There are some men who to feel like they are doing something by setying aside an entire month to grow a moustache—forgive me for being sexist, but most women cannot grow a moustache. Growing a moustache; a great idea in the 70s, when plaid, bell-bottom pants, long hair, and platform shoes spoke against Vietnam and Richard Nixon—tanned, rested and ready. (To those of you who grew up post-1975, the word Vietnam referred to a war. Now it refers to a country.) The moustache is not a great idea in 2016.

One thing about being a consultant is that we will talk to anyone about anything. At consulting school, you are encouraged to be a listener, and you are taught how to read upside down any material that may be sitting on the person’s desk with whom you are meeting—see how I avoided ending that sentence in a preposition? You are also made aware of the fact that many of your clients will want you to walk ten feet in front of them while shouting ‘unclean’ as you walk through their hallways.

Doesn’t that sound like fun?

For the longest of times I thought of myself as the Bill Murray of healthcare consulting. “Nothing prepared me for being this awesome. It’s kind of a shock to wake up each day and be bathed in this purple light.”

One thing that remains consistent in healthcare’s C-suite is that their business plans are closely aligned with what worked most recently. They are highly attuned to following what worked, not what needs to work. They are focused on staying in business—which requires making money; and that is not a bad thing. But, you don’t have to limit yourselves to making money the same way each year. This is where coloring outside of the lines comes into play. Grab a crayon.

The thing I try to bring to every meeting I attend is the notion, “This is not a rehearsal. Somewhere there is a score being kept, so you have an obligation to be as present as you can and to do as well as you can.” The thing is, when you give your best with others who are doing the same, you set the stage to accomplish great things. And that works every time, right up to the point when someone says, “That will never work here.” And maybe it won’t, but you’ll never know unless you try.

BYOK. Bring Your Own Khakis. If you understand what follows, if it makes the hairs on the back of your neck tingle with anticipation, you are capable of slamming a revolving door.

I begin 2016 by following up the apocalyptical moment that hit me over the head with a wilted asparagus two days ago, the be all end all of where the U.S. healthcare system will be three years from now. You can choose to play, or you can chose to watch. Love. Set. And Match.

If you are forced to attend a meeting this year that does not begin with the words, “What if,” or, “Imagine a World,” leave the meeting, pull out your knitting, or find someone in the meeting across the table from you willing to take you on in a game of Battleship on your tablet. Lead, follow, or get out of the way; and the Get-Out-Of-The-Way bus is full.

There are not many moments where you can watch the world change. Twenty years from now when your grandchildren ask, “What were you doing when this happened,” what if you could say that you were driving the bus? I’m not sure of the correct punctuation for the prior sentence, but I was a math major.

Lead. Be present. Think.

So perhaps I should stop rambling and tell you what I am thinking. At a New Year’s Eve party I am listening to my neighbor tell me about how impressed he is with his new best friend and personal concierge, Amazon Echo’s Alexa. I lasted long enough in the conversation to learn about paper towels. My neighbor said, “If I am running out of paper towels, I tell Alexa”—a cloud-based service that injects Apple’s Siri with a 2001 Space Odyssey intelligence—order paper towels.”

Alexa replies…”We have a 24-pack of paper towels that is on sale for 20% off. Shall I order them? Or, do you want to give me additional information to help me narrow down what you want?”

Now you and I both know that ninety percent of you just clicked out of my blog to go view Far Side cartoons—here’s a link to keep that group of you occupied (http://ow.ly/WwsxN). You are thinking, I am a highly educated healthcare professional, and I am not going to waste my time reading what some healthcare consulting want-to-be has to say about equating the purchasing of paper towels to innovating healthcare.

To those who chose to continue playing along, hopefully what follows makes it worth you having spent another thirty seconds reading.

