Consumer Responses to Online Decision Aids
Consumer Responses to Online Decision Aids
The results of this online evaluation of three decision aids for preference-sensitive health decisions provide baseline feedback on the direction and magnitude of the learning that occurred for each decision aid and on user assessment of the value of the decision aid in thinking through dimensions of choices to be made.
User feedback from this study can be put into two contexts. First, the results add to the understanding of how consumers evaluate the health information they find online. The little evidence available on this question speaks to the importance of ongoing and detailed assessments of how consumers react to what they find in their searches. The Pew Research Center reported that 50% of respondents in 2008 and 65% of respondents in 2011 believed that the medical advice or information found on the Internet was of no help, and 31% and 24%, respectively, found the information to be of minor or moderate help.` In contrast, the overall positive pattern of responses from the study reported here speaks to the potential benefits of providing such tools online if consumers find the information credible.
Health care reform offers a second context for considering the implications of the user feedback obtained for the DPs. The aforementioned 3022 section of the Patient Protection and Affordable Care Act explicitly calls for use of shared decision making as part of the eligibility requirements for Accountable Care Organizations participating in the Medicare shared savings program. Decision support tools and shared decision making methods are options for operationalizing a necessary and measureable level of patient engagement. A mandate to bolster patient engagement raises questions about the complexity of patients' responses to a shared decision making experience and questions of where best to place interactive health information in the sequence of patient care. Each of these questions is discussed, in turn, after recognition of study limitations.
One limitation concerns the lack of a control group. This study used the participants as a baseline against themselves with no comparison to other individuals who had not used a DP. Inclusion of a control group in further testing of the DPs would strengthen the internal validity of the results obtained. Having comparative data on the knowledge questions would be particularly useful. Generalizations of the results of this study to actual consumer or patient behavior are not possible because of reliance on short-term changes in self-report about participants' intentions to consult with their physician and abide by their physician's direction. People's intentions, however, are widely regarded as a proxy for behavior, and the volunteers for this study were carefully screened before being given access to the online tools. Additionally, the feedback obtained was not in the context of a clinical trial or clinical setting. On the other hand, most decisions about health and medical treatments are ultimately made outside the immediate clinical setting. Finally, the effect sizes observed for the changes in knowledge were very small by conventional standards.
The benefit of using an online decision aid is seen in the confirmation of the percentage of respondents who felt they learned something new and had their decision making clarified through use of the DP tool. The complexity of the process of decision making is seen in the different profiles of assuredness and intentions for each health issue. Across the three health topics covered in the DPs tested, there were significant differences in user perceptions of what was learned, intentions for interaction with the user's physician, perceived support for the choice to be made, and feelings about that choice.
The potential of online health information and decision-making tools to spur conversations with health care professionals raises the question as to where and when to present such tools to patients in the course of their care. To date, most decision aids have been tested in clinical settings under the direction of physicians. This level of clinical control speaks to the opportunities to create environments in which patients and their health care providers can engage in participatory dialogues. However, many clinic workflows preclude extension of the time available for patient-provider dialogues, and clinicians may require fairly extensive training in the use of decision aids. The widespread use of the Internet to find health information and the likelihood of this pattern increasing in the future suggests that clinicians should consider when their patients might best benefit from referral to trusted Internet sites and when, in the course of care, physicians and their health care teams would be available to review patient feedback from such information sources.
Considerably more evidence is needed on how consumers are using the internet to inform themselves about health issues and to arrive at decisions regarding the health care they receive. Clinicians may find the task of procuring such information overwhelming both because of the time required and because of the potential complexities involved in interpreting consumer feedback as seen in the different profiles of consumer reaction for each of the three health issues presented through a decision aid. On the positive side, however, decision aid tools such as the Healthwise DPs have the benefit of being vetted for the accuracy of the information summarized and for the capability of electronically capturing user feedback to questions of knowledge, intentions to act, and personal preferences for care. Internet-supported health information may be one of the keys to meaningfully expanding patients' participation in their care, especially given the impetus to expand consumer engagement under the national health care reform activities.
