A thought for Thanksgiving: Thank you for reading my little blog

May I take you on a tour of my home?  You enter through the front door.  On the right is the living room, on the left sits the dining room.

The living room looks exactly like it did the day the movers dropped off the furniture.  It might as well be cordoned off with red velvet rope and polished brass stanchions.  It reminds me of taking the tour of Independence Hall, seeing the quill pen right where Mr. Hancock left it.  Nothing has been disturbed over the years.

We don’t use our living room.  We vacuum and dust it, just like everyone does.  We didn’t use it when I was young either; I’m starting to think it might make a good spot for a hot tub.

Opposite the living room is the dining room.  If your family is like mine, when the dining room isn’t being used for folding laundry, building jigsaw puzzles, or preparing taxes, it is used for high holidays, proms, weddings and funerals.

We have a hundred year old china service I bought from England on eBay.  We’ve probably used it a half dozen times.  It’s for special occasions—like the passage of the healthcare reform bill.

Thirteen years ago this Thanksgiving I was sitting on the floor of our dining room, inspecting our china and silverware when I came upon an unopened box of off-white, tapered candles. I found it tucked away under a pile of starched cotton linens.

The discovery of the candles gave me pause.  The receipt was still taped to the candle box—purchased five years ago.  Why?  In case we needed them.  In case there was an occasion so special as to warrant candles. At the rate we were using them, our candles and china would have lasted for hundreds of years.

I remember thinking, what occasions warrant the lighting of candles? 

I almost never had the chance to learn what occasions would cause me to light our candles.  Less than two weeks after our candleless Thanksgiving, December 8, 2002; a Sunday evening. I was alone in our theater room, engrossed in an episode of the Sopranos. My chest was expanding and contracting with each breath, the only thing missing was the oxygen. I was having difficulty breathing, a lot of difficulty.  I paused the show, and I snuck outside to have a cigarette, thinking I could clear my head and sort out why I the whole breathing thing wasn’t working.

Not finding an answer, I returned to the Sopranos. At the end of the show I headed upstairs. According to my family I was looking pale and I was sweating profusely. I remember mentioning that I was having trouble breathing. Apparently I was having so much trouble that I collapsed to the floor.

Less we be distracted, these few paragraphs are about the unwrapped candles, not the heart attack.

I remember thinking, as I lay strapped to a gurney in the back of the ambulance, about those darned, unused candles. The candles I was saving for an important occasion.

I am willing to bet that a lot of people are saving their candles for more important occasions.

What I have worked hard at remembering during the last thirteen years is that no occasion will ever be any more important than the occasion of simply having tomorrow.  These days we burn the candles. We joyfully stain the linens, and occasionally we break the crystal and the china. For whatever it may be worth, consider lighting a lot of candles this year.

Warm regards, Paul


How Could Healthcare Relationship Management Change Healthcare Forever?

“If you’re in a horror movie you make poor decisions. It’s what you do.” A group of kids are running from a murderer in the middle of the woods when they stumble upon an old cabin. “Let’s hide in the attic. No, in the basement.” One woman starts breaking down and is in tears “Why can’t we just get in the running car?!” She is dismissed as crazy “Are you crazy?! Let’s hide behind the chainsaws.” They agree “Yea, smart.” They run behind the chainsaws but don’t notice the murderer standing behind them. The murderer gives them a look as if he can’t believe how stupid these kids are. They finally notice the murderer and run off “Head for the cemetery!”

Poor decisions. Head for the cemetery. Whether you are in the provider, payer, or pharma communities, we’ve all been in one of those meetings where someone suggests why can’t we get in the running car. And we dismiss her and run towards the chain saws.

Suppose the running car suggestion is, “We need to create daily habituation with our patients and consumers.” Stated more simply, we need to get them to interact with us daily, not just once every two to three years. If a patient or consumer only contacted us once a year, creating daily habituation means getting people to increase their rate of contact by 36,500%!!!

So, how do we achieve daily habituation, and what would it look like?

There is a great deal of activity in healthcare around cloud computing. Almost every health organization is doing something with a cloud, but only with their own cloud. But few if any health systems share their cloud any more than they share their cafeteria. Not only do they not share it with other providers, they don’t share it with payers, they don’t share it with pharmacies, and they do not share it with their patients and consumers.

For example, Philadelphia has several very good health systems. Imagine looking out from the top of one of the city’s highest buildings—what would you see? You would see a cloud hovering above the Hospital of the University of Pennsylvania (HUP). Across the street another cloud would be floating above CHOP. One above Thomas Jefferson; one above Einstein, Hahnemann, Cancer Treatment Centers, and the Philadelphia VA.

