Patient Engagement: “Paul, have you ever spoken to a woman?”

We only need about a hundred more reads for this little missive to hit 100,000 reads. Nobody is more amazed by that statistic than I, but I am also very appreciative of the fact that you continue to play along, and I have learned a lot from your thoughtful feedback.

And I have decided that the hundred-thousandth person to read a post will win my neighbor’s new BMW—he is not among the readership, so that will serve him right.

Over the last few years several of you have been kind enough to read and comment on the draft of my second novel. As an undergraduate I majored in math, in part because I wanted to get through university without writing a term paper. My strategy worked, save one. Political science.

A philosophy professor mentioned that if you ever did not know how to reply to an essay question on an exam, the best approach was to rewrite the question in a manner that turns the question into one you could answer. I took his advice. Apparently my Poly Sci professor had also taken philosophy. He wrote on the top of my Blue Book, “Great answer. But we both know that was not the question I asked.”

Fifteen years ago I was taking a flight to Rio to meet with my client. The book I had purchased at the airport wasn’t worth the money; it wasn’t even worth it in Canadian dollars. I started thinking about what it might take to write a novel, wondering what authors had done that I had not done. They wrote. I tossed the paperback aside and I began to write about a former boss of mine. A gentleman for whom I had very few fond memories.

Twenty pages later he was dead. I read what I had written, and concluded I was even less fond of him than what I had written, so I did away with him in a more egregious manner. It was a very cathartic experience. Six weeks later I had written almost four hundred pages.

The second most entertaining part of writing is that some character that I would invent during the day would wake me in the middle of the night and tell me what he was going to do next. The best part about writing is that I had finally found an outlet for the voices.

A month after that I had an agent. The agent said I wrote like a mathematician, and she suggested I might want to use a few adjectives. She would see me again in a month.

Upon reading the revised draft, chocked-full of adjectives, she asked, “Paul, have you ever spoken to a woman?”

Her question left me confused and concerned. She saw my look and knew I had no idea as to why she had asked. She explained saying, “Women do not talk the way you have them speaking in your book.”

“Have you even spoken to a woman?”

I thought of that question today and I thought we could tie that question into the topic of customer/patient experience.

“Have you ever spoken to a customer?” To a customer outside of the hospital. It is easy to speak to a customer or patient inside the hospital. Part of the reason it is easy to speak to someone in the hospital is that the ratio of employees to customers is probably something like one to five.

What I am asking is have you ever spoken to someone outside of the hospital, someone who was trying to schedule an appointment? To someone who wanted to understand their bill? Get a refill, and so forth and so on. Outside of the hospital the ratio of employees who speak to customers is astronomical; probably something like one to several thousand.

It is not a fair fight. And the employees do not get much better at it over time even though they answer the same questions day in a day out. Their failure to speak well with your customers is not a reflection of their skills or their motivation.

The people who answer your phones speak with more of your customers each day than most people speak to in a month. They are usually the ones with the lowest compensation. They have little or no authority to meet the customers’ needs, and they have no tools to help them present the health system properly.

If asked, hospital executives would tell you that people (customers) call the health system to get answers to questions about billing, refills, and scheduling. They would tell you that, and they would be wrong. They would be wrong because they have never spoken to their customers outside of the hospital.

In the last month I have spoken with two non-provider healthcare executives. We were discussing patient access, patient engagement, and patient experience. I did not ask them what they thought of their health system. But they availed themselves of the fact that they had a captive audience; me. Paul’s 12-Step program for disgruntled patients.

One of the executives mentioned that the experience was worse than what he imagined Beirut was in the 1980’s. The other, who is friends with the CEO of a large health system in our nation’s capitol told me that trying to do business with his friend’s health system was the worst business experience of his life. He continued by saying, “These people have no idea how bad it is because they never have to interact with the system as a customer.”

The people who call the health system, your health system, are actually calling to answer for themselves one of two questions; will I buy healthcare from this health system, or will I buy healthcare again from this health system?

My first novel has yet to be published, but I remain hopeful. My agent died. And no, I did not do it.

How Does Patient Engagement Drive Revenues?

I am thinking about creating a fantasy-consulting league modeled on the fantasy football league. My sense is that the players will be somewhat more nebbish, and the tattoo factor may be less than that in the football league.