Just suppose, Alexa, or Siri, or Ask Google was your current healthcare wellness partner? Just suppose you could, through a device, have this conversation with your provider or payer or pharmacy? What would your loyalty be to that firm? How much more confidant would you be about the real-time status of your health? (The technology exists. The missing link is that nobody has yet to tie it to healthcare.

“Alexa, my knee hurts when I walk down a set of stairs.”

“Does your Achilles also hurt?”

“It does. What do you suggest?”

“I think you should see an orthopedist at Penn. Would you like me to schedule an appointment for you?”

“Yes, please.”

“Is there a specific doctor you wish to see? Or, do you want me to schedule an appointment for you to see whoever has the next available appointment?”

“I would like the next available appointment.”

“I scheduled you to see Dr. Winston, next Tuesday, at 10 A.M. Your copay will be ten dollars. Shall I send you a confirmation along with a copy of your receipt? You should park at the garage on 34^th Street. Attached is a voucher to cover your parking.”

“Yes, please. I also realized I am out of paper towels. Can you also help me with that?”

The Five Most Important Things You Overlooked About Healthcare In 2015.

I lied to you. I read that more people will read your blog if you title it with ‘best’, ‘most important’, or ‘Top Five Something or Another.” Sue me.

Writing is the ultimate way for me talk to myself, and it seems to clam the nascent voices vying for attention in my head. Besides, at least when I talk to myself, I know I am talking to an intelligent person, although I sometimes emote a certain consulting idiocy that encourages people to underestimate my brilliance—Maybe I should not require the people I meet with to play the music from ‘Goldfinger’ or ‘Ride of the Valkyries’ before I enter a room. “Roemer. Paul Roemer.”

More often than not, my attempt at suavity is quashed like the ugly little bug that it was. I find that when I push the idiocy limits it encourages others to want to send me to a re-education camp to atone for my sins. Not everyone follows my penchant for irrational behavior.

The military has an expression I like; the diversion you are ignoring is actually the main attack. Sometimes things exist that although they seem unconnected are actually part of a larger plan. Not your plan, to be sure, but a plan nonetheless. Sort of like access, experience, consumerism, context, and cognitive health.

We’ve all been in planning meetings to suss out what we should be doing. There is innuendo, double-talk, evasive phrasing, and arcane code words. You leave the meeting believing your task is to report back on what consumers really want, when what they really wanted you to do is find out what the hospital cafeteria’s soup of the day will be next Tuesday.

To most of us the concept of ecommerce means nothing more than buying something over the Internet.

Ecommerce begat mobile commerce; shopping using a device other than a PC or laptop. However, mobile commerce is nothing more than reproducing desktop commerce, which is ecommerce.

Under either solution, consumers are forced to fill out forms to verify their identity, search inventory, and add items to their shopping carts. And in many instances, to close the sale, the consumer has to leave whatever app they are using, and pay for whatever they purchased from a different app.

Conversational commerce could also be called inference commerce using capabilities of artificial intelligence through machine learning. Pushed even further you arrive at cognitive learning and hence, cognitive healthcare. It creates personalized virtual assistants, like Nordstrom’s personal shopper, only without having to pay for the person.

I like to think of it as an Assistant-As-App (AAA), although today many of those apps are nothing more than an online IVR tricked out to connect you to a real person. A real Assistant-As-App does not require a person behind the digital wall to help you complete your task.

Take this for example. During any given day I’ll chat with colleagues online, use Messenger with friends, use LinkedIn to stay in touch about work, and text my wife and children. Conversations. Conversations using my phone but without speaking to anyone. What is missing from all of these conversations is commerce. Messaging is how people communicate, but it is not how people do business.

But what if it was? Why not create an AAA that was a digital interface that enabled users to accomplish complex tasks through a natural dialogue with an assistant? I deliberately left a word out of the preceding sentence. The preceding sentence is the digital IVR solution. The missing word in that sentence is the 2^nd digital. The sentence should be, creating a digital interface designed to enable users to accomplish complex tasks through a natural dialogue with a digital assistant.