A few dozen single clouds. Partly cloudy.

You continue looking, and you see that the sun is shining on all of the people entering and leaving the various health systems. That is because the clouds only cover the health systems. The clouds do not cover the patients or the visitors or the family members.

If you are asking yourself, so what, the answer to so what is the missing link for achieving daily habituation. As a matter of fact, that answer is the missing link for achieving any kind of habituation. People, your patients and your consumers, are missing the two things they need the most to drive any kind of habituation:

  • They have no easy way to communicate anything about their health with you—we both know that your call center is not a communication tool; calling your organization is the last act of a desperate person
  • Your organization has not given them a compelling reason to communicate with you more than they do

What healthcare needs is Healthcare Relationship Management to interconnect:

  • Patients and providers
  • Consumers—prospective patients—and providers
  • Consumers and payers
  • Consumers and pharmacies
  • Providers to payers to pharmacies to consumers

Healthcare needs a Healthcare Relationship Management Cloud, a HRMC. An interactive (think 2-way) interconnected way of communicating about whatever one party wants the other party to know.

And what do patients and consumers want you to know about them? Nobody knows. And the reason nobody knows is that nobody ever asked them. Heck, if we are being honest, most providers do noteven track why people call.

Last week I met with a senior executive of a very large payer. During our meeting I drew a large, oblong shape to represent his customers. Way over by one end if the shape I portioned off a small bit of the shape to represent the fraction of his customers that interacted with them on a regular basis. Our discussion focused not on the tiny portion of people that communicated with his firm, but rather on the much larger group of customers that never communicated with them. He said they call that group of people the tail. While the term probably was not intended to reference the idea of the dog wagging the tail, it could apply.

Providers have a portion of the population they serve that represents the tail—patients and consumers who do not interact with them. So do pharmacies. Not interacting, and not needing to interact are two different things. Not interacting results from:

  • No compelling reason to interact
  • No easy way to interact

Now suppose consumers had an easy way to interact with your organization on a regular basis. And suppose they had a compelling reason to interact with your organization on a regular basis. Why would that be a good thing for both parties? These are a few things that spring to mind:

  • Healthier people
  • Improved care coordination
  • Reduced admissions and readmissions
  • Population health management
  • Patient acquisition and retention

And that is why I wrote about the HRMC. While there are benefits from everyone having their own clouds, there are many more benefits to everyone being interconnected through a single cloud. Something like the NwHIN on steroids. Of course that is overly ambitious, but there is no reason for a provider not to build one for its patients and consumers.

How Is OpenTable’s Concept Improving Healthcare Consumerism?

You may remember reading that I have never seen a health system website that seemed to reflect an understanding, even at a very basic level, of consumerism; never seen a website that let people schedule appointments—I’ve never seen my pancreas either, but that doesn’t mean it doesn’t exist.

There are a small number of health systems whose websites suggest people can schedule appointments. There will be a link titled, “Schedule and Appointment.” But when you click on the link you will be sent to a page that has a phone number and has instructions to call between 8 AM and 5 PM Monday through Friday. Or there will be a text box in which you can request an appointment.

I wrote about a Philadelphia health system whose gala I am attending this Saturday night, whose advertisement on the local television channels instructs viewers to go their website to schedule an appointment. Went there, did that. The words schedule an appointment was not to be found.

A pancreas?

At 3 PM yesterday, I still held firm to my belief that online patient scheduling was my gossamer ideal. I was tilting at windmills. By 3:15, my opinion had changed. I was speaking with the Chief Experience Officer of St. Thomas Health in Nashville, Dawn Rudolph.

I was midway through my disquisition, droning on about how I wished I could find a single organization that was doing anything resembling consumerism. “We’re doing that,” she said after I mentioned online scheduling.

I’m doing my best not to say, “Sure you are.” I’m picturing a link to a phone number, or perhaps an empty text box. Perhaps she sensed my doubt. Maybe that is why she spelled out the letters of the system’s URL, and told me where to navigate on the page to find the scheduling link—it’s about halfway down the page. (https://www.sths.com/Pages/Home.aspx)

Click, click. And staring back at me were physician’s faces, available appointment types, appointment dates, appointment times, and a big blue button, CHECK IN.

For those of you familiar with the OpenTable website that provides real-time restaurant reservations, it is the same concept. Is it the be-all end-all of how I envision consumerism? No, it’s not. But it’s a good start—sort of like the answer to the question, “What do you call a thousand lawyers at the bottom of the ocean?”

Healthcare Consumerism: What Is The Most Important Missing Link?

