Is This Healthcare’s Number 1 Problem?

I received an email asking if I would consider presenting at TED Talks this fall. I read the email twice just to make sure it was not meant for someone else.

I am the guy who brought the elephant into your room. It doesn’t do to taunt the elephant—it makes you look foolish, and it irritates the elephant.

Today we are going to irritate the elephant. A lot. And then we are going to look at how to calm it down, and hopefully get it out of your room.

Healthcare has a lot of balls in the air—population health, accountable care, value-based purchasing, and the Affordable Care Act. While managing all of those, it is supposed to provide care, manage care, and drive wellness.

Healthcare’s ability to provide care is generally exceptional across the board. However, its ability to manage care is far from exceptional, and its ability to drive wellness is basically nonexistent. Gartner estimates that 275 million wearable devices will be sold this year.  I estimate that 275 million people will still not know any more about their health than they did before they bought them.

Speaking of wearables, a parole officer knows more about where his parolee is than the average clinician knows about the current state of someone’s health.

Now before you get blinded with rage, permit me to explain my reasoning with an example involving all of the healthcare sectors.

Issue 1.

Suppose I am your patient, and your health system treated me ten days ago for one thing or another. Payers, suppose you are reimbursing me for some fraction of the cost of that treatment. Retail pharma, you sent me my medication, and life sciences, you do not even know that I exist.

Given that, how am I?

None of the players can answer that simple question. They cannot answer the question because they do not have any new information about how I am doing from the day my treatment ended. Nobody is actively managing my care for the condition for which I was treated.

My provider does not know if the treatment or procedure worked. My payer doesn’t know a single thing about me except for my claim, but I am giving them a temporary hall pass because they are way too busy sprinting away from Obama Care. My pharmacy knows nothing about beyond whether I picked up my medication. And the firm that made the medication does not even know that I exist.

In short, nobody is managing anything about the care I received ten days ago. The Care Gap—the point in time from when someone knew how you were until today.

Under the existing model of healthcare, the only way anything is going to be managed regarding my care is if I initiate contact. One hundred percent of the responsibility for managing my care post-treatment falls on me. The problem with that model is that I am the least qualified person on my care team to manage my care.

Manage is a verb: I manage, you manage, and he, she, or it manages.

To manage my care somebody has to have relevant information about my current state of health regarding the treatment I received. Without that, they are managing air.

Issue 2.

Still focusing on the patient in Issue 1, other than the condition for which he was being treated, what else may be going on with his health? Suppose that over the last four months the patient’s weight increased by twenty pounds and, unknown to his PCP, his blood pressure had increased from 80/130 to 95/145.

The patient had all of that data; he’d been collecting it for two years. He’s also been collecting beer cans. But, he knew more about his collection of empty beer cans than he knew about his health data. His data uploaded automatically to his laptop every day. And there it sat in dozens of disparate folders in a digital version of Al Gore’s lock box on his C drive.

The disparateness, if left unchecked, might kill him. And that would be a shame since he had all of the data necessary for someone to know that he had a serious health problem.

Unfortunately, there is no app that serves as a data aggregator. There is no tool that marries the data from someone’s smart watch and the apps collecting all of their health data.

So to summarize where healthcare’s care and wellness gaps are concerning the first two issues:

  • We have no knowledge of the health of someone who was treated after they leave the building
  • We have no knowledge of whether that person has other health related issues
  • We have the ability to solve both of those problems
  • We do not have the leadership to solve them

Issue 3.

Healthy people—people not under care. This is the largest group of people. For many of them, they fall into the healthy category only because nobody told them they were not healthy.

And that gets us to the crux of the problem. On any given day, most people do not really know whether they are healthy. The best information they may have is that they do not feel ill and that nobody has told them otherwise.

I have a lot of data about the factors, that when combined could tell me a lot about my current state of health. But until someone with the knowledge to assess my data actually assesses it I am left to rely on how I feel.

We do not have to settle for that. This problem could be solved within a year. What is needed is a tool capable of aggregating, monitoring, and assessing someone’s health data on a regular basis, and a firm with the desire to built it.