This is the Super Smart App, the SSA.

Let’s try something on for size. Sally and her family moved to Philadelphia in August. She received an email about the Hospital of the University of Pennsylvania (HUP). HUP found Sally by mining data about people who moved to Philadelphia. The email told Sally that she could do everything she needed to do with her health by downloading HUP’s SSA, MyHealth. (I was going to call the SSA, ‘When Will Philadelphia Get Professional Sports?’, but that is just something I am trying to work through with counseling.)

So, Sally downloads MyHealth—not a trademark infringement of MyChart since MyHealth actually does things, and also works for non-patients. Sally speaks to the app, “My name is Sally Stoops. We are insured by Cigna. Does HUP accept Cigna?” “We do,” it replies.

“I want to sign my family up with HUP.”

MyHealth recognizes Sally from the email it sent her. “Sally, we have your address and phone number. Other than yourself, whose health do you want us to help you manage?”

Sally provides the profile information of her husband and children. MyHealth replies, “Everyone is registered. Your account is secure because we use voice recognition to identify you. Your husband may also want to add a voice signature to the account. If you want, you can tell me the name and contact information of your PCP, your husband’s and your children’s pediatrician, and I will contact them and get their Electronic Medical Records.”

Wow! Exclaimed Sally. MyHealth chuckled digitally, but Sally couldn’t hear virtual chucking. “I see you have two children, one in high school, and one in middle school. Pennsylvania requires all new students to have a physical before school starts. We have three pediatric Primary Care Practices within five miles of your home, one of which will come to your home to do the annual physical. Would you like to schedule an appointment?”

“Does it cost more to have the doctor come to our home?”

“It does, but because you are with Cigna, and new to the area, we can discount the cost by twenty-five percent, and your total cost will be three dollars.”

Sally scheduled the appointment. MyHealth replied, “If you tell me the name and contact information of your pharmacy, I can have all of your family member’s prescriptions transferred to the CVS Pharmacy two miles away from your house. Or, I can have them set up on automatic renewal through their mail-order pharmacy.”

Sally tells MyHealth the prescriptions her family members are using. MyHealth replies, “If you switch to our mail-order pharmacy automatic renewal program we can save you forty percent.”

So, that is how healthcare works in my mind. All of these capabilities can be designed today. The only thing missing is the leadership to do it.

The number one fashion search on Google in 2015 was how to walk in heels. I hope my search did not skew the results. There are lists of top searches by category, and the leading searches in every category lead you to believe that if those same people are voting in next year’s election the results may be skewed because many of the voters have the IQ of a bowl of mice.

Notably missing from the lists of searches are topics requesting information that couldn’t be found on either Cosmo or People. For example, nobody asked the proper naming convention to use when confronted with a terrorist; Are you with ISIS, or is it ISIL?

Speaking of fashion, my wife and I were finishing our Christmas shopping—I thought about writing holiday shopping, but we were Christmas shopping. We were being consumers. Actually, she was being a consumer, and I was simply the guy looking for a chair and constantly looking at my watch.

Consuming, by my definition, and in the context of this article means to purchase—as opposed to eat. We were going to consume shoes. Black heels, to be specific…more black heels, to be really specific.

“Would these shoes go with my outfit?” She asked.

Half of you reading this know that the rest of my day was now perched precipitously on a slippery slope. I cannot answer ‘yes’ or ‘no’ without knowing which outfit we were discussing. I believed I was supposed to know, but my cognitive skills had been depleted several stores and many pairs of shoes ago. I suppose I could have pulled out a deck of Tarot cards, but any form of divination seemed inappropriate.

And so I asked, “May I have a hint as to the context of the occasion for which you would be wearing those shoes with the aforementioned outfit?” My question allowed me to sound engaged, and to do so without giving away the fact that I still had no idea as to which outfit we were discussing.

So perhaps you can see my quandary. Consuming, being cognitive, and knowing the context were each key factors in determining the measure of how successful I was going to be.