Health systems are approaching the eleventh hour with regard to reinventing how they do business. The bad news about the eleventh hour is that nobody will ever warn you when the time is quarter to—you only know the time when it is five after.

If a health system tried to trace the results of its failure to recast patient access to a seminal point the failure would point to their failure to engage, to interact the way people choose to interact with all of their institutions.

Patients leave their health system. They leave it before they are admitted, and they leave it after they are discharged. And people leave it because after trying to accomplish something on the phone with the health system they feel that their time would have been spent better teaching a hamster to tango. And the health system is left with a permanent look of surprise and irony.

One of the curious things about how healthcare is managed is its ability to count and account for things. Supply chain management. The number of bedpans. The number of patients. The number of wilted hibiscus plants by the elevators.

There is also a category of uncountable things, things like leaked patients. Nobody knows when he or she leaked or why they leaked or how many leaked.

For the most part, health systems do not engage people, even though engagement is a priority. They do not have plans to interact. That is because health systems react. Answering the phone is not interacting. It is Pavlovian—stimulus, response. Phone rings, phone is answered; at least some of the time.

This lack of an engagement strategy makes revenue growth for many, many health systems a zero-sum game. One of the teams, Team 1, playing the game is comprised of people from the health system’s marketing and business development departments. They have a budget and tools. In simple terms, their job is to fill the revenue funnel. Get patients. Get new patients; ‘Like us”, ‘Follow us’, ‘Call us’. Millions of dollars are spent trying to get people to buy their healthcare from a given health system.

The membership of the other team, Team 2, playing the zero-sum game is ill defined. Its members include people at the health system’s call center—a euphemism for what is really just a scheduling center. Its members also include people in billing, authorizations, referrals, registration, admissions, and so forth and so on.

The game works like this. Team 1, Marketing, gets a point each time it convinces a potential patient to consider buying healthcare from their health system. Team 2 causes a point to be subtracted every time they fail to engage the potential patient. Team 2 earns bonus points for patient leakage—leaked patients are those who leave the hospital and disappear into a black hole.

In many health systems, patient acquisition, patient retention, patient referrals, and revenue growth are not zero-sum games. They are negative-sum games, games in which both sides lose. Patient revenues are falling, costs are rising, and reimbursements are falling.

The October 2014 issue of Health Leaders Media included an article, “What’s Your Growth Prescription?” The article included a chart showing survey answers to the question, “How will your organization fuel financial growth over the next five years?” The responses, listed in declining order are:

  • Expand outpatient services
  • Strategic marketing campaign for the existing market—59% plan to do this
  • Strategic marketing campaign for new market—41% plan to do this
  • Develop or join an ACO
  • Acquire or merge with hospitals
  • Develop or partner with a convenient care facility
  • Acquire or develop a health plan
  • Increase inpatient bed capacity

While those may be interesting ideas, none of them does away with the fact that the health system will continue to play the same zero-sum game. Increasing bed capacity without retaining patients will lead to empty beds. Having a strategic marketing campaign will be no more effective than having a non-strategic marketing campaign if the health system cannot engage with the people who respond to the campaign. Acquiring a hospital or a convenient care facility or an ACO or a health plan, without recasting access and engagement will likely pair one zero-sum organization with another zero-sum organization, thereby reinforcing a negative-sum outcome.

Sometimes I am a bit of a pedant when I feel the need to make a substantive argument, and I am afraid that this was one of those times. All of the growth options listed above will require a significant capital investment, and they will take years to become operational.

However, initiatives to improve patient engagement and patient access are measurable, and they can deliver significant short-term results, without a gross outlay of capital. If anyone asked, my plan to grow revenues would focus on recasting access and engagement. And its three tenants would focus on increasing retention and referrals, and a significant reduction in leakage.

I read recently that Vision without execution is hallucination.

Patient Engagement: Why Do Patients Get Frustrated?

The feed from the satellites tethered above the northern hemisphere beamed down. I could hear the synthesized voice of my GPS chuckle as I tried to find the field for my daughter’s softball game. The location for today’s game was posted to my calendar by my wife—you will understand shorty the italicizing. The location placed us in the middle of a harvested field of corn.

