The Exponential Decay of Patient Experience

While I was teaching my son to drive we encountered a stretch of highway that did not have any other cars on it. As he was talking to me I noticed that the dial on the speedometer had passed seventy.

I told him the next time he is traveling that fast in something with wheels on it that there had better be a stewardess in the same vehicle.

NPR was celebrating the life of a poet and it made me think, the last time I considered poetry was in high school, and that was because someone made me consider it. I suspect one’s knowledge of, and familiarity with poetry, decays exponentially—the further removed you are from it the less familiar it seems. There are times when for a Chi-Chi effect, when you happen to be at a Chi-Chi function, there are benefits to being able to quote a stanza from something like In Flanders Field:

We are the dead: short days ago,

We lived, felt dawn, saw sunset glow,

Loved and were loved: an now we lie

In Flanders field

I feel it gives me a certain je ne sais quoi. Sort of like looking at some of the art hanging in your corporate offices. Find a piece that looks like a child’s refrigerator art, and wait until someone senior is in the area. Then step back from it, hold one arm across your chest, and rest the elbow of your other arm on the first arm and place your fingers against your lip the way Bill Clinton would when he was feeling your pain. Then say hmmm, as though you understand the depth of what the artist was trying to convey. If you really have the technique down, you may even wish to use the opportunity to quote poetry.

Exponential decay of knowledge about something. The further removed you are from it the less familiar it seems.

Experience with Patient Experience has a similar exponential decay.

Who Is Your Chief Failure Officer?

Willingness to make mistakes, trial and error, the idea comes first

To me, one of the great unknowns about Albert Einstein is the question of what he did when he was not publishing his theories.  Assuming you are not among those who read People Magazine, the average layman has probably heard of his Theory of Relativity.  Fewer still can state the theory, and only a small number of people have any idea of its implications.

So, he’s got a couple of theories to his credit.  I’ll ask again, what did he do with all of his non-theory time?

He failed; prolifically.  Einstein always began with an idea, something simple like explaining the entire universe with a single equation.  In between the idea and the equation were years of trial and error—lots of errors.

Einstein planned for failure.  If he did not fail nobody alive would know his name.

Who is in charge of failure at your firm?  Whose career hinges on making colossal failures?

Everyone in business fails.  Somebody didn’t plan correctly.  A large customer went elsewhere.  The new plant in China is two years late.  Joe was 1.3% over budget.  In the grand scheme of things, those failures are irrelevant, they are rounding errors, errors which over time have little impact on the bottom line.

There are two types of failures; operational—like above—and strategic.  Given the choice I’d opt for strategic failures every time.  To fail strategically means somebody is at least trying to do something.

Don’t place someone in charge of making sure everyone is on budget.  If you want to be innovative, make sure you have someone overseeing failure.

Are Silly Mistakes Causing You To Lose Patients?

Terrence Holt, a geriatric specialist at the University of North Carolina at Chapel Hill, describes a situation in Internal Medicine, fictional fables based on his residency:

Any patient in a hospital, when we take their clothes away and lay them in a bed, starts to lose identity; after a few days, they all start to merge into a single passive body, distinguishable … only by the illnesses that brought them there.

Lost identities, distinguishable only by their illness. Unless, of course, the person calls the health system. When they call they are not even distinguished by their illness because the person speaking to them usually has no information about the caller.

Less than twenty percent of hospitals have a customer relationship management (CRM) system. Of those that do, ninety-five percent of those CRMs are only used by business development and marketing to try to acquire patients. Very few health systems use CRM in their call centers to help them retain patients.

And that is a silly mistake since the people who are calling are usually grappling with one of two questions; will I buy healthcare from this system, or will I buy healthcare again from this system.

Maybe after they make the decision to change health systems their old system will call them back on a marketing call using the CRM they should have used when the person was still their patient.

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.