with new facts. >Health-related decision-making is complicated because the substance of the problems and choices is itself complex and exceeds the knowledge and education of most laypersons

>In addition, health-related decision making is complex because it generally involves more than a single person. For this must involve the family members and the healthcare delivery team. SHARED DECISION-MAKING AND INFORMED CHOICEinvolving patients in healthcare decision making, they >By are best able to determine which values should govern their care. >Shared decision-making is also known as relationship or collaborative decision-making which empowers patients to choose among the options available to them. >Shared decision-making is the concept of evidence-informed choice. -informed consent involves the patient acknowledging that they have received adequate information to assent to the care that is recommended by their clinician PATIENT PREFERENCES >There were theoretical foundation for building health informatics tools that aid in the assessment of patient preferences: *Von Neumann and Morgenstern (1964)- they proposed that values and attitudes that drive individual choice could be understood through mathematical formulations. *Ledley and Lusted (1999)- they introduced the concept of mathematical reasoning to medical decision-making *Raiffa (1968)- explicated decision analytic strategies that brought treatment of personal preference and uncertainty *Pauker and McNeil (1981)- demonstrated the feasibility of using decision analysis to better understand treatment choices that are complicated by multiple uncertainties

Two main branches of decision theory: *decision analysis-helps in choosing one course of action *normative decision theory MAUT (Multiattribute utility theory)- provides the mechanism for quantifying the subjective value of health states and therefore can be very useful to patients. - it is based on compensatory rules that allow for assessing tradeoffs among entities in such a way that a high value for one entity is compensated for by a low value ALTERNATE MEANINGS OF THE TERM "PREFERENCES" >Some consider preferences as an input to a decision while others view preferences as the final choice resulting from a decision. >Some use the term "preference" to represent an individual's final choice of one option from many possible treatment options CHALLENGES TO USING PATIENT PREFERENCES FOR HEALTH-RELATED DECISION-MAKING >Although the value of understanding and using patient preferences in healthcare decision-making is well-recognized, still it can present a daunting challenge to patient for such a reason that many patients lack experience with thinking about abstract concepts like values, preferences, and risks.

>Those who were basing their decision on survival data preferred the treatment in question less often than those of who were basing on mortality data. >A study shows that the use of multimedia testimonials in which patient describes his/her experience with a health state or with a treatment decision process found that a mismatch between the race or gender of the patient in the video and the patient viewing affected the preference for predicted health states. >Preference assessment is an iterative, cognitive process designed to help a person understand and clarify personal values, healthcare situations treatment options and likely outcomes and to elicit statements of preference. >Use of computer technologies reduce the demand for repetition of analysis or communication on the part of the patient and helps to insure that data collected is transmitted in a timely fashion to involved clinicians. >The patient is considered to be the direct user of these ethnology preference applications, but the results are used collaboratively in a shared decision process with his/her clinician. >Achieving congruence between a patient's preferred and actual role in the decision-making process contributes to the level of satisfaction with the treatment process.

Computer Technology and Patient Decision-Making Computer Technology and Patient Decision-Making *Stanford Center for the Study of Patient Preference -pioneer in the use of computers and the internet for low-cost elicitation of patient preferences for health states Methods used for Preference assessments 1. Standers Gamble (SG) method -asks the patient to determine the indifference point where living in specified health state is perceived to be equivalently preferable to a specific probability of death 2. Visual Analog Scales (VAS) method -uses a visual representation of a linear scale with one end representing the best possible health state and the other representing the worst possible health state 3. Pair-wise Comparisons(PWC) method -asks patient to evaluate their preferences for each possible heath state or treatment in a pair-wise fashion 4. Trade-off (TT) methods -asks the patient to determine the number of years that life in perfect health would be equally preferable to a longer period in the health state in question

*Shared Decision-Making Program (SDP)

-Developed within a framework grounded in the idea that rational treatment decision making considers both what the patient wants and what the clinician views as appropriate -designed for use in the clinical setting to aid patients facing complex treatment choices

Facilitating data management *Health related quality of life (HRQOL) -the value assigned to the duration of life as modified by the social opportunities, perceptions, functional states, and impairments that are influenced by disease, injuries treatment or policy. Linking preference with treatment decisions *Health Touch -designed by the Department of Family Practice at the Medical College of Virginia, Virginia Commonwealth University -a computerized health information system for health promotion and disease prevention fro use in the primary care -Intended to supplement clinician involvement in patient focused preventive services -incorporated in the health practice in two ways: >Actively- by staff directing the patient to complete the survey >Passively-by placing the computers in the waiting area and allowing use based on patient choice Decision aids -developed to provide assistance to patients who are facing complex healthcare decisions -goal: to support and enhance patient ability to choose a course of treatment that is consistent with their values -targeted to providing the patient with a level of information adequate to allow them to make informed choices and participate in the shared decision process -can function as an intelligent disease management agent -effective at assisting patients with assessments of the individual risks of having the latent disease along with understanding the implications of the result of the test as viewed through the patients values