All things being equal. We use the phrase a lot. It occurred to me that the only reason to use the phrase is that more often than not, all things are not equal.

In healthcare, experiences never equal expectations. The last best experience that anyone has anywhere becomes the minimum expectation for the experience they want with their healthcare organization–I borrowed that phrase from a colleague.

If you look at which U.S. firms were market leaders ten years ago, and compare that list to today, you will find many of those firms are no longer on the list—go digital or go home. What is it that the best consumer-focused firms in the country do that others don’t? They created a value-experience that gets consumers to visit them daily.

And how did they do that; were they just lucky? The easy answer would be to say that they put much of their business online. But that cannot be the whole answer. Providers and payers are online and none of them are listed as the best firms to work with. Being online does not get their customers, or patients if you prefer, to visit them daily. Heck, many customers and patients never visit their provider or payer online. And why not? Let me toss the question back at you; why would they? Can you think of a single reason why one of your customers or patients would visit your organization online every day?

Simply being digital is not the solution. Your EMR did not create a bold, new way of healthcare; it simply digitized the old way.

The statement about inequality at the start of this piece becomes relevant in this discussion because your organization likely created the inequality. It all comes down to expectations. Fact 1: If you do not know the expectations of a customer or patient you will never meet or exceed those expectations. The user experience continues to be less than the user’s expectations of what that experience should be.

Fact 2: Nobody’s user experience on the phone with their provider or payer will exceed their expectations. That is because given the choice most people would rather interact with you online. You don’t want to call your payer or provider anymore than they do, so why make them?

Terry Orlick published “Pursuit of Excellence” decades ago. The book was an instant hit; everyone read it. And the reason everyone read it is because people were astonished to learn that simply being average was the new excellence. The rule of thumb for delivering a customer experience became, “We may not be great, but we are at least as good as they are.”

Imagine a world where every single interaction you had with your payer or provider could be done online and done while providing a remarkable user experience. Now imagine a world where the user experience was so good that your customers came to you every day—I know, that sounds absurd.

Providers who are saying, “There is no way we could get people to visit us daily, we cannot even get them to visit us once a year,” are not imagining a world. To get people to come you must give them a reason to come.

“Why would a healthy person want to visit us every day?” How about because they want to stay healthy? Try this exercise. Put your most creative people in a room and tell them not to come out of the room until they have imagined a compelling reason to get people in your community to visit your health system online every day.

Here’s a hint. I visit my phone every day, going to two different health-related applications—tracking my exercise and my diet. These applications don’t share information with each other. They do not assess my health, and they do not warn me when my health data should raise an alarm. They simply store data—just like your hundred million dollar EMR.

Other than a lack of imagination, there is no reason your health system cannot offer your customers, members of the population whose health you are supposed to be managing, a web-based super-app that creates a super experience. One that causes them to reach out to you.

What if that super-app let consumers do the following?

  • Enter a range of health-related data; exercise, diet, vital signs, track use of prescription medications
  • Share data among the apps
  • Review the data
  • Assess someone’s health based on that information
  • Warn the person if something seems amiss
  • Let them chat with you
  • Let them ask you to call them

People who are not even your patients might sign up for that. Sally did. Sally is forty-one, married, and has two children. Sally and her family just moved to your service area.

Now imagine that from that same super-app Sally could:

  • Select a primary care provider
  • Schedule an appointment online, using a mobile device, or by phone
  • Choose between an office, tele-health, and in-home visit
  • Be provided with the different prices for each appointment type
  • Be told what her out-of-pocket cost would be for the appointment
  • Receive payment confirmation
  • Be notified that her payer information was submitted
  • Update her health profile online and create profiles for her children
  • Track her health-points
  • Chat with a nurse
  • Review her labs
  • Request an authorization
  • Be notified her doctor is running 20 minutes late
  • Set up a payment plan
  • Be notified to schedule their children for school physicals
  • Have her families prescriptions refilled automatically…and so forth

That is what we have been talking about. That is a customer portal. Sally thinks you did this all for her. But you know that once Sally has entered all of her information into your health system she is no more likely to change health systems than she is to change banks.

Zero-cost patient acquisition and retention–the missing link. Imagine a world.

How To Hire A Patient Experience Officer

So I’m making dinner the other night and I’m reminded of a story I heard on NPR. The narrator and his wife were talking about their 50-year marriage. One of the stories the husband mentioned concerned his wife’s meatloaf. Their recipe for meatloaf was one they had learned from his wife’s mother. Over the years they had been served meatloaf at the home of his in-laws on several occasions, and on most of those occasions his wife would help her mom prepare the meatloaf.

