Integrating a Patient Decision Aid into the Electronic Health Record: A Case Report on the Implementation of BREASTChoice at 2 Sites

Patient decision aids can support shared decision making and improve decision quality. However, decision aids are not widely used in clinical practice due to multiple barriers. Integrating patient decision aids into the electronic health record (EHR) can increase their use by making them more clinically relevant, personalized, and actionable. In this article, we describe the procedures and considerations for integrating a patient decision aid into the EHR, based on the example of BREASTChoice, a decision aid for breast reconstruction after mastectomy. BREASTChoice’s unique features include 1) personalized risk prediction using clinical data from the EHR, 2) clinician- and patient-facing components, and 3) an interactive format. Integrating a decision aid with patient- and clinician-facing components plus interactive sections presents unique deployment issues. Based on this experience, we outline 5 key implementation recommendations: 1) engage all relevant stakeholders, including patients, clinicians, and informatics experts; 2) explicitly and continually map all persons and processes; 3) actively seek out pertinent institutional policies and procedures; 4) plan for integration to take longer than development of a stand-alone decision aid or one with static components; and 5) transfer knowledge about the software programming from one institution to another but expect local and context-specific changes. Integration of patient decision aids into the EHR is feasible and scalable but requires preparation for specific challenges and a flexible mindset focused on implementation. HIGHLIGHTS: Integrating an interactive decision aid with patient- and clinician-facing components into the electronic health record could advance shared decision making but presents unique implementation challenges. We successfully integrated a decision aid for breast reconstruction after mastectomy called BREASTChoice into the electronic health record. Based on this experience, we offer these implementation recommendations: 1) engage relevant stakeholders, 2) explicitly and continually map persons and processes, 3) seek out institutional policies and procedures, 4) plan for it to take longer than for a stand-alone decision aid, and 5) transfer software programming from one site to another but expect local changes.