Discussion
The results of this online evaluation of three decision aids for preference-sensitive health decisions provide baseline feedback on the direction and magnitude of the learning that occurred for each decision aid and on user assessment of the value of the decision aid in thinking through dimensions of choices to be made.
User feedback from this study can be put into two contexts. First, the results add to the understanding of how consumers evaluate the health information they find online. The little evidence available on this question speaks to the importance of ongoing and detailed assessments of how consumers react to what they find in their searches. The Pew Research Center reported that 50% of respondents in 2008 and 65% of respondents in 2011 believed that the medical advice or information found on the Internet was of no help, and 31% and 24%, respectively, found the information to be of minor or moderate help.` In contrast, the overall positive pattern of responses from the study reported here speaks to the potential benefits of providing such tools online if consumers find the information credible.
Health care reform offers a second context for considering the implications of the user feedback obtained for the DPs. The aforementioned 3022 section of the Patient Protection and Affordable Care Act explicitly calls for use of shared decision making as part of the eligibility requirements for Accountable Care Organizations participating in the Medicare shared savings program. Decision support tools and shared decision making methods are options for operationalizing a necessary and measureable level of patient engagement. A mandate to bolster patient engagement raises questions about the complexity of patients' responses to a shared decision making experience and questions of where best to place interactive health information in the sequence of patient care. Each of these questions is discussed, in turn, after recognition of study limitations.
One limitation concerns the lack of a control group. This study used the participants as a baseline against themselves with no comparison to other individuals who had not used a DP. Inclusion of a control group in further testing of the DPs would strengthen the internal validity of the results obtained. Having comparative data on the knowledge questions would be particularly useful. Generalizations of the results of this study to actual consumer or patient behavior are not possible because of reliance on short-term changes in self-report about participants' intentions to consult with their physician and abide by their physician's direction. People's intentions, however, are widely regarded as a proxy for behavior, and the volunteers for this study were carefully screened before being given access to the online tools. Additionally, the feedback obtained was not in the context of a clinical trial or clinical setting. On the other hand, most decisions about health and medical treatments are ultimately made outside the immediate clinical setting. Finally, the effect sizes observed for the changes in knowledge were very small by conventional standards.
The benefit of using an online decision aid is seen in the confirmation of the percentage of respondents who felt they learned something new and had their decision making clarified through use of the DP tool. The complexity of the process of decision making is seen in the different profiles of assuredness and intentions for each health issue. Across the three health topics covered in the DPs tested, there were significant differences in user perceptions of what was learned, intentions for interaction with the user's physician, perceived support for the choice to be made, and feelings about that choice.
The potential of online health information and decision-making tools to spur conversations with health care professionals raises the question as to where and when to present such tools to patients in the course of their care. To date, most decision aids have been tested in clinical settings under the direction of physicians. This level of clinical control speaks to the opportunities to create environments in which patients and their health care providers can engage in participatory dialogues. However, many clinic workflows preclude extension of the time available for patient-provider dialogues, and clinicians may require fairly extensive training in the use of decision aids. The widespread use of the Internet to find health information and the likelihood of this pattern increasing in the future suggests that clinicians should consider when their patients might best benefit from referral to trusted Internet sites and when, in the course of care, physicians and their health care teams would be available to review patient feedback from such information sources.
Considerably more evidence is needed on how consumers are using the internet to inform themselves about health issues and to arrive at decisions regarding the health care they receive. Clinicians may find the task of procuring such information overwhelming both because of the time required and because of the potential complexities involved in interpreting consumer feedback as seen in the different profiles of consumer reaction for each of the three health issues presented through a decision aid. On the positive side, however, decision aid tools such as the Healthwise DPs have the benefit of being vetted for the accuracy of the information summarized and for the capability of electronically capturing user feedback to questions of knowledge, intentions to act, and personal preferences for care. Internet-supported health information may be one of the keys to meaningfully expanding patients' participation in their care, especially given the impetus to expand consumer engagement under the national health care reform activities.
