Every fast food restaurant has a menu item called a Number 1, none of them start their menus with an offering called a Number 2.  And the Number 1, is always the most ordered item simply because it is first.  In most instances, being first is good.

This weekend I watched a fascinating documentary about the annual Army-Navy football game. Just to be transparent, I should note that I attended the other military academy, the Air Force Academy. To say I attended it is a bit unfair to what these young men and women did; I stayed long enough for several haircuts. The Midshipmen and the Black Nights featured in the documentary really attended.

During the two-hour presentation, an important phrase was stated, one that could have easily been missed unless you were paying attention closely. Cadets and midshipmen alike mentioned that their goal for the game was to sing second.

Sing second. Those two words are sewn inside the uniform collars of Army’s football jerseys. One of the many traditions of the game is that at its conclusion the two teams, along with the entire corps of cadets from each school, out of mutual respect and admiration, sings their school’s alma mater. The losing team’s alma mater is sung first. The losing team’s players face their fellow students, and the winning team stands respectfully behind.

Then the players of both teams cross the playing field to where the entire student body of the winning team is seated. The winning team’s alma mater is sung, and the losing team’s players stand respectfully behind.

While this may be the greatest rivalry in sports, part of what makes it so special is that once the players leave the field of competition they do so with the knowledge that they are brothers and sisters in arms. Duty, honor, country.

Win first; sing second.

In most of the rest of the world being second can be reworded as being the first loser. Being the second person or organization to do something is never good, especially in business.

This will prove to be true with healthcare, with patient access, engagement, and experience. Suppose the competitor to your health system reinvented patient access, engagement, and experience? Suppose they made it easier for people to do business with them, and they did it by creating a remarkable online interactive experience?

Using their system’s customer and patient portals, people could access that health system. And that health system could access people; patient people and consumer people—two-way access. People could store and manage their health data, daily data about their health. People could easily conduct all of their business with that health system without ever having to call someone.

It would be like doing business with any other large innovative company.

If your health system becomes the second health system in your area to offer this type of user experience you have already lost.

Why? Think about your bank. Think about all the work it took to set up your accounts, all of the work it took to set up all of your online banking transactions. Once you have set up your online services with your bank, how likely are you to change banks?

Not very. If a competitor to your bank offers a free toaster you will not change banks. Why? Because you are all settled in; you are comfortable. Banks have figured out how to lock in their customers, how to retain their customers. And they did it by making it easy for people to do business with them. I have not walked into a bank in more than a decade because there is no need to.

The first health system in your market to make it easy, really easy to do business will win. They will win because once customers have all of their data locked into that system they will not be so keen to move it. Patient retention.

So, here are your choices if you are a health system; choose to sing second, or buy a boat load of toasters and hope you have better luck with them than the banks had.

One of the problems with getting across a new idea is presenting it in a manner that allows others to visualize something they have not seen before.

I think people have that problem when it comes to understanding how to recast patient experience and patient access. We have patients, they think to themselves, therefore those people must have access or they would not be our patients. It is this kind of thinking that allows them to check the box—problem solved, now let’s move on.

So let’s ask the question; exactly what kind of access do people have? Do they have good access? Do they have a good experience when they try to access our health system? Can they accomplish what they set out to accomplish in one attempt? Did they have to talk to more than one person to have their needs met? Was there an easier way for them to do what they needed to do?

Perhaps we can define a few things.

Access: Everyone can interact with the entire organization in a manner that was designed by the organization to provide a good user experience for every type of interaction–not just scheduling.

Ease of Access: People are not willing to work hard to access the health system. Access should be intuitive.

Effective Access: People are able to accomplish what they set out to accomplish 100% of the time.

To learn if your health system has access, or merely has a group of phone numbers for people to call to try to accomplish tasks requires work. You have to look around, and you have to ask questions.

It also helps to have an example of what good access and experience look like. UBER is an example of a company that designed access, designed access to be easy and intuitive, and designed it in a way to be effective. If you have not used UBER, you can see how user-centered-design reinvented the task of getting a taxi by watching this YouTube video: https://www.youtube.com/watch?v=U9A86Nh75xQ

For non-UBER users, the idea of hailing a taxi evokes memories of standing in the rain on a crowded street and competing with others for the attention of the cab headed your way.

For UBER users it works like this:

• Activate the UBER app on your phone
• A map comes up on your screen that shows where you are
• On the map are images of moving vehicles—UBER cars—in your area
• You enter where you want to go
• The screen shows you a photo of your UBER driver, a description of the driver’s car and the car’s license plate, and an estimate of how many minutes it will take for the drive to arrive at your location.

Your work is done. When you arrive at your location you exit the car. You do not need to ask for a receipt, it is already being emailed to you. You will then be asked to rate the driver by clicking on how many stars you award. Every driver gets rated on every trip, and the driver rates every rider. If a driver’s average rating gets below 4.2 stars out of a total of 5, the driver will be removed from UBER.

That is the brilliance of UBER. They took a highly dysfunctional industry and turned it on its ear, and the only thing they require of their customers is to enter the address of their destination.

Very slick, and very effective and efficient. A great user experience. In fact, it provides a remarkable experience every time, and the reason the user experience is great each time is that it was designed to be great. Great design, user-centered design, is difficult work.