Until then, population health and accountable care are just pipe dreams.  You cannot manage the health of the population when you know little or nothing about the current health of the individuals in that population.  How can healthcare profess to provide accountable care when it knows nothing about my health from the time I walked out the door.

There is a lot of talk about Big Data.  There should be a lot more talk about No Relevant Data.

The good news is that I feel pretty well today; thanks for asking.

Instead Of Fixing Patient Scheduling, Why Not Eliminate It?

This link is to a presentation that attempts to answer the question, “How could the same type of augmented reality used in Pokemon Go! be used to change how consumers consume healthcare?  Please share your opinions.

Instead Of Fixing Scheduling, Why Not Eliminate The Need For It?

Want A Kumbayah & S’mores Healthcare Experience?

These are the weeks when millions of bright high school students begin their college journey. We drove our son to orientation at the Rochester Institute of Technology. His next five days will be filled with Kumbayah moments with intermittent breaks for s’mores around the campfire while the parents haul refrigerators and ion-fans across the quad. It will be one big celebration of diversity and the individual.

His orientation is different than I remember mine being. Maybe that is because my orientation was at the US Air Force Academy. By noon, every head was shorn to its respective scalp and fifteen hundred individuals were all dressed identically. We were told that we were only allowed to say, “Yes sir, no sir,” and “No excuse, sir.” So, when I asked a senior cadet if I was allowed to keep my puka shell necklace, I did not experience a Kumbayah moment celebrating our mutual diversity.

We’ll get back to orientation at the end of this piece.

I spent two years in Rio in the role of the acting Chief Customer Officer fro a startup phone company. For me, most of the fun I’ve gotten from watching the Olympics has been from seeing Rio again.

For people of my generation, the Olympics will never regain the importance that it had when we were growing up. In my day, the Olympics was the battle of right and wrong played out in the pool, the boxing ring, the track, the basketball court, and the hockey rink

It was us against them. The ‘them’ were the Soviets and the East Germans. ‘Them’ were the communists and the drill that made us practice hiding under our school desks to protect ourselves from nuclear attack.

Back then nobody had the temerity to suggest that synchronized swimming was an actual sport.

I think the Olympics would be more interesting if there was a way to show just how good these athletes stack up against people like you and me, people who think they are good, but who do not possess Olympic skills. Take cycling for example. During my run Saturday, I passed a group of middle-aged men all kitted out in their cycling gear—padded, crotch-hugging shorts, skin-tight, logo-emblazoned jerseys, riding gloves, cycling shoes, and aerodynamic Kevlar helmets.

They wore pulse-monitoring devices, GPS trackers for measuring speed, distance, and feet climbed. Their fanny packs held nutrition bars made of steel-cut oats, and their water bottles were filled with some sort of electrolyte replacement drink. Nowadays, you have to spend a lot of money to ride three miles. And you have to look better than you ride.

They thought they looked good. I thought they look like old trick-or-treaters. I would pay money to see them ride against an Olympic biker. Or to see some guy who has a Ping-Pong table in his basement play a Chinese Ping-Pong player. Or a group of guys who like to wear the jerseys of the Philadelphia Flyers play the US hockey team.

Those of us who participate at some level in some sport may all be equally good when compared to people of our same age and ability in any given sport. Those of us who used to be runners have turned into joggers. Having been good enough to be a bench player on your high school basketball team may have made you cool enough to sit at the popular senior lunch table. You may still retain enough of those skills to play a game of pick-up ball.

That does not mean you are still a good player. It probably means that you are no worse than the other guys playing pick-up ball.

But that is okay. Being no worse than others, as long as you are in the right group of others, can make you feel pretty good about yourself. “I’m no worse than that guy.” Having that as a goal is okay in Ping-Pong, the Saturday cycling club, and a lot of other activities that don’t matter.

All other things being equal, if you were given the choice to buy something from among K-Mart, Target, and Walmart, which chain would you choose? More than fifty percent of you would choose Walmart. Given the choice of Acme, Giant Foods, and Wegmans, most people would choose Wegmans.

