The Dartmouth Center for Health Care Delivery Science

The Preference Lab

Some of the most promising advances in health care delivery are coming from a different kind of inquiry — one centered not on drugs or procedures but on what patients actually want.

Health care that supports patient engagement has become an integral aspect of health policy in many countries. In fact, shared decision making — known by its acronym, SDM — has been described as “the pinnacle of patient-centered care” and is as relevant to managing long-term conditions as to situations where multiple treatment options exist. Yet its implementation in the U.S. has been limited. Inexplicably, solutions to improve patient engagement at the point of care continue to meet resistance in real-world clinical settings. Among the many challenges: physician skepticism, workloads that don’t allow sufficient time for interaction at the point of care, and misperceptions of patient expectations. The question that lies at the heart of the issue: Recognizing that our health care culture is built on a belief in quantifiable, hard science, how can physicians integrate the softer, social science of their patients’ knowledge, experience, and desires in decisions that — ultimately — improve not only clinical results but higher quality of life?

Through these and other initiatives, we’re conducting experiments in a setting different from the wet bench and clinical space our country’s health care system is built on. We’re taking the human element inside it, and calling it "The Preference Laboratory."

In an attempt to encourage more widespread adoption, shared decision making has been included as a quality metric in the Patient Protection and Affordable Care Act, as part of testing for new health care payment and service delivery models. But a key barrier stands in the way of widespread implementation: the challenge of developing a measure of the process that is reliable, valid, and suitable for existing clinical workflows. One of the key tenets of our work is to address this measurement challenge by developing a deeper understanding of the issues and by creating measures that overcome existing limitations. One of the measures we are developing, with the help of patients and clinical staff, is something we call CollaboRATE. The survey-based tool is designed create a fast and frugal way to measure how much effort doctors make to explain their patients’ health issues; how much effort they make to listen to the issues that matter most their patients, how much effort they make to integrate what matters most in choosing what to do next. After demonstrating excellent performance in simulations, we are now moving to real-world testing.

Most current methods reflect heavy use of passive (one-way) information to inform and activate patients. We are creating point of care engagement (POCET) tools, which integrate those methods along with with the notion of collaboration to emphasize, support, and structure treatment solutions. These combined tools and approaches promote less patient workload, require fewer clinical resources, and fit within existing systems of practice. A pilot research project at Dartmouth-Hitchcock Medical Center provides opportunities to explore the SDM implementation potential and feasibility of integrating POCET tools in clinical work flows.

The Dartmouth community is producing new generations of physicians trained in the techniques of patient engagement and activation, using the skills of SDM. We are leveraging the unique position of The Dartmouth Center by bringing together the strengths of current faculty at the Geisel School of Medicine, The Dartmouth Institute for Health Care Policy & Clinical Practice, and Dartmouth College to shape the nation’s first medical school shared decision making curriculum.

Through these and other initiatives, we're conducting experiments in a setting different from the wet-bench and clinical space our country's health care system is built on. We’re taking the human element inside it, and calling it "The Preference Laboratory."