I asked my daughter to Google the high school in the hope of getting us to the game before it ended. She responded telling me she found a picture of the school online.

I asked, “How does having a picture of the school help me find it?”

“Because I’ll know it when I see it.”

“Do you see it now?” I asked as I pointed to the rows of denuded corn.


“Well which way should I turn to get you to where you can see it?”

“I don’t know.”

“Do you think maybe you should have Googled the address instead of a picture?” I could see she had no understanding of why I asked the question.

I called my wife, having failed to engage my daughter, hoping to engage my wife’s help. “By any chance do you have any additional information to help me find where the game is being played?”

She checked her email, and replied, “Oh, it looks like the game was cancelled.”

“And you know this how?” I was still trying to engage her in a meaningful conversation, hoping she would give me access to the information I needed.

“I got an email at nine this morning—four hours ago.”

“Do you think this information would have been helpful to me? We have been driving over corn kernels for an hour.”

“Oh, quit whining. You are having special time with your girl.”

My desire to engage my wife in a meaningful conversation about why I did not have the information had hit a virtual Chinese wall. The empathy fairy wasn’t going to make an appearance.

When the need to engage someone fails repeatedly, people become frustrated. And when people become frustrated they become stupid. And when they become stupid they get a time-out. And when they get a time-out America’s prisons become overcrowded.

My desire for empathy, my effort to engage my wife, to have her help me solve my problem had failed. Were I less amiable, less even-tempered, had I less jocundity, I would have become frustrated and done stupid things. And I would have received a time-out, and I would have added to the problem of prison overcrowding.

Had I received a time-out and added to the problem of overcrowding our prisons, I would have been among friends. After a few months of being locked in the big-house, I would meet other husbands who had failed to engage; simple men who had become frustrated and who had received a time-out.

We would shuffle around in our prison slippers and K-Mart pajamas, and we would play pinochle in the prison’s cafeteria. Then, after a few months of planning, my group of men would have devised an escape to get back to our former lives.

Then one of us, the one who had been serving his time-out the longest, would make the point, “Look, if we break out, and return home, sooner or later something will happen that will get us sent right back here. It may be from one of us trying to engage by asking something stupid like, ‘Why do you need so many pairs of black shoes?’ It may come from a misunderstanding of how to use pronouns, like if you asked, ‘Why do you ask me can we take out the trash when what you really mean is can I take out the trash?’”

Then the other guys on the escape committee would look forlornly at each other. Then the guy who had been inside the longest, the one who had carved a hacksaw blade from a bar of Dial soap would get up, walk to the closest guard, and hand over the blade.

The guard would simply nod. For he had been a guard for many years, and he had learned to spot the groups of husbands planning their escape. And he knew that as the planned date for their escape approached, sooner or later the men would see the folly of their plan.

Then the guard would return to the guard’s locker room, as he always did, and he would drill a hole through the end of the soap hacksaw blade, and thread a string through the hole, and tie the ends. He would place the soap-on-a-rope blade in the jar that held all the other roped blades that had been made by all the disillusioned groups that had preceded this group.

Patient engagement is good. Patient disengagement causes people to get frustrated and it makes them want to carve a bar of soap. And when patients get frustrated they get stupid. And when they get stupid they take a time-out. And they take a time-out from trying to engage their health system.

After a while they may think about trying to reengage their health system. But many of them will remember how frustrating their last engagement experience was. And instead of taking another time out they will try to engage a different health system.

An important rule of patient engagement is that people do not want to work hard to engage a health system. People want to engage the system when it is convenient for them, not when it is convenient for the health system.

Patient Engagement: Do We Deliberately Disengage Patients?

The reporter on ESPN stated that cyclists in a forty-kilometer race could shave seventy-nine seconds off their time by shaving all of their hair. The reporter failed to mention how much time could be shaved by pedaling faster. Sometimes the easiest answer is overlooked, perhaps because it is too easy to be believed.

Patient engagement. Hospital disengagement. I get the image of what happens when trying to push two oppositely charged magnets together. They repel one another.

Patient Engagement is a phrase bandied about as much as the phrase population health management. The phrases have two things in common; patient engagement is a tenant of an effective population health management program, and both phrases are equally amorphous.

One definition of patient engagement used the words empathy, trust, respect, and empowered. Amorphous with a capital A.