Given a choice of experiences among good, better, best, or a choice of being worst, really bad, and simply bad, people—customers and patients—choose the best experience.

Being “no worse than the other guy” fails as a growth business strategy. Target doesn’t advertise itself as being better than K-Mart because that is nothing to write home about. Unfortunately, no-worse-than-the-other-guy in terms of customer experience is a pretty popular business strategy. It fails the innovation test. It fails the test of relevancy and sustainability. If your firm or your health system is no better than the firm across the street, one of the two firms is superfluous. Isn’t it?

And that is where nearly every health system and every payer stacks up when it comes to customer experience, access, and engagement.

Being just-as-good, or being no-worse, is the business equivalent of being just-as-bad. It makes for a poor marketing campaign. But those firms keep on marketing.

“Call us to schedule an appointment.”

Permit me to conclude by referring back to college orientation. The Air Force Academy’s approach of everyone will do everything our way works great if you are rearing military officers.

Healthcare’s approach to customer experience requiring every patient and customer to call them for every need is a resounding failure when it comes to acquiring patients and improving care.

Nobody wants to have to call his or her health system or payer. Even the people who tell you that they want to call you only say that because you have never shown them a better alternative.

Your patients and customers want a Kumbayah and s’mores healthcare experience. And that experience only needs three things. Access and engagement:

  1. When I want it
  2. Every time I want it
  3. On any device I want it

She died today. Monday. August 15, 2016.


Sometimes my only reason for writing is to try to explain something to myself. This is one of those times.

Healthcare has two rules:

  1. People die
  2. Doctors can’t change Rule 1

She told us it was called it MDS, Myelodysplastic Syndromes. Bone marrow failure disorder.

I heard someone say once that you are never really dead until nobody speaks your name anymore. Her name is Heather. Heather and her husband have three children that are the same age as ours.

We’ve known for five years that this day was coming. A part of me is crushed.

Most of me is rejoicing. Heather is the best person I ever met and, today she is with God. I know that for a fact because every time I was with Heather I saw God in her. Nobody could be the way Heather was simply by trying. There was something about Heather that was not of this world. Heather let God live through her, and His spirit was made visible through her life.

I also know that she is with God because it is the only explanation for why I feel so at peace with what happened today as I do. I am as comforted in her death as I was in her life because of the knowledge that what I believe is not in vain.

When someone dies, people utter conventional phrases that often seem trite. “She’s in a better place.” Or they ask, “Why her?” “Why do bad things happen to good people?”

I used to be someone who asked ‘why me?’ Today I ask, ‘why not.’ I find great comfort in knowing that I do not have to understand God in order to have God.

Many years ago I was reading the Old Testament book of Job and got to the part where Job is yelling at God demanding answers about why God is allowing all sorts of bad things happen to him. Instead of answering Job’s questions, God responds with questions of His own and demands that Job answer. Essentially, God asks Job, do you know how I do what I do? At one point He asks Job; do you know where I store the snow and the hail?

God is saying, when you can answer my questions, I will answer yours. Until then, I am God and you are not.

I find great comfort in knowing Heather’s God, and I am grateful that He allowed me to see Him in her.

Is This The Real Way To Be Patient-Centric?

kind of a big dealWhy are so few executives willing to lead?

In 1775, America’s David Bushnell invented the first submarine. 1774—no sub. 1775—sub. Why? Because he decided we needed one.

In 1943 the U.S. Army needed a jet fighter to counter Germany’s jet threat. The Army approached Lockheed. Lockheed had never built a jet fighter.


The Army did not deliver the contract until four months after the work on the fighter had started. In just 143 days, 23 days after the contract was delivered, Lockheed delivered the first jet fighter to the Army.

The project group was eventually named the Skunk Works.

