Hubcaps, Cufflinks, and Patient Access

Some of you may be old enough to remember when cars had hubcaps. Shiny metal things that made your wheels look nicer.  Shaped like a Frisbee; round, convex, and designed to fly. Today, cars do not have hubcaps. I think that is because when your car hit something the hubcaps tended to leave the wheel at a speed of Mach 2 and impact whatever they hit with the force of a cleaver.

If you were riding in your car, you did not know if your hubcaps were on the car, or if they took flight when you hit the last pothole.  You didn’t know because you could not see them from your position.

Last week the woman next to me complimented me on my cufflinks.  I had to turn my shirt sleeve around to see which ones I was wearing.  Cufflinks are a lot like hubcaps in that way—you cannot see them unless you make an effort.

Patient access is a lot like hubcaps and cufflinks.  From where most hospital executives sit they cannot see patient access or patient trying to access their hospital.  To see whether access works, to assess its effectiveness one must go and observe it.  Observe what happens when a patient calls the hospital to accomplish a task. Observe what happens when a patient tries to accomplish something online.

From what I have observed, if hospital executives actually looked at access they would either find it to be broken or at least in need of a makeover.

If you haven’t made over access since people started conducting their business on smart phones and tablets your access is not what it needs to be. And if I cannot access you, it does not matter to me how noisy your hospital is or how communicative your clinicians are. I will keep calling hospitals until I find one that thinks my call is important to them.



What if Amazon ran Population Health Management?

One reason I chose this title is because Amazon may be able to do it better than healthcare providers could do this, and they could probably do it in the blink of an eye.  Let us begin with this.

For two years we’ve all been besieged by the goings and comings of our fellow citizen, nay possible traitor in the eyes of many, Edward Snowden—no middle name available or required.  That in turn has led us to supposedly “learn” more about his former employer, the NSA—The Puzzle Palace. (My father’s former employer.)

Even so, I do not have a dog in this hunt.  Evidently, the NSA has been collecting data; a lot of data.  As a result of the uncovering of Mr. Snowden’s activities or proclivities, several journalists have won awards for their reporting of this story.

The Cliff Notes of the headline of the Snowden story could be stated as: Employee of organization publishes information about people the organization was tracking—clearly this is a bit of an oversimplification since the information that was published could involve national secrets.

Employee of organization publishes information about people the organization was tracking.

Now, if the organization in question was Amazon, Kayak, YouTube, or any other such firm, how would the dialog change?

To allow you to get back to what you are doing, let’s keep this simple.  Amazon.  You shop. I shop. We, she, or it shops.  And when we shop, what does Amazon do?  It recommends, based on the information it has collected about me, what movies I may want to watch—Mel Brooks, what books I may want to read—Lee Childs, and what items I may wish to purchase.

When an organization such as Amazon does this, we do not even blink. We do not shout “treason”. We may even think, “Aren’t they being helpful.”  We certainly do not think that Amazon just committed treason.  We do not jump to the conclusion that Amazon just violated our constitutional rights.

Catch your breath.  Big, awkward segue.

Hospitals.  Hospitals are the anti-Amazon, the ant-NSA.

How so?

Hospitals track everything.  If you went to any kind of healthcare conference and swung a dead cat over your head—not that I recommend you do that—you would hit several vendors selling you healthcare analytics, data warehousing, or business intelligence.

And why do they do that?  How do they use that to their benefit?  They do it to learn what else they should track.  Data collection.  Lots of data. Everything they know about the person whose data they track.

Here we go.

What is the monumental difference between the data accumulated by Amazon or Netflix and the data collected by hospitals?

The difference is that Amazon uses the data to initiate a two-way communication.  Based on this, we recommend that.

Healthcare applications—apps—do the same thing. “If you ate this, you are over the number of calories you should eat today.”  “You walked this many steps today, and you need to walk six-thousand more to maintain your planned fitness level.”  “You did not record having taken your medication today.”

These apps, apps used faithfully by millions of people every day, for the most part could have been written by two people working out of a closet in their basement.  Their users have no knowledge of the background of the people who developed the apps. 

Nonetheless, people use the apps.  They input their data, they get feedback, and based on that they do one thing or the other about their behavior.

So it seems that what is missing is that hospitals have reams of data on patients, discharged patients and former patients, and for the most part the only thing they do with it is use it internally.

So, here is my point.  What could be gained if hospitals did an Amazon, did a Netflix? Would hospitals reduce readmissions and improve population health if instead of simply collecting data they used the data they collected and made recommendations, or communicated wellness options to the people whose data they had collected?  Could they manage better the health of their population?