To be a consumer, it helps to know what you will consume, and in what context you will consume it. Hence, Meatloaf’s Two Out Of Three Ain’t Bad does not make for a good fit. People—hint, consumers—need to align all three, consumption, cognition, and context, or they have nothing.  The 3 C’s.

So, what does that say about healthcare? I am willing to bet there is not a single provider or payer in the U.S. looking at the intersection of cognition, context, and consumption. Evaluating consumerism, which is at least getting some lip service, will not deliver the results you need without incorporating healthcare’s cognitive and contextual requirements.

The CEO of a major U.S. health system recently tried to make an appointment for himself. Displeased with how that turned out, he’s gone shopping, and his shopping seems to be focused on buying call center technology—a cart before the horse solution.

Cognitive health, consumerism, and context being and end with access. If you cannot answer your phones all other considerations are moot. If there is nothing for a consumer to do online all other considerations are moot.

Why is any of this important? Let us consider this question: What percent of people actually know with some certainty their current health? I’m guessing that number is in the low single digits. And how many primary care physician’s, health systems, payers and pharmacies actually know with some certainty the current health of any of the individuals whose health they oversee?

Most individuals think, I don’t feel sick therefore I must be healthy. I had a physical last year and was told I’m healthy. That does not seem like much information to bet the ranch on.

The only way to know with a hundred percent certainty the current health of an individual would be to test that person every day for every possible illness. And that is a non-starter. On the other end of the spectrum is not knowing anything about the current health of an individual; also a non-starter.

We need to figure out how to effectively bridge the gap between knowing everything and knowing nothing. We would do better at managing someone’s health if we could call him or her each day and ask him or her. Did you take your medications today? What did you eat? Did you exercise? What is your blood pressure?

Obviously, we cannot do that. But we can ask those questions and others through the use of a customer portal. And the people we are asking can ask questions of us using that same technology. The technology exists. What doesn’t exist is the leadership needed to make it happen.

By 2013, more than one billion smart phones had been purchased. Those people want to be able to do more with those devices than call your call center. But they cannot, because healthcare, for the most part, has not given them a way to use them.

Think about the health-related apps you use on your smart devices. One thing that can be said about those apps is that they are not smart. In fact, the term smart devices is a misnomer. For the most part, the same can be said about wearables.

Let’s look at two types of apps; one for diet and one for exercise. Those apps are basically nothing more than buckets that hold recorded data. Data about what you ate and how far you walked. And they can perform basic math—I need to walk 10,000 steps, I walked 3,000 steps, I missed the stated goal by 7,000 steps. Same idea with the amount of calories consumed, except with that one you can lie about what you ate.

At the end of the day what do you have? You have two buckets; a step bucket and a calorie bucket. Each bucket functions independent of the other bucket. The exercise bucket cannot infer anything about the exercise data it recorded, and it cannot relate the exercise data to the data collected about how much you ate.

For example, assume your diet app recorded that you ate 2,000 calories a day by eating a bag of Twizzlers every day for a week. The output from the app would be the same as if those 2,000 calories came from eating fish and vegetables all week.

Neither app knows what medications you are taking or what foods you should be eating. The apps do not know if you have high blood pressure or heart disease or whether you are pregnant. They know nothing more about your health than your doctor or payer or pharmacist. They do not tell you anything that you didn’t already know—the app tells you that you ate an apple for lunch; it can do that because you told the app that you ate an apple for lunch.

Based on your available health data, your ability or your doctor’s ability to know how healthy you are right now would be no more accurate than asking an 8-Ball or using a Ouija board.

The apps are dumb. The data is dumb. Thinking you are managing your health by using those apps may also be dumb. There is no point in collecting data about your health unless there is a way to make it actionable and a way to draw conclusions from it.

But what if we could make them smart? What if there was a way for a consumer to effectively manage their health? What if there was a personalized Super-Smart-App, an SSA? (Just so you know, this is not science fiction.)