Design is a verb. In health systems, access and experience were never designed; they simply evolved. Having phone numbers for people to call did not involve design. Having a place where lots of people sit and answer calls did not involve design. Having a website that only allows people to read about the hospital never involved designing the user experience.

Access to most health systems by phone involves a poor user experience. Having said all of that, what is the first thing that a health system should do to dramatically improve the access experience? Since access, using the definition from above, involves everyone, not just surgical patients, not just acute patients, and not just scheduling done by phone, it is important to determine just how poor of an access experience your health system offers by phone.

That said, the first step for improving the access experience is for health systems to determine is to determine how broken the phone experience is, and then design an experience that provides a remarkable experience every time for every caller.

Simply having happy and smiling people answering the phones does not mean the access experience is good. They can smile all day long, but if people have to call multiple times, and/or have to speak to several people, and are still not getting their needs met, their experience is poor.

Sooner or later poor user access will result in people buying their healthcare from another provider.

The woman in front of me at the checkout line in the grocery store had two full shopping carts piled to the rim with food.  She began placing her items on the belt, one item at a time, sorting them into neat categories; perishables, organic, canned goods.  I tried using my ventriloquism, repeating the phrase “get out of the line…get out of the line.”  I could see her looking around trying to place the voice, but she remained fixated on her sorting…place the frozen Salisbury steak next to the TV dinners.

I felt a bead of cold sweat start to wind its way down between my shoulder blades, and a slight shiver overtook me. I started to picture her in front of me at a salad bar, inspecting individual chickpeas prior to placing them on her plate.  The only other thing that could have made the situation more untenable is if the grocer decided to play Celine Dion’s Christmas CD over the loud speakers.

After about twenty minutes the last of her items had been scanned, and the clerk announced the amount. The woman fumbled about in her purse, pulled out a large white envelope, and withdrew a fistful of coupons.  The voice in my head whispered to me “I thought we agreed there would be no killing this time.”  Ten more long minutes passed.

The store manager and I simultaneously saw her reach back into her purse.  Even before we saw it, we both knew she was reaching for her checkbook.  The manager knew he only had a couple of seconds to try to stop the bedlam that was about to explode.  He leapt the service counter, pushed aside the boy bagging the groceries and flung me to the floor.  A Good Samaritan in the next aisle straddled my legs while the manager hooked me up to an IV of Benadryl, and shielded my view from the woman.

That was my day.

If experience teaches us anything it teaches that if we represented the people who think they understand business strategy and planning on a Venn diagram, and also represented the people who actually understand business strategy and planning on the same diagram, the number of those who actually understand it would be like comparing the circumference of the donut hole to the circumference of the donut.

About one hospital in seven has a defined patient experience strategy, and of those that do almost all of those strategies focus exclusively on what occurs within the hospital, and almost all of them rely exclusively on improving HCAHP scores.

That said, we can make a few observations about why it is difficult for any hospital to make any significant improvements regarding patient experience:

• 85% of hospitals do not have a system-wide patient experience strategy even though ninety percent of hospital executives rank improving patient experience as their first or second priority over the next three to five years.
• Of the fifteen percent with a strategy the vast majority of those strategies are constrained by what occurs to the patient in the hospital.
• Most hospitals do not measure the experiences or levels of satisfaction of their outpatients.
• It is possible that no hospitals measure the experiences or levels of satisfaction of prospective patients.

Should providers be improving HCAHP scores or improving patient experience? While it may seem like splitting hairs, the two efforts are no the same. Should we be trying to improve patient experience, or should we be trying to improve patient experience scores? I think you can improve the scores without improving the experience, but you cannot improve the experience without having it raise the scores.

What is the health system’s definition of improvement?  Where is the plan?  For most systems the goal is to raise their score. Move the number from A to B. But then what? Where is the strategy? What is the retention goal?  The referral goal?

Not a single patient or consumer in the country can tell you the HCAHPS score of their health system. I bet none of Press Ganey’s employees knows the score of their provider.

And what is the unicorn in the patient experience waiting room, what is the question nobody is asking? It is this—why are providers trying to improve their scores? Other than not being penalized, how does the provider benefit from having a higher score?

Alternatively, how would a provider benefit by actually improving patient experience? Actually improving patient experience, patient access and patient engagement results in:

• Higher patient retention
• Higher patient referrals
• Improved revenue cycle
• Lower customer service costs
• Reduced admissions and readmissions

Now that seems to be a strategy that if I were the CEO or CFO or COO or CNO that I could get my arms around.

It is snowing. Flight home cancelled.  My hotel room was cancelled, cancelled while I was still in it..

This is also happening for newly-minted MBAs.  Blizzard; no worries.  Smart phone, new reservations, care to join me for drinks?

I wonder how they would handle it the way we real men had to handle it in the days before Al Gore invented the internet.  Would they even know where to begin?

In the old days, when mastodons still roamed downtown Boston, a good snow storm meant you might not get home until the lawn needed mowing.  They way this mastodon remembers it, everyone in the cities affected by the storm would call the one phone number for the airline to see about rescheduling their flights.

If you could not extend your stay at your hotel, you were basically out of luck.  There was no way to Google the hotels in your zip code, there was no way to even know which hotels to call.  You would simply dial ‘411’ and start