I think they could. What do you think?

When is Patient Experience like Deck Furniture?

Sometimes it is worth pointing out the obvious; or not. An analyst on CNN, talking about the missing Malaysian plane was explaining why it was so difficult to locate the plane. “Light objects float, and heavy objects sink, and a plane is heavy.”  The evolution of the lizard brain.

Years ago, because of the lizard brain, the government decided that for important decisions, decisions like launching nuclear weapons, the responsibility had to be shared between two people.  That is why two thumbs are required on two launch buttons.  I do not know how things are in your home, but in ours, for important decisions about things like deck furniture, there is only one launch button, and I do not have a user-ID.

Twice a year, in early spring and late fall, my wife and I do the lizard brain dance, and we do it about patio furniture. The spring patio furniture dance is more difficult than the fall dance because the metal patio furniture has been hibernating downstairs in the basement all winter; metal brown bears do the same thing.

Then, when the metal furniture awakens it has to be carried by hand, by the husband from the basement, up enough stairs to make me wish I had installed an elevator, to the deck—the deck that was just power washed by the same husband.  By now I am missing the snow.  I plodded along slowly like a trained pachyderm, a variety of furniture types raised overhead.

I was waiting for my neighborhood friends, guys like me, to set up lawn chairs and watch the parade, but then it occurred to me that they were either hiding from their spouses, or were having their own parades.

Our metal, outdoor patio furniture is unlike any other patio furniture.  Unlike others in that, according to my wife, our outdoor furniture was not built to live outdoors. Not in the winter, and not in the rain.  The seats and cushions were extruded from some unidentified made-material whose half-life was probably exceeds that of the fruitcake my grandmother made when I was twelve, but if it gets wet it may do a Wicked Witch of the West and melt.

Even so, with April being the month of showers, I know I will be hauling the cushions, the same cushions that I just hauled outside, back inside the first time we see a cloud drift overhead.

“They don’t melt,” I tell her.

“Are we missing a cushion?” She asks.

“No, I’ve been soaking one in the guest bathtub all winter.  It looks good as new,” I tell her.

“That is not the same as leaving it out in the rain.” So much for trying to make a point.

So, how do we tie this into something that hopefully makes this few minutes worthwhile for you?  I think that when it comes to assessing patient experience many hospitals think that when their patients are not in the hospital that the patients are hibernating safely and soundly and without a care in the world.

That makes it worthy to ask the questions, what do hibernating patients do?  Often they call the hospital.  They want access.  And how is access defined? A patient tries to schedule an appointment or a lab. A patient needs a refill.  Or has a complication from a medication or a procedure.

Here is why something as simple as being able to answer successfully a call is the first experience for many of people.  And guess what? If we cannot answer a call it does not matter how noisy the hospital is, or how communicative the staff is because that person will not hear the noise.  They will do one of two things, neither of which are good.  They will choose a hospital who can answer the phones, or they will go to ED. Oh, and they will tell others.

A colleague was receiving chemotherapy at a top US cancer hospital.  She spent three hours on the phone trying to schedule an appointment.  Now she spends her hibernation telling others not to go to that hospital.  Hospitals cannot put that toothpaste back into the tube.

If this fall they find any debris from the missing Malaysian airliner, my guess is that they will find a seat cushion.  That cushion will have survived a fiery explosion at thirty-thousand feet, and will have spent six months floating in seawater.  I will point that out to my wife just as soon as I finish carrying my deck furniture back to the basement to begin its hibernation.

If an outpatient falls in the woods, does it make a noise?

There are three ways in which bipods can err.  We can make mistakes, make a social faux pas, or we can just be stupid.  A mistake is something like doing long division and forgetting to carry the one. An example of a social faux pas is practicing your one-man recital of Les Misérables on the flight home from the Beryl conference and because you’re wearing headphones forgetting that those who aren’t can hear you.  Being stupid involves something like being on the train to DC and hoping that you left your car keys in the car, because if you didn’t you will either be sleeping on the streets of Wilmington tonight or filing a police report and hoping they recover your new car.

So in the last twenty-four hours I have accomplished two of the three, and in case you are wondering, no, I was not doing any long division.  So, that was my day.  How was yours?

If you stay abreast of all of the comings and goings in healthcare, one of the first things you note is that there are a lot of comings and goings.