Lockheed’s Kelly Johnson managed the Skunk Works. Johnson wound up running several successful Skunk Works projects. At one point, Johnson documented a set of rules and practices he employed in each project that required innovating big ideas. Some of those rules included:

  • The project manager reported to a division president or higher
  • The project team consisted of less than 25% of the people that would be used on comparable projects
  • A simple drawing defined the project
  • Very few management reports were used
  • Continuous testing was implemented
  • Specifications had to be specified prior to building
  • Funding must be timely
  • Access by outsiders was controlled strictly
  • Good performance was rewarded

The Skunk Works still exists. It just delivered the Air Force’s newest jet fighter, the F35-A.

I recently heard a story about a problem Cowboys’ owner Jerry Jones had building Cowboys’ Stadium in Dallas. His wife wanted certain areas of the stadium to be installed with a particular type of granite from Europe, and she ordered it.

Unfortunately, so did a lot of other people, and her order was at the bottom of the quarry’s list. Her husband called the company and offered to pay a premium to ensure that his order would be ready in time for the completion date of the stadium. That did not work.

What did he do? What would you do? He bought the company, moved his order to the top of the list, installed the granite, sold the company, and made a profit.

Leadership. If you make me figure out how to solve the problem I will, but that makes you superfluous.

H&HN posted its 2016 list of Most Wired Hospitals in June. I read the list. And those hospitals do use a lot of wires. And then I researched several of those hospitals online to see what all of those wires were for. It turns out; the wires are used for and by the hospital and its employees. And that is probably a good thing.

When I was doing my research, I looked at whether all of those wires would help me if I were a patient or a caregiver or a family member. I looked at whether the wires would help me before I entered the hospital and whether they would help me after I left the hospital.

And here is what I concluded. Because I was not at the hospital, I did not have access to any of the hospital’s wires except for the wire connected to my landline phone. That wire was of no help.

People who are not in the hospital need do not need wires to help them. They need wireless. 4G & WiFi.   And they need to be able to do things wirelessly. Day and night. And on weekends. But they can’t.

Just look at how real people interact with their world.  When was the last time someone drilled a hole through their floor or a wall to install stereo speakers? They buy wireless speakers and wireless headphones.

When it comes to innovation, if you want to get my attention, print a list of the Most Wireless Hospitals. That is the fastest route to being patient-centric.

Great ideas like submarines and jet fighters and storing your emails on a server in your bathroom will never happen unless someone chooses to make them happen.

Healthcare companies do not have any Skunk Works groups. Is that because healthcare executives do not think that there are any big ideas that require innovation? (Note from the author: implementing an EMR does not qualify.)

My list of Most Unwired Companies includes firms like Amazon, Google, and eBay. People can do stuff. Patients want to do stuff outside of the hospital, but they can’t.

Executives: create a Skunk Works group to deliver unwired, patient-centered solutions.

If that doesn’t work, do what Jerry did. Buy a granite company.


Healthcare Consumerism: “We Are Not In That Business”

kind of a big deal

The very first thing you say when communicating an idea has everything to do with whether your audience will pay attention to the rest of your message.  For example, if you are writing a suspense novel a good first sentence might be, “The man sitting across from me in the diner did not know he had less than ten minutes to live.”  If the man was truly enjoying his breakfast during those last ten minutes, another good opening sentence might be, “It was the best of times, it was the worst of times”—but somebody already wrote that line.

When presenting an idea to a hostile audience it doesn’t do to leave a live dragon out of your calculations.  Sometimes you can lead your audience to where you want them to go by leaving a trail of breadcrumbs.  There are times, however, when the audience looks like they are still trying to figure out why Gilligan never got off the island.  That is when you know leaving a trail of breadcrumbs won’t suffice, and you the only way you can get them to follow your train of thought is by leaving entire loaves of bread.

During my last presentation, I should have hijacked an entire bakery.  A woman in the front row kept shaking her head each time I spoke.  She was slim and trim, poised and preppy, and had the look of someone of keen intellect—the final step in the evolution of the species; or perhaps she was supposed to have been in the Wellesley Tri-Delta sorority reunion across the hall. I was trying my best to explain that healthcare consumers’ use of technology in other industries is what created healthcare’s driving force towards consumerism.  She looked at me as though I had suggested subliminally that she should assassinate the president of Colombia. I did not know if she was going to faint, cry, or ask for asylum in Iowa.  Though I thought she and I were on the same journey, I had overlooked the fact that she may not have been issued a roadmap.