Her mother would mix the ingredients in a large wooden bowl including the ground beef and ground pork, which were sold in one-pound packages. She’d knead the mixture together, shape into a loaf, and place the loaf into the one and a half pound baking pan, discarding the leftover mixture.

His wife always prepared the dish exactly as her mother. One day he asked her why she threw away the extra meatloaf instead of cooking it all. She replied she was simply following her mother’s recipe. The husband said, “The reason your mom throws away part of the meatloaf is because she doesn’t own a two-pound baking pan. We have a two-pound pan. You’ve been throwing it away all of these years and I’ve never known why until now.”

Therein is the dilemma. We get so used to doing things one way that we forget to question whether there may a better way to do the same thing.

Many health systems are taking a two-pound baking pan approach to hiring a patient experience (PX) officer. I think most health systems are looking for a ‘px’—lower case—patient experience officer, someone to manage and monitor HCAHPS.

But, if you happen to believe that patient experience begins before someone is admitted and lasts well after discharge a ‘px’ won’t be of much help.  If you happen to think patient experience is not just limited to patients, but also includes consumers (prospective patients), family members, caregivers, and referring physicians a ‘px’ won’t be of much help.

I believe that when it comes to hiring a ‘PX’—upper case—patient experience officer, and knowing what to do with a PX officer, a health system would be better served by paying more attention to the person’s knowledge of the ‘X’ and less attention to their knowledge of the ‘P’.  After all, your health system is chocked-full of people who understand the P-side, the clinical-side. I believe there are substantial benefits to hiring someone who is a customer experience thought leader and who has designed great experiences across a range of industries.

What most health systems need is someone who can help them envision and design a remarkable experience for every person every time on every device.

Health systems need a PX officer whose knowledge of consumer experience will cause the PX officer to fight hard to get the executive team to agree to implement a customer portal even though the system already paid for a patient portal. While that point may seem trivial to some, or seem like an excessive expenditure to others, it should be at the top of the PX officer’s to-do list.

And here is why. Your patient portal is of no value to anyone who is not a patient. Consumers, that big block of non-patients, cannot accomplish a single task. Take a second to think about your bank, and your online relationship with it. That online relationship, your entire relationship, exists in the bank’s customer portal. Chances are it took you a few hours to create your financial profile and to set up all of your vendors for automatic payment. Now that you’ve done that you carry your entire financial institution and your financial history around in your purse or back pocket. You never have to talk to your bank on the phone, never have to stand in a line to see a teller to deposit or withdraw money, never have to negotiate a mortgage face to face. No more stamps to buy.

And if another bank came to you offering free toasters to switch banks, you wouldn’t even consider it. You see the thing is that your bank made you believe that what they were doing was making things easy for you. What they really did was to make it easier for them to acquire customers and to retain them.

Health systems should look for a patient experience officer whose knowledge base comes from customer experience, someone who recognizes that the people in the cafeteria and the people in their church and the people in the grocery store are all healthcare consumers.

Health systems need someone who can create an easy button, someone who can make the experience of doing business with your system seem easy. There are two points overlooked by most health systems:

  • If your system cannot make it easy for a consumer to schedule an appointment by phone, that person will never be your patient
  • If people cannot conduct business with your health system using an effective and well-designed customer portal—like the one they use with their bank—they will soon change health systems

Hiring a patient experience officer is a good thing. Hiring the right patient experience officer is a better thing.

Shop & Click Healthcare–Is It Really That Difficult?

Do you find the process of pairing buyers and sellers using Craigslist or Angie’s List easy?

I just upgraded my treadmill using Craigslist. I knew what model I wanted and all I had to do was find someone who was selling that model. And bingo; new treadmill. I went back to Craigslist to see if I could find someone willing to run on my new treadmill, but that did not work as well.

It occurred to me that the reason it is so easy to match buyers with sellers is because that is what the site was designed to do. EBay does the same thing, millions of times each week. Oh, and did I mention Amazon?

The business models for all of these organizations were designed. At some point a group of people drinking lattes gathered around a table and had a conversation that went something like this:

“We want to sell stuff. And to do that we need two things; stuff and people.”

“We don’t even need to own any of the stuff. We could just find someone who wants to sell something, and then find someone who wants to buy it, and we are done.”

“That is way too complex. Why do we have to find them? What if we simply enabled them to find each other? I see it happening along the lines of what happens when someone calls someone else. The phone company simply does a handoff. We should do that. Let’s say some guy in Iowa has a ’32 Chevy in his barn, and somebody in Arizona wants a ’32 Chevy. All we have to do is enable the guy in Arizona to find the guy in Iowa.”

And so they did.