One of the more popular comings is trying to associate recoveries—recoveries of mistakes—by tying them to patient management.  Think of complaint letters, missteps, and plain old mistakes.

Recoveries are a good thing.  But before we waive the flag too loudly and shout look at me, perhaps we ought to see whether all we are doing is blowing out the match that started the forest fire.

Case in point.  We can only correct what we can see.  And, we can only see what we look at or at what we want to see—woe to those with eyes who cannot see.

It seems that in the realm of patient experience the only thing that people can see is inpatients.  The line of outpatients could be wrapped around the block, but if nobody is looking, they do not matter.  The same is true with discharged patients, former patients, and people trying to schedule a first appointment.

These are the people who make up the forest that is burning while everyone is putting policies and procedures in place to blow out the match.  If you are going to try to improve patient experience by not only dealing with recovery issues, let alone walking back the cat to prevent them, why not raise all of the boats—doesn’t work well with the match metaphor, but I’m feeling a bit punkish today.

What do you think?

While you mull this over I’ll be singing Bring Him Home while I am looking for my car.

How to hire an effective Patient Experience (PX) Officer

So, two nights ago, a pretty aggressive rain storm—the local weather people call it an ‘event’—was blowing through my little town.  My neighbor was traveling, and I noticed that the door on his deck was wide open.  I mentioned the open door to my wife and she suggested we might want to call the police.

She suggested we should walk over and see if the Taliban had taken over his house.  Being supportive, she offered to walk over with me.  Just before I popped my head into his family room, I looked over my shoulder only to discover only to discover that her definition of ‘we’ was very similar to a former president explain that “it depends on what your definition of ‘is’ is.”

She was not over my shoulder.  In fact, she was not within a hundred feet of my shoulder.  She had decided to hang back. Perhaps she was thinking that she would be closer to the phone in case she needed to call 911 if she saw my bullet-riddled body convulsing on the rain-soaked deck.

This type of thinking is probably why I am also the go-to-guy in my family for all things that have six or more legs.  Get Dad to do it—he’s expendable. 

So, enough about why I am the poster child for our local therapist.

A lot of people are thinking it would be cool to be on the reality show “Real Housewives of 7-Eleven.”

A lot of hospitals are considering hiring a patient experience (PX) officer.

So, if your hospital is among those considering hiring a PX, what should you be looking for?  If all you want is someone to manage/monitor HCAHPS, you know more about what skills that person should have than I.  I call that role a ‘px’—lower case officer.

However, if you happen to believe that patient experience begins before someone is admitted and lasts well after discharge then read on.  If you happen to think patient experience is not just limited to inpatients, but also includes outpatients, discharged patients, former patients, people with labs and therapy, and prospective patients then read on.

If you are still playing along, my contention is that when it comes to hiring a ‘PX’—upper case, and knowing what to do with a PX, pay more attention to the person’s knowledge of the ‘X’ and less to their knowledge of the ‘P’.  After all, the hospital is chocked-full of people that understand the P-side, the clinical-side.

What most hospitals need is someone who can help them with visioning a remarkable experience for every person every time on every device, not someone who can squeeze out the last decibel of noise on the floors.

Hospitals should look for someone who can ask the right questions, the questions that make everyone else uncomfortable.  Questions like:

  • What if every person could go from and to:

o   I need an appointment

o   I want to schedule an appointment online

o   I want an online appointment for today

  • Can patients pre-admit using their iPad
  • Can patients interact with their physicians online regarding their compliance with discharge orders
  • Can readmissions be reduced by recasting patient experience
  • Can patient experience play an active role in population health management

While that is not an exhaustive list of the types of questions a PX officer ought to be considering, it is a pretty good start.

Population Health Management: What if it included Patients?

Being efficient at population health management that doesn’t include the patients that comprise the population is pointless. 

Suppose that on Thursday a meteorologist, or a sociologist, or a philatelist came to my little town located west of Philadelphia with the mission of reporting to their constituents the weather in Downingtown, Pennsylvania.  From three days of observation they would report the following—it doesn’t snow, the grass is always brown, and they skies are always grey.

Would they be able to produce a report that provided an accurate assessment of the weather of Downingtown, or would they only be able to produce a report of the weather for those three days?  If those individuals tried to forecast Downingtown’s weather for the year based on three days of extrapolated data they would be ridiculed, even worse, they would be wrong.

The biggest problem with most population health management efforts is that they overlook a critical success factor—the health of their patient population throughout the year.  It is too easy to scrutinize a patient during the short brief period prior to their visit, during the visit, and just after discharge.  Those are only snapshots of someone’s health, snapshots that discount what is happening during all of the days and weeks and months when the patient is not front and center.