The good news is that if someone—a patient or customer—has never been engaged then they do not have to worry about being disengaged. Or do they? Mr. Webster defines disengage ‘to release from attachment, to flee, break off contact as with the enemy’. The thesaurus offered, “pull the plug” and “weasel out”.

I think patient engagement falls into two buckets. Bucket One, the one getting all of the attention, is clinical engagement. This bucket predominantly deals with interactions that occur at the health system or at the primary care provider.

Bucket Two, the empty one, is accessibility. It deals with the interactions between patients and prospective patients, and their health care provider. It is mostly transactional. And it is almost always a one-way interaction; from the health system to the individual. At the health system level there is almost no engagement because there is very little access.

Rule 1: Without access there is no engagement.

Rule 2: Engagement, like access, should be two-way

Health systems want access to their patients. Patients want access to their health system. If I cannot access my health system my health system and I are not engaged. If my health system cannot access me, my health system and I are not engaged.

Another term for engage is betroth. It means to contract, to tie oneself to, and to make a compact.

I am engaged with every company with whom I do business, everyone save my health system. We have an agreement, an understanding. Whether it is formal or informal does not matter. What matters is that when I want to interact with them I can. Day or night. And they can do the same with me. And at a time and on a device of my choosing.

I can call them after 6 P.M., and I can call them on weekends. More importantly to me, I can do everything I need to do with those companies without every speaking to someone. I can even do that with the healthcare apps on my phone.

Why does this matter? It matters because my healthcare apps have more data about the state of my health than my health system. The app does not care a thing about my data. The app does not know what to do with my data, it simply records it. If I gain fifteen pounds in two months, the app is not going to tell me that I am showing signs for Type 2 diabetes. Have another cheeseburger Paul.

That data only becomes information when it is accessible and actionable. It becomes actionable when my health system collects it and monitors it. It becomes information that benefits my health system and me only if my health system has access to my information.

My health system is U Penn, an outstanding institution in every way. My cardiologist is a water-walker extraordinaire. And once a year I learn that my heart is healthy; EKG, stress-echo, blood work. The other three hundred and sixty-four days I assume my heart is healthy, and my barometer for gauging the rest of my health probably comes down to something as simple as whether or not I had another heart attack. No heart attack today, I must be healthy.

I record my exercise each day on a fitness app. And my diet. And my data is locked away in some cumulus cloud doing nothing for anyone.

Good data; almost worthless information. That is because my apps do not engage me. But then again, neither does my health system. Engage is a verb, but only if one is engaging.

In three years more data will be collected about my health in a month than had been collected cumulatively prior to then. In three years millions of people will be collecting this data about themselves. Unfortunately it will not be available to any health systems unless the health system develops a plan to access it. And that is not a trivial exercise.

My loyalty as a patient will be to whatever institution is able to engage me each day about my health. Data about my health and wellness is being amassed everywhere; through apps and wearable devices and smart phones and watches.

If you want to engage me, if you want to retain me as your patient, do so more than once a year. If you want to really own population health management, design a way for your health system to capture daily health and wellness information about the people who make up the population you serve. People would prefer that someone who knows more about their health than they do is monitoring their data.

That is patient engagement. It is an interactive exchange of information; I tell you something, and you tell me something. And if we do it enough I will be healthy proactively, and I will remain your patient. This approach to patient engagement is more expensive and more engaging than having a recorded message telling callers to ‘call back during business hours’, but in the end everyone wins.

Patient Experience: What can be learned from Newts? (not Gingrich)

The smartphone’s screen showed “incoming call.” I thought the message was superfluous. I tossed the phone on the hotel room bed and headed off to dinner with my colleagues. Returning two hours later, I was headed for bed. That was when the beeping started. I turned my head and was eye to eye with the clock radio. The alarm, I thought. But whichever button I tried, the beeping continued. I unplugged the radio. Beep, beep. Turning the radio over I found the secret compartment that help the backup batteries, removed them, and tossed them aside. Beep, beep.