Her behavior had usurped what little poise I had. “You’re not really into complex sentence structures, are you?”  I thought of asking her. Then I said, “If you display my slides in reverse order it says ‘Paul is dead.’ ” (For those of you who didn’t grow up listening to the Beatles you may have to Google the allegory.)

Trying to explain healthcare’s immediate need to move towards consumerism to some people is like trying to explain the idea of cholesterol to a Big Mac; they don’t get it.  Judging from the looks of some members of my audience I realized I could have communicated the idea of consumerism better had I displayed a single slide depicting the game Wheel of Fortune, and prefilled the slide with C, O, N, S, U, M, E, R, I, S, _, leaving audience members wondering whether they needed to buy a vowel.  I mentally texted myself to start my next presentation with something more upbeat like the music, Ride of the Valkyries.

There is a worn military expression, which states the diversion you are ignoring is really the main attack. I suggest respectfully to the provider community that healthcare consumerism is not a diversion or a feint; it is the main attack.

I displayed a slide showing how healthcare consumers expect to be able to interact with their providers.  Click-to-buy.  Twenty-four-seven access.  Up-to-date records of all interactions and real-time health data. (The concept sort of follows a generalized retail business model, but that is the concept because the retail model works.)  If you count yourself among the healthcare consumerism misanthropes you may be better served by opting out of the rest of this blog.

“Have you ever seen the model you are describing being used by a provider?”  A gentleman in the back row asked.

“No,” I replied. “But I’ve never seen my pancreases either, but that doesn’t mean it doesn’t exist.”

The most material difference between retail firms approaching healthcare from the perspective of consumers, and healthcare providers approaching patient acquisition and retention from the antediluvian perspective of the new-kids-on-the-block, the new-kids are actually adding customers hand over fist. If you do the math, they are actually adding customers hand over fist, and hand over fist…and so forth.

And here’s my point—yes, it took me a while, but hopefully it was worth the wait.

So, if you are a provider executive or a board member of a provider, you should be screaming at someone.

Most of the people in your health system’s radius of service, the population you serve—think population health management—are regularly spending their healthcare dollars everywhere else but with you, spending it on retail providers.

Perhaps you are thinking, “We can’t make money testing people for strep throat.” CVS has a line of dump trucks carting away the money they are making from performing those tests.  Provider executives vehemently decried they are not in the business of healthcare consumerism. And they are correct in their declarations.  They aren’t.

Maybe they should be.


What Is Healthcare’s Most Unanswerable Question?

When people tell me I’m funny, I say looks aren’t everything.

Suppose you and I are together at a ballgame—you pick the sport. We are sitting in a large arena.  You are eating something that looks like trail mix, but I can’t identify what trail it came from.  You look at my cheeseburger and remark, “That meat is pink.”  “I told them just to lean the cow against the radiator for a few minutes.”

“The snack bar has croissants that were flown in from Paris this morning.  If you hold one to your ear you can hear the sound of a sidewalk cafe.  For the next hour,” I told her, “I am going to teach you how to be a good consultant.”

“Good.  Do we really need the whole hour?”

For the sake of keeping the math simple, suppose that, including us, there are one thousand people at the game. You have an M.D. and a PhD.  You are a thirty-two-year-old population health professional, you wear sensible shoes, you live with your mother, and you love cats.

For the next few minutes, just think of me as a man of mystery.

You try to impress me with your knowledge of the health of the 1,000 people in the arena. “Do you know…?”