Suppose providers, payers, and pharmacies had such an app, a SSA? What could that SSA do for patients, consumers, providers, payers, and pharmacies?

• Collect data daily from apps and wearable devices
• Analyze the data
• Tell providers, payers and pharmacies if a person is at risk or needs a lab or needs to be seen or is having an adverse reaction to a medication
• Schedule the appointment
• Ask questions of patients and consumers
• Answer questions of patients and consumers
• Answer questions of providers, payers, and pharmacies
• Tell patients and consumers what they should be doing
• Track whether patients and consumers are doing it
• Award wellness points

And what if people could use that SSA from any device at any time? Sure beats having to call the provider before 6 PM Monday through Friday.

All of these things can be done today. The reason they haven’t is that nobody has bothered to imagine a world. The Internet of Things is an asset and a strategy. Why not make it yours?

If you were called into a meeting and someone asked you to defend why your firm has a website, what would you say? “So people can find our phone number? So they know what hours we are open?”

That is not much of a defense, is it? Most of your organizations have a website that is nothing more than in information portal—a digital pamphlet. I have not seen a provider or a payer whose website can be considered a corporate asset. The value of the URL may not be any higher than what the company paid for it.

So, what is the difference between the value of a website that lists the time the gift shop opens and one that lets people interact with the entire organization in the same way they would if they were sitting in your lobby?

Here are a few facts I found on blog.invisionapp.com that should startle those whose website value is below several million dollars.

• ESPN.com’s revenues jumped 35% just by incorporating user feedback into their design
• Over the last ten years, investors who had invested in companies that are digital-centric would have received a return 228% higher than those who invested in the S&P
• As an example that trivial decisions about your website are never trivial, Bing’s choice of the hue of blue they chose over other hues was worth an additional $80 million dollars in annual revenue. How many colors are on your website and how much time did your people spend analyzing them? Thought so.
• Every dollar spent on email marketing returned $44.25. Sort of puts billboard advertising to shame.
• 88% percent of site visitors are unlikely to return to the website after a poor user experience. Did you firm even define what constituted a good user experience? Were patients even included in its design?
• Slow-loading websites resulted in $2.6 billion in lost revenues last year—and that only accounts for speed, not functionality
• 75% percent of viewers assess the credibility of an organization based on the aesthetics of the organization’s website
• 94% of first-impressions are design-related
• 85% of adults think a company’s mobile website should be as good or better than their desktop website. That feature, the ability of your website to be just as easy to use on a five-inch phone as it is on a thirty-inch monitor is called responsive design

Planning your digital presence ought to be a key component of your annual business strategy process, and if your website happened to crash, that crash should have a huge negative impact on your business. It would on Amazon’s. Perhaps the good news though is that if a payer’s or provider’s website went down for a week it wouldn’t cost them a dollar of lost revenue.

Someone asked me how I was getting along in my new role. I replied, “I am growing and learning, meeting new challenges with confidence and enthusiasm while developing good work habits and people skills.” I thought that sounded pretty good.

I’ve been told I have the gene for sarcasm, which I’ve taken to mean shows intelligence and good mental health; I think my wife believes it means something else.

I thought we could begin today’s post by asking everyone to take thirty seconds—you won’t need forty—to go the website of your favorite health system or your favorite payer and complete all of the tasks or transactions the site lets you perform.

I am willing to bet that on more than ninety percent of health system websites the only interactive task (a task where you can actually enter data) available to you would be clicking “Like” on the health system’s Facebook page.

Why do I like harping on this issue? Suppose you purchase a shovel from Home Depot. The reason you bought the shovel is because Home Depot does not sell holes. If you have a think about it, you will find there is actually a lot of depth to that statement—you need ‘A’ but you cannot create ‘A’ without using ‘B”. The logical healthcare analogy is needing an appointment, but not being able to get the appointment without making a phone call.