EBay makes millions and millions of connections of buyers to sellers around the world.

Healthcare, on the other hand, has untold difficulty connecting one consumer to a single physician even though the two are only separated by a few miles. The consumer’s thought process is something like this:

“I have a phone. I bet the doctor has a phone. I will call and schedule an appointment.” Not so fast Skippy.

When that fails, and fail it will, the consumer thinks, “I have a computer. I bet the doctor has a computer. I will go online and make an appointment.” Not so fast Skippy.

I had dinner Saturday night with a member of the board of a very large health system in Philadelphia. She told me she had purchased her healthcare through the institution she served. She then said that she had a lot of difficulty recently making an appointment, and that after several attempts she now goes to another provider. (This is the same institution for which another of their board members told me, ‘We do not have customers, we have patients.” To which I replied, ‘Pretty soon you won’t have either.)

Health systems never bothered to think about designing how to put buyers and sellers together. ‘We are not in that business.” You most certainly are not. But you should be.

On a lark, I called a large New England health system to try to schedule an appointment with a pediatric orthopedist. I was not successful in my endeavor. I was told they did not have an orthopedist at the children’s hospital. I was not told that the health system had 181 orthopedists among their other facilities.

Suppose your doctor referred you to Dr. Joe, orthopedist at said health system. You call for an appointment, only to learn that the soonest Dr. Joe can see you is in eight weeks. A reasonable person will book the appointment, and then that person will call another health system trying to be seen sooner. What would it have taken for the health system to say, “Dr. Joe is booked, but Dr. Sally, one of our other 181 orthopedists could see you this afternoon?”

There are two groups of thought leaders on this issue. One group believes they should be able to go online, and get access to the care they want when they want it. The other group either does not think this way, or they simply have no idea that people cannot get easy access to their services.

This would seem to be a good solution to the problem of missed and canceled appointments. It would seem to be a good way to manage capacity. But then, what do I know?

Shop and click healthcare. It is really not that difficult. Unless you make it difficult.

It is easy to say, we are in the business of making people better; we are not in the business of connecting buyers and sellers.

Maybe the time has come to rethink what business you should be in.

What Is Healthcare’s Moonshot Opportunity?

An executive from Microsoft was seated next to me on yesterday’s flight from Seattle. So that American could earn additional revenues, we both had our knees positioned by our ears. We could not have been closer together had we been conjoined twins—brothers from different mothers. My briefcase was on the floor, about three feet from my hands. I am certain I invented a few new yoga positions in my effort to retrieve my computer.

I spent the flight trying to become familiar with my MacBook Air. My cellmate pulled a very thin device from his bag. He typed. He moved things around on the screen with his fingers and with a stylus so rapidly that it left my head spinning. Unable to reach my keyboard due to the proximity of my laptop to my chin, I watched him run his device through its paces for a while.

I have been using a portable computer since the days Compaq came out with one the size of a steamer trunk. Nobody would call me exceptionally proficient with a portable, but I get by in most situations, and when I can’t I just pretend. But this guy was doing things on his I have never seen anyone do. He opened a copy of someone’s resume. Using his stylus he highlighted some of the information. Still using the stylus, he began to circle other items, and he wrote notes to himself on the screen.

I have a MacBook. He has a laptop, a touchscreen, and the functionality of a pen and paper all on a device that weighed less than half of mine. My expectation of what a remarkable portable experience should be had changed in an instant.

And that is what this is all about, isn’t it? Great experiences are those that exceed someone’s expectations.

Now on to healthcare, customer experience, and consumerism.

Healthcare’s moonshot opportunity is consumerism. Consumerism will change healthcare more than any other change in the last fifty years.

Or it won’t.

At least for a lot of providers. The thing is, very, very few providers even seem to be aware that there is a moon worth shooting for, and even fewer are aiming for it.

If providers started now to develop a strategy to effectively implement a consumerism business model, it would take them a minimum of two years to be able to replicate the functionality their competitors had in place five years ago.

A seven year lag. Maybe it is time to start.

Just to be clear, consumerism is not valet parking. It is not we proudly serve Starbucks. And it is not free Wi-Fi in the waiting rooms.

There are all sorts of presentations and white papers on consumerism you can read. You can collect consumerism bullet points like some people collect seashells. You can create a healthcare consumerism exploratory committee—if you cater the lunch more people will be likely to attend. But it helps to know what consumerism is, and it helps to be able to explain it to someone in one sentence. So, in case you are having trouble coming up with a sentence, I’ll lend you mine:

Consumers expect to be able to carry their health system around on their smart device and interact with it to the same degree they interact with Amazon.