*Ottawa Health Research Institute (OHRI) -developed a set of evaluation measures and instruments that can be used by implementers of DDS to assess their system performance Acute Disease Decision Support Systems -DDSs that are employed in the support of acute disease states -focused on supporting the patient by providing for their informational and preference determination needs regarding a single episode of treatment choices Chronic Disease Management Decision Support Systems -enable the patient to better monitor and treat chronic diseases resulting in increased lifespan and QOL Primary Components: >assessment -used to measure the patients health state along the key dimensions of physical condition, functional status, and behavioral tendencies >information -used to provide information and guidance that is customized to the current health status of the patient >communication -provides an integrated mechanism for communicating with clinician -public/private options: 1. An unrestricted public bulletin board 2. Private electronic mail 3. A question and answer area

Decision-Making to Promote Health Behavior Change There are dozens of theoretical models have been proposed for how to bring about a change in health behavior and lifestyles and these proposed changes fall into three broad categories. 1. Individual change Four theories of individual change; a. health belief model b. stages of change model c. reasoned action d. stress and coping model of change These theory focus on the individual and imply that a change or the lack of it can be explained by individual characteristics. 2. Interpersonal change Three theories of interpersonal health behavior; a. social cognitive theory b. social support theory c. patient provider communication These focus on the interaction of two or a group of individuals and how these interactions can promote change.

3 .Community change Four theories of community group intervention models; a. community organization b. diffusions of innovations c. organizational change d. communication theory These models are helpful for leaders who want to make changes in organizations. Most behavior change models assume that individuals are aware of their alternatives, know their own values, and process information quickly and efficiently to choose what is in their best interest. When actions are repeated frequently over time, habits are formed. Decisions are linked to many prior large and small choices, and affect future options. To change habits, it is not enough to change a single act. All related decisions and reinforcements also must be examined and modified. Successful change requires careful study of reinforcements and an understanding of linkages among decisions so that all decisions support the same action. It is proposed that to change the system that maintains a habit one must; 1. Identify and examine the linkages among decisions. 2. Measure and receive feedback about behaviors. 3. Proposed and try out new activities to improve these habits. 4. Build these decisions and behaviors into everyday routines and continue over a long period of time. In this context, willpower and discipline are organized and enhanced by changing the system of linked decisions.

Decision Support in Screening for Latent Health Conditions Patient decision making in the context of application of screening test has a different set of characteristics than those applied in acute, chronic disease management, or behavioral modification situations. Screening test may have an effects on a patients life that are far broader than just their state of health and carry a different sets of side effects including the potential for individual and family psychologic harm as well as for affecting a persons ability to obtain insurance. In the event the patient chooses to undergo screening, an additional layer of decision making requiring decision support is undertaken to determine what clinical course of treatment is to be followed in the context of the test results. Decisions regarding screening invoke an additional layer of uncertainty that involves the correctness of the test results, which is their sensitivity and specifity. Sensitivity is the ability of a test to determine which patients have a disease. Specifity is the ability of a test to determine which patients do not have a disease. SUMMARY: Decision Making and Choice in Healthcare Decision-making is a choice in healthcare is shaped by three important trends; a. recognition of both the value and limits of a science as a guide for care b. a philosophy of care management that emphasizes standards and coordination c. a growing importance of a patient as a key participant in selecting and implementing clinical treatment

Each of these trends supports the need for explicit consideration of patient preferences as a guide to choosing healthcare In summary, computer technology can solve some, but not all, of the challenges inherent in employing patient references practices. As a new computer tools are developed to support health-related decisions, clarity about the models of decision-making being employed and their and their match to the type of decisions being addressed is crucial. Computer networks can insure the rapid, efficient transmission of their patient preferences in the privacy of their homes or away from the anxiety-producing health encounter. Computer algorithms build and integrated into a computer based patient record, have the ability to insure that care is in accord with patient preferences. The WWW, CD-ROMs, and other computer tools can deliver informational interventions tailored to the needs, interest, and display requirements of individuals.