I have never been accused of being patient or tolerant. I was tired, and the alarm clock was possessed. I slipped it between the mattress and the box spring, and the beeping continued. I caught a glimpse of my face in the mirror. The impression I got was of a man dressed in dark clothing, who drove an old Chevy panel van, the windows spray-painted black, the back seats removed. Heavy-gauge wire mesh screening blocked off the back of the van from the driver. If you were an FBI profiler you would probably have me high on your Top-10 Most Wanted list.

That is a shame, for all I wanted was sleep. As I pulled the pillow over my head, I heard something flop to the floor. My cell phone. The low battery indictor flashed red. And my phone went beep, beep. Who’da thunk it?

So, where did we leave off? We made an argument for closing the call centers and an argument for deleting the website. One might think my mission here is complete; not so fast Skippy.

People—your customer people and your patient people—want to communicate with your health system. A health system is many things, one of which is that it is very, very complex. The part that is overlooked is that not all of the health system needs to be complex.

Suppose you are an executive at a health system and somebody calls you at your home wanting to know how much they owe you for the work you did repaving their driveway during your spare time. The phone rings and rings. The caller gets a message stating that the estimated wait time is fifteen minutes. They hang up and dial again. They ask you a question to which you do not know the answer. You transfer the caller to someone else in your family on the off-chance that your daughter’s, niece’s cat may know the right answer.

The cat looks bemused. The caller looks you up on LinkedIn, Facebook, and on your website, The website provides a lot of information about cats, about the benefits of repaving your driveway, and about things you can purchase at the feline-repaving gift-shop.

Not very helpful. It leaves the caller thinking that the next time they need to repave their driveway they will call someone else. The caller remembers to tell his neighbor to get his driveway repaved from Joe’s Taxidermy and Repaving instead of calling you.

A lot of readers are mumbling to themselves, Paul, you are out of your mind and you have no understanding of how healthcare functions. We can turn a newt into an ear, and we can transplant a face. Indeed you can, and that is a good thing. And the surviving newts are frightened, and the recipients of the transplanted faces are grateful. The thing is, I concern myself with the parts of healthcare that do not function. Blocking and tackling. Basic, very basic, business functions.

If the newts cannot get your health system on the phone, if they cannot access your health system online, if they cannot talk to a nurse, or pay their bill or, schedule a newt checkup, the newts will be disappointed. The newts will find an organization that does not disappoint them, one that does not make them work hard to buy healthcare

The thing is, this is a really silly analogy. The other thing is, it really isn’t.

A board member of a major Philadelphia hospital told me recently, We do not have customers, we have patients.

I replied, I wouldn’t loose sleep over the distinction because pretty soon you won’t have either.   A less optimistic person would think that hospital would never be one of my consulting clients. I beg to differ because I have never met a pessimistic newt.

Patient Access: Should You Delete Your Website?

The time to thin the herd was overdue and so was my train. The man who sat next to me on the train to Washington wore an outfit, that had he been a domestic pet, he would have been put down purely on aesthetic grounds. His jacket looked like it had been knitted from atomic waste. Apparently, the ability to decide what to wear has very little in common with the ability to perform multi-dimensional calculus.

He was interested in telling me his life story; I wasn’t interested in hearing it, but it would have been rude to climb over him and run down the aisle like I was being chased by a mastodon. He explained that he was into several different kinds of therapies, as well as fortune telling and tarot. On the functioning side of his brain he had a degree in accounting.

Which brings me to today’s missive.

A reader of yesterday’s blog wrote to let me know that her hospital could benefit from a little Patient Access 101 strategy for its call center.

Not being someone to let sleeping dogs go unturned, or something like that, I thought there might be some merit in visiting the health system’s website. Unfortunately, I was not surprised by what I saw.

If you become aware that someone in your health system is about to update the system’s website, for the benefit of the entire health system and for the benefit of all the people who may be tempted to visit the website, someone should tell the website’s designer to step away from the keyboard. It may be necessary to use force to ensure compliance.

The website I visited had the following links on its homepage.

  • Employees
  • Medical staff
  • Media
  • Volunteers
  • eCards
  • Thanking an employee
  • Donations
  • Hospital news
  • Hospital events
  • Podcasting
  • Free newsletters
  • Chaplain
  • Amenities

There was even a link for patients—who’da thunk it?

Maybe my brain is not wired like the rest of the population, but when I visit certain companies/vendors online, I go to their website with a certain objective in mind.