Perhaps the second biggest problem when it comes to tackling population health management, managing the health of the population, is that the effort must include the population. Mustn’t it?  What I mean by this is the following.  Let’s say a hospital has a registry of three thousand OBGYN patients, and it discovers that one thousand of them are overdue for a mammogram.  It contacts those one thousand, and five hundred women respond and schedule their mammograms.  

Clearly, scheduling those five hundred women is a good thing.  Addressing their needs passes the test of being necessary, but it does not pass the test of being both necessary and sufficient. Doesn’t it beg the question about what is being done to manage the health of the other two thousand women?  Doesn’t it beg the question of what is being done to manage the health of the other women in their radius of service?

The problem lies with providers’ inability to interact all of the time with all of the people—patients, discharged patients, former patients, and prospective patients, that comprise the population.

Most population health efforts are based upon what the hospital knows about you, the patient.  These efforts rely solely on the data they have about you; business analytics, data warehousing, EHR—Healthcare Information Technology.

The can slice and dice your data, and the more they have the better they can manage you.  If the hospital sees you once this year, they get more data to slice and dice.  If they see you twice this year they may have twice as much data.

But for how many days of each year does the hospital not know anything about the health of the patient it is managing?  Three hundred?  Three hundred and sixty?

Glenn Steele, Jr., MD, president and chief executive officer of Kiesinger Health System stated “Another really good example: When we, as a group of providers, whether it’s docs or PAs or nurses or pharmacists, when we hand an individual who’s got a chronic disease a prescription, we assume that they, number one, agree with our recommendations for the treatment, and we assume they’re going to get the prescription filled. Those assumptions are wrong between one-third and 50 percent of the time. Isn’t that amazing?”

Hospitals have no way of knowing if their patients refill their prescriptions or take their medications.  If hospitals knew this information they would do a much better job managing the health of those patients who make up their populations.

For hospitals to know this type of information the model for population health management would have to change. It would have to go from a 1-way model to a 2-way interactive model.

One of the critical success factors for population health management is getting patients to take ownership for those parts of their health for which they can self-manage.  Twenty-one percent of American adults, more than fifty-five million people, use healthcare apps, and half of them use those apps more than once each day.

I use MyFitnessPal, a run-tracker app, and count my steps using my phone.  The last time I interacted my hospital was to schedule my annual appointment, and I had to call them to do it.

What if population health management were two-way?  Me to the hospital and the hospital to me.  What if my communication to the hospital was daily?  What if my hospital had a way for me to upload information about my workouts, my diet, my weight, pulse and blood pressure?  What if I could upload daily when I took my medication?

What if the hospital had a way of monitoring and responding only to data I submitted that was an exception?  What if the hospital could email or text me attaboys?

Twenty percent of the population are using apps and smart devices to manage their health.  Almost none of those twenty percent are using apps developed by their hospital.

What if?  What if they could?



Patient Experience on Banker’s Hours

Sometimes I can’t help myself.  I am still stuck on the question of whether people believe that adding a screen saver to the computer terminals of hospital staff employees reminding everyone to be quiet is the equivalent of reinventing the patient experience mousetrap.

Accordingly, I thought I would offer a few ideas of my mine on that mousetrap to move the conversation in a different direction. 

A 15 cent innovation—Raise your hand if you know someone who snores.  Now, if you have ever used earplugs to combat the snoring, raise your other hand.  Now look around.  Most of you have raised both hands.  You wear the earplugs because it blocks out the noises other people make.  Offer your patients earplugs, and for good measure through in a sleeping mask. I have not done the math but I’d bet the ROI—Return on Innovation is pretty high.

A slightly more expensive investment, but what is the real cost of a comma or two when patients go somewhere else? When was the last time you called your phone company or your cable company? It is never a pleasant experience.  But, you know what? You can have that unpleasant experience 24 x 7.

You cannot do that with hospitals.  That is because most hospitals concluded that there is never a good reason to talk to you before 8 AM or after 6 PM Monday through Friday.

Banker’s hours.

Banker’s hours used to mean something.  You had to run to the bank to deposit your check before it closed.  Now you can do whatever you need to do with your bank, except get the lollipop, 24 x 7.

Try scheduling an appointment with your hospital Saturday evening. If that doesn’t work, use your time more wisely.  Call Verizon and ask them to explain your bill.