  • 450 of them will have at least one chronic disease
  • 333 of them will have two or more chronic diseases
  • 100 of them will be treated in a hospital this year
  • 20 of them will be readmitted with 30 days of their discharge
  • 10 of them will be readmitted for a reason not tracked by CMS
  • About 200 of them smoke
  • About 300 are obese
  • Roughly 100 have no insurance
  • 10 of them will die within twelve months
  • None of the men are pregnant

“Wow, you know a lot of stuff,” I said. You beamed.  I knew that to make my point, a simple trail of breadcrumbs was not going to work.  I had to make sure the breadcrumbs were croutons.

I scanned the crowd with my binoculars. “Do you see that woman in Section B, row 6, third from the left?” You looked and acknowledged that you did, in fact, see the woman.

“Is she healthy?” I ask you. “Section A, row, 2, seat 1. What about the boy wearing the Make American Great Again baseball cap who is seated next to the man wearing the Lock Her Up t-shirt? Does any of your data tell you if he is healthy?”

“No, but it tells me that the man and his son are idiots.”

“I get up every morning and practice my liberal cliches in the mirror.  Wanna hear one?  Income disparity in this country hasn’t been this bad since the Great Depression.”

I show you my t-shirt.  On it are the words, “I am with Her(b).” You look at me like I am an idiot—that’s okay. I get that look a lot.  You said, “You remind of the type of person who might walk into a 7-Eleven one day and kill everyone inside because the Slurpee machine wasn’t working.”

“Both flavors?” I asked.  That was when you kicked me.  I knew you were thinking that someone ought to send me to a re-education camp.  “Shall I continue?” I asked. “Section A, row 7 seat 4? Section C, first row, the one in the middle?”

“You are not into complete sentence structures, are you?  You have made your point, I think. I do not know the health of a single person here. Was that your point?” You ask.

“I wish it was that simple. What if I told you this about one of the people in this arena? Over the last year, the person’s resting heart rate has increased by fifteen beats per minute. He has gained twenty-five pounds, he does not exercise, he drinks four cans of soda a day, and he eats fast-food more than five times a week.”

You reply, “I would tell him that he should be examined for heart disease.”

“Your diagnosis is correct, doctor. Now, tell me which of the people here am I referring to?”  It was like trying to explain cholesterol to a Big Mac.

“I have no idea.” Of course, you don’t. And that is healthcare’s biggest problem. Nobody who is managing the health of the population knows anything about the current health of anyone in the population.

Nobody can answer this question, “I am healthy?”

And here is the really bad news. The person we were just discussing collects all of that data on a myriad of health apps and wearable devices. And he will continue to track it right up to the moment he has a heart attack. And he will continue to track it because he does not know that he may have heart disease. Neither does anyone else know it. Collecting health data is no more valuable than not collecting health data. Neither is monitoring it.

For example, does anyone know the exact status of your current health beyond whatever information you added to your health history form during your last annual exam? Do they know if you exercise, and if so, how much? Do they know if you drink or smoke, or whether you have gained or lost weight? Does your PCP know if you are experiencing any new symptoms?

  • Your primary care physician does not know these answers.
  • Your payer only knows what claims you are filing, and they have no idea whether the illness or procedure for which you are being treated is being managed effectively
  • Your pharmacy does not know whether the medication they gave you is managing your health
  • And the life sciences firm that manufactured your medication does no even know that it was prescribed to you

Every provider or payer or national pharmacy could answer all of these questions if it wanted to. It could because that data is being collected every day by millions of people in the populations whose health is being managed.

Your firm could collect the data, monitor it, and assess it every day. It could do that with my data and yours. It could notify you and tell you when to be examined and for what to be examined.

To manage the health of the population wouldn’t it be more effective if we knew the health of the people who comprise the population?  Getting healthcare to try a new idea is like teaching a hippo to play the clarinet.  It’s not fun for the hippo, and nobody else wants to play that clarinet after the hippo.

Unless we want to agree that effective population health management is nothing more than having the ability to forecast the health of large numbers of people , for population health to work we must reverse engineer what we are doing.

It doesn’t do to leave the dragon out of your calculations if you live near him.  While there may be value in knowing that twenty percent of the population will have diabetes, the only thing that will get my attention is knowing if I will get diabetes.  I call that me-Health.