President's Desk, October 2013
Liana Lianov, MD, MPH, FACPM
Diffusion of the Lifestyle Medicine "Innovation"
Every summer I teach the behavioral and mental health section of the ACPM board review course. One of the constructs we cover is the diffusion of innovation by Everett Rogers. This year I have been reflecting on how the lifestyle medicine movement faces challenges similar to any innovation or approach that moves away from established methods and procedures.
Lifestyle medicine requires a disruption in the way medicine is routinely practiced, a different approach to the clinical encounter and office setup. Replacing an old process with an advanced tool can't be successful without making appropriate changes in the entire system. Implementation of electronic health records by simply using them in place of paper records is a good example of how not to advance transformational change.
Let's take a look at the advancement of the LM movement through the lens of diffusion of innovation model. How does the potential spread of lifestyle medicine measure up relative to the twelve elements that determine the speed at which innovations are adapted by systems?
1. Does the innovation offer a relative advantage to the established way of doing things? LM has the advantage of improving outcomes at lower cost, enhancing patient and provider satisfaction and boosting patient engagement. Also, as payment of healthcare shifts to be outcomes dependent, reimbursement will rely on practices that align with LM.
2. Is the innovation compatible with the existing system? LM is compatible with the Chronic Care Model and patient centered care. In fact many of the LM competencies are similar to elements of the Care Model.
3. Is implementation of the innovation low in complexity? LM focuses on the four key behaviors: healthy eating, physical activity, not smoking, and avoiding risky alcohol use. The clinical and counseling practices appropriate for these four behaviors can also be applied to other health behaviors. That simplifies the overall practice approach. And although nutrition is complex, the basic recommendations can be simplified and can be summed up by emphasizing a whole food, plant based diet. Changes in clinical practice to emphasize LM can be simplified by utilizing the resources, training and tools being developed by ACLM and its partners.
4. Can the new innovation be tested on a trial basis? LM can be implemented on a short term or intermittent basis in order to test potential results. A clinical practice can offer LM focused care on certain days of the week in order to test the clinic flow processes and business model. For example, shared medical appointments to address lifestyle related conditions can be offered one day a week to start.
5. Can the impact and outcomes of the innovation be easily observed? Provider and patient satisfaction can be noted fairly quickly after initiating LM focused clinical encounters. The interaction is patient centered and directed to achievable outcomes that can feel positive for both patient and provider almost immediately. It takes longer to observe impact on outcomes, of course. But cholesterol and blood pressure, among other indicators, can improve as quickly as a couple of weeks for patients fully immersed in a healthy lifestyle.
6. Does the innovation protect valued social relations? Innovations that disrupt well accepted and comfortable social interactions are not quickly adapted. LM actually offers the opportunity to enhance what is valued in the provider-patient relationship, as well as harness the power of the clinical team, boosting team satisfaction. The provider can briefly discuss and prescribe specific diets and physical activities. The team can offer supportive counseling and education and refer the patient to resources.
7. Is implementation of the innovation reversible? A clinical practice can integrate several elements of LM throughout a primary care setting or dedicate part of the practice to LM. That way, the practice can easily revert to its original practice style if the business model or other elements are not satisfactory.
8. Is the innovation easy to communicate to others in the system? This element presents a challenge to the LM leadership. The value of LM is easy to communicate. But convincing practitioners that they are not practicing LM as envisioned by the LM community is more difficult. Many practitioners believe they are already addressing lifestyle factors as much as is feasible. The LM community is working on crafting value messages and effective communication vehicles about how LM differs from standard practice.
9. Does the innovation take minimal time to implement? Redesigning a clinical practice to focus on LM takes additional time and resources. The LM community is developing training and tools that are easily implemented to shorten this time.
10. Is there little risk and are outcomes fairly certain when implementing the innovation? Starting a LM clinical practice can be financially risky, as we are challenged by the lack of adequate reimbursement. Some models have been identified, such as shared medical appointments and collaboration with health psychologists who can obtain independent reimbursement. The shift to outcome-based care may open doors for LM practices within larger systems, such as accountable care organizations, that offer new streams of reimbursement.
11. Is minimal commitment required to implement the innovation? Practicing LM successfully does take commitment to move out of the comfort zone of offering brief interventions, prescribing medications and referring to other practitioners. Success depends on revising every step of the clinic flow to emphasize lifestyle factors, adjusting medical records to fully align with LM, training team members about their specific role in offering LM care, identifying community and digital resources to support patients between visits, and conducting quality improvement cycles until improved process and outcomes are achieved.
12. Can the innovation be modified to specific populations and settings? LM can most certainly be modified to address the specific needs and interests of various ethnic populations, geographies, medical specialties, and practice settings. As LM takes hold across settings by a variety of practitioners, we can aim to build a "library" of effective approaches to LM across the world!
Upon reviewing the elements of the diffusion of innovation model, how did LM measure up? My count reveals that LM fares well on eight of the twelve elements. LM "passes" on relative advantage, compatibility, simplicity, trialability, observability, maintaining valued social relations, reversibility, and modifiability. The challenges are communicability about LM's unique aspects, and risk/uncertainty, commitment as well as time required to set up a successful practice. On the bright side, LM is working diligently to overcome these challenges with resources, tools, training, and practice models.
The future looks bright for the diffusion of lifestyle medicine! Please join us in October in Washington, D.C. for the ACLM conference to learn more and help spread the LM "innovation".