If I visit the website of my bank I do so with the intent to bank, not to read about their amenities. If I visit the website of my favorite restaurant I do so with the intent to dine, not to view a podcast. If I go to the website of my favorite clothier I do so with the intent to shop, not to read about upcoming clothing events.

My sense is that well over ninety-percent of the people who visit a health system’s website do so because they are either a patient or are considering becoming a patient. Yet the design of well over ninety-percent of health system websites do not reflect the fact that most of their website visitors have no pressing interest in more than ninety-percent of the information presented on the site.

The business purpose of a health system’s website should not be about the health system. It should offer information that is both compelling and relevant to the people who go to the site—patients and potential patients (customers). it should serve as a business tool, not a rendition of what the hospital wants you to know about it.

If the health system wants to have an online tool for medical staff and employees it should create an employee portal that resides on the health system’s intranet.

Healthcare is competitive enough whereby health systems should use their website to gain a competitive advantage. No competitive advantage will be gained by having a more rigorous eCard link than the other hospitals in the area, or by having a snazzier newsletter.

If your website presents itself like a Chinese menu of offerings, you probably want to rethink it. The site’s visitors will still be hungry thirty minutes later.

Improve Patient Access: Close Your Call Center

“The first thing we do, let’s kill all the lawyers,” Shakespeare, Henry VI.

No small feat considering the number of lawyers. Rather than take such a radical step, let us begin with something more achievable.

Let’s close all the health system call centers. Customer experience may go up, and customer access may not be affected negatively.

Now that everyone is paying attention, perhaps we could spend a minute or two looking at why that may not be such a bad idea—the call centers, that is, not the lawyers.

A few warm up questions for the executives in the audience. Do you know the location of the call center? Have you visited it in the last year? When was the last time you eavesdropped on a few calls?

I have done this so often that at times I feel like Frank Bruni, the gentleman who writes the restaurant reviews for the New York Times, trying to surreptitiously offer a sensible review without being outed.

Most of the hospitals I have visited whose leadership believes has a call center, does not have a Call Center. They have a place people call. In ninety-percent of those centers what they actually have is a place for people to call to schedule appointments. They have a scheduling center, and rarely does the scheduling center even do a good job of scheduling calls.

It is worth noting that only twenty to thirty percent of callers call to schedule an appointment. The other seventy to eighty percent of calls have nothing to do with scheduling. And the people answering all of those other calls know very little about providing the caller with the correct answers to all of those other calls.

That means if your health system receives a million calls a year more than three thousand calls each day have to be transferred to someone who may know the answer and who may have the tools needed to help them answer the caller. (The daily number would be less if callers could speak to someone on Saturdays and Sundays, but then I would be being silly even to suggest that.)

On the flip side, we have two hundred thousand people calling to schedule something or another. I would guess that less than sixty percent of those callers have their needs met the first time they call. Adding the two categories of disappointed callers gives a number of around 900,000 calls that result in an unsatisfactory experience. At a fully-loaded cost of around thirty dollars a call, which means that health system will spend about twenty-seven million dollars to underwhelm its customers and prospective customers.

Surely less money can be spent to achieve the same result. One way to do so would be to close the call centers and disappoint everyone at zero cost to the health system.

Here is what I observe health systems are doing to try to improve the caller’s experience. They hire more call center agents, and they throw technology at the problem, technology like scheduling applications. Applications that do nothing for the other 80% of calls. Applications which without an understanding of the business problems, without a strategy and a plan, will get in the way of creating a great caller experience across the enterprise. They debate centralizing or decentralizing the places from which they answer calls. They debate implementing a single number for anyone to call about any thing.

“We don’t know where we are going, but we are making really good time.”

Perhaps the time has come to decide what the business reason is for having a call center, to decide what business problems the health system wants to solve through the call center.

People are going to call the health systems whether or not the health system has a real Call Center. There are real costs associated with having a call center that can do what needs to be done. The good news is that those costs pale in comparison to the costs of having a call center that does not do what needs to be done.

The best reason for doing this correctly is that a functional call center is the health system’s most valuable point of contact for retaining patients. Or it isn’t. chances are that the one currently being operated by the call center is not doing the health system any favors.

And once you have fixed the call center, then we can think about what to do with the lawyers.