MDM in practice – Page 3 – Minimally Disruptive Medicine

Care plans and goldilocks healthcare

By Allison Verdoorn
Designer researcher at Mayo Clinic Center for Innovation

Patients with multiple chronic conditions often experience not only the burden of their physical illness but also the burden of treatment caused by the work associated with the interventions prescribed to them by their medical team. While the work a patient has to do increases, the illness that necessitated the treatment typically reduces a patient’s capacity to do that additional work.

The Minimally Disruptive Medicine model seeks to reduce the burden the medical community places on patients in the delivery of care. With interventions that range from reducing the amount of paperwork a patient is asked to filled out to consolidating prescription pickup and refill times to coordinating appointments of families and spouses, the Minimally Disruptive Medicine model identifies the elements within the health care system that add more workload onto patients and works to eliminate those tasks from their experience.

Care plans are widely recognized as a need across many areas, both inpatient, outpatient and out among community health services. Our vision for a care plan is that it is more than just a document, but a shared reality that is created together with the patient. This speaks not only to the need to create a space for shared decision making among patients, their families, clinic care team, and community resources, but also to display this information in a way that is readily accessible to all involved.

The Community Health Transformation platform at the Center for Innovation is connecting with Minimally Disruptive Medicine and Shared Care Plan teams at Mayo Clinic to understand how dashboard tools can help the clinical team, patients, caregivers, and their social support networks to visualize patient goals, levels of health care workload and capacity, and to assist in decision making and interventions.

MDM in practice

Farmacia minimamente impertinente

Desde La Sala de Lectura, el muy recomendable blog del Rincón de Sísifo, viene un primer eco a la presentación sobre Medicina Minimamente Impertinente que dimos en el congreso nacional de farmacéuticos de atención primaria en Bilbao. Fue un gran placer presentar en esta ocasión y disfrutar luego de los comentarios en twitter y en este blog sobre lo que podría ser. Gracias por soñar con nosotros.

MDM in practice, Reflections on MDM

Tailoring treatments to patient capacity

In a provocative piece, Slate magazine’s Darshak Sanghavi writes about “tiered medicine” and proposes that clinical protocols be titrated to patient capacity. This again approaches the notion of “Goldilocks” medicine we spouse in Minimally Disruptive Medicine. We have also discussed the need to have guidelines that appreciate this issue and that perhaps efficacy may need to have a secondary priority, particularly among patients who are overwhelmed with multiple chronic conditions.

MDM in practice, Reflections on MDM

Administrative disruption as a component of treatment burden and as opportunity for minimally disruptive medicine

I had a patient who told me that she was not experiencing any significant burden of treatment from caring for her type 1 diabetes. A minutes later she went on to tell of a tragicomic experience trying to get an Omnipod insulin pump: calls to diabetes clinician, educator, insurance company, Omnipod rep, plus their administrative assistants, voicemails, faxed forms requests, etc. This story made me think of this brilliant video by The Altons:

This video of Air Healthcare is based on an article by Jonathan Rauch in The National Journal Magazine here.

Clinicians need to be aware of what happens in their own front offices, back offices, and the administrative challenges patients face with access to them, their medicines, devices, and other components of their care. These disruptions may lead to poor treatment fidelity and outcomes. A minimally disruptive medicine approach would apply lean methods from a patient centered perspective to correct this situation. Thoughts?

MDM in practice, Reference material, Research on MDM

Who benefits the most from minimally disruptive medicine?

We are actively working to make MDM a reality in our primary care practice. A key step involves identifying patients who may benefit the most from MDM, or the most intensive form of MDM at least.

After some discussion we came out with this list (order does not necessarily implies importance)

Patient has a complicated treatment regimen and is overwhelmed by it (as judged by self report, nonadherence or other strong clue)
The current form of care does not meet the patient’s needs
The patient’s health is at risk of a health catastrophe if we do not take action
The patient is willing to invest in MDM work with the goal of achieving the patient’s goals for life and healthcare while reducing the burden of treatment (the imbalance in patient workload to patient capacity)

We will probably need to develop some criteria to flag charts in a busy primary care, yet all these require “conversation” – the healthcare team needs to become aware of the first one, needs to realize the second and third one, and needs to engage the patient for the last one.

I look forward to your thoughts and ideas on who would benefit the most from MDM?

MDM in practice, Reflections on MDM, Views from the frontline of care

The patient voice – the need for a minimally disruptive medicine service

We are working as a multidisciplinary team to develop a service offering for patients with multiple chronic conditions that will reduce the burden of treatment while pursuing patient goals in primary care. We are trying to learn as much as we can from other models such as PACE and Graded care. We are also learning as much as we can from our colleagues in multiple disciplines and in public health. And, of course, from our patients.

During an in-depth interview, one of our patients commented to the notion of a MDM service the following

I wouldn’t mind having like the whole team of doctors that I work with being able to sit down with them and look at the whole picture and decide a plan that would work out for all of my illnesses and how maybe I could avoid certain things or certain costs or just help me live better, period.

…I just think the biggest, most important thing in illness is having all the doctors be on the same page and know what is going on with you individually so that they can help you meet your best expectations and your best health.

Hi expectations we will have to satisfy if we are to make a difference to the workload/capacity balance of these patients. Onwards!!

MDM in practice, Reflections on MDM, Views from the frontline of care

Minnesota to be first in nation to embrace ‘goldilocks’ medicine

This week marks the potential start of the implementation, evaluation, and eventual adoption of minimal,y disruptive medicine in Minnesota. Three events marked this week.

The first one involved the formation of a team that will be implementing MDM in a primary care practice. This iterative effort will involve identifying complex patients and figuring out what healthcare and the community can do to reduce treatment burden. This effort will be oriented by the application of the cumulative complexity model based on normalization process theory and the insights we have accumulated from interviewing patients.

The second development involves the publication in Minnesota Physician of an article about minimally disruptive medicine. A similar piece will be published in their publication for patients. The dissemination of the concept I thing creates the space and mind frame for experimenting with care delivery models with an underlying approach to care, not just with an underlying approach to reimbursement. The former being much more exciting and motivating than the latter.

The third development took place April 4th 2011 in Saint Paul, MN. Möbius Inc convened a citizens meeting to discuss healthcare. I was in the first panel along with Dame Jo Williams and Sanne Magnan from ICSI. Sanne and I turned to do a 1-2 on healthcare as we know it, making a big push to redesign the system, reducing it’s footprint, and pursuing more health based on community action. Groups got together later in the day around their areas of passion. Our group started working right away looking for ‘bright spots’ (AA, diabetic bus, habitat for humanity), thinking about pilot projects; and job-creation schemes that will connect the isolated, connect existing resources to people that would benefit from these but does not know of them or of how to access them (e.g. Dial 211). We were able to present our findings to the Commissioner of Health and other officials. Citizens power was never so palpable, and that some of them rallied behind goldilocks care is just awesome. More to come soon!

MDM in practice, Reflections on MDM

More about reducing treatment burden – this time from burden “caused” by patients

Dr. Michael Wolf and his team from Northwestern University have published an interesting article in the Archives of Internal Medicine looking at the complexity in medication intake. We had reported on a case like the ones explored in this study in our original Minimally Disruptive Medicine paper.

In this new study, the authors conclude that:

Many patients, especially those with lim- ited literacy, do not consolidate prescription regimens in the most efficient manner, which could impede adherence.

Although this study consisted of a simulated situation, it is indicative of patients approach to medicine use (without the assistance and input of other team members, such as a spouse which in my experience often assists with these tasks). In this study, patients with low literacy complicated their program!! This means that the patient unwittingly contributed to increase their own disruption.

Arguably, this happens because patients do not have the knowledge, skill, or self-efficacy to treat medicine schedules as they treat picking up the kids or brushing their teeth. These are activities they understand in their nature and consequence and as a result they can modify to make very efficient (like applying lean to your own life…lean consumption). But this is not available to these patients regarding the meds. As a result they overly complicate their routines! Fascinating, and a great opportunity for minimally disruptive medicine.

MDM in practice, Reflections on MDM, Views from the frontline of care

A patient ¨pushes back against physicians¨? Minimally disruptive medicine brought about by patients

This post in the Wall Street Journal highlights a point of view to which I keep arriving: clinicians may not be able to bring about changes in healthcare consistent with minimally disruptive medicine unless patients demand it. A real patient revolution will be necessary to help clinicians realize a future that — as I learned from Judt — they cannot make happen because the ideology of the healthcare industry does not allow them to imagine it. But patients may not yet be help by the same limitations. This WSJ post is therefore, to me, a manifestation of hope.

MDM in practice, Reflections on MDM, Views from the frontline of care

How I came naturally to minimally disruptive medicine!

By Kevin Larsen, MD (Chief medical informatics officer, Hennepin County Medical Center)

I really love this concept since I first saw the opinion piece. I think I came to this naturally growing up with a brother who is a type 1 diabetic. In the early days of diabetes management it was maximally disruptive medicine – managing your life around your diabetes. Type 1 self management revolutionized this and when done right puts the patient in control of managing his/her own diabetes around their diet, lifestyle etc. I try to bring this approach to all of my patients conditions whenever I can.

Another aha! moment I had around this was at a site visit to a hospital in Panama. They had developed a program called “hospital at home.” Nearly all non-ICU patients had a one day stay or less in the hospital. The hospital arranged for doctors, nurses and therapists to go to the patients home, often multiple times a day to deliver care. They proved they had better outcomes with less falls, less delirium and it cost much less money. Plus patients loved it.