“This is my shovel. There are many like it, but this one is mine.”

You take the shovel home, and you see that there is a pamphlet taped to the shovel’s handle. The pamphlet tells you all about the history of shovels. It describes the different types of shovels. There is information about how to go to their website and select a shovel. It tells you about the company that manufactured the shovels, the people who are on the board of the shovel making company, and about all of the different tools they make. There is even a sentence telling you what hours you can call the manufacturer if you have questions about your shovel. And, there is a paragraph in the pamphlet about touring the shovel manufacturer’s plant, and the hours the shovel gift shop is open.

After reading all about shovels, you notice that a blunt safety device has been attached to the business end of your shovel. You cannot use the shovel until you remove the safety device. You try a number of ways to remove the device but you cannot get it to budge. You then reread the pamphlet to see if you overlooked the information about removing the blunt object. The information is not there.

Where does that leave you? It leaves you knowing everything about your shovel but without a way to use it to benefit you. The utility you gained from reading the pamphlet just nosedived. There is no reason to ever read the pamphlet again.

Now think about your health system’s website. Chances are it is a lot like your shovel pamphlet. People—customer people and patient people—can read about the history of the health system, they can read who is on the board, read about the different services—shovels—the system offers, read about the gift shop and about taking a tour. They can read about what hours to call the organization. Heck, anyone who is interested could read about the health system for hours.

However, when they are done reading, they are done. There is no reason for them ever to return to the website because there is nothing for them to do when they are there. In most health systems the only reason for a person to visit the website more than once is if they forgot to “Like” the system on Facebook during their initial read-through.

Consumer and patient access are absolutely worthless unless your customers can do something once they have accessed your health system. Calling is not access. More often than not it is a barrier to entry.

The great features of accessing a health system through its website are that there are no wait times, no dropped calls, and no wrong answers.

The bad feature of accessing a health system through its current website is that once you have been there, there is no reason for you to ever access the health system through its website again.

Every health system has a website, but it often seems that few people have asked the question, ‘Why do we have a website?’ I think too many health systems built their website because someone felt a need to check the We have a website box.

More people—customer people and patient people—go to your website every day than ever walk into the health system’s expensive lobby. Yet nobody pays any attention when they are designing the website to the fact that people go to the site hoping to be able to do something.

They go the site hoping to avoid calling the health system. They do so because they have tried calling on other occasions, and that experience was painful. In all likelihood, the people who designed the website have never tried calling the health system. Had they tried calling, they would have designed a better website. They would have made access to the health system a priority. They would have made it actionable. They would have made it a place where people—customer people and patient people—could accomplish any task they set out to accomplish with the possible exception of having their knee replaced.

And the really silly thing is that when hospital executives go the websites of other vendors they use—vendors like airlines and hotels and phone companies and retailers, they go to those sites to accomplish tasks.

Roemer’s Immutable Patient Experience Laws: There are only two types of people who go to a health system’s website; those who are deciding will I buy healthcare from this provider, and those who are deciding will I buy healthcare again from this provider.

Please permit me to offer an observation. People go to the website with the expectation that they will be able to complete tasks. Tasks like Referrals, Authorizations, Registration, Scheduling, Refills, Triage, Billing, Payments, Admissions, Discharge, Disputes, Claims, Insurance, ED, Labs, Primary Care Provider, Clinics, Medical Records, Imaging, Therapy, Pre-surgery, Find a Doctor, Payment Plans, Pharmacy.

They leave the website, never to return, because they could not accomplish anything. Never to return. Never to be a new patient. Never to be retained as a patient. Never to refer the health system to anyone.

The lifetime value of the person who had a bad experience is around $200,000 dollars. The lifetime cost to the health system that provided the bad experience is around $200,000.

Multiply that by one hundred thousand disappointed callers and website visitors a year and all of a sudden the cost of not providing good access is pretty high. The good news is that all of these problems can be fixed.

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

“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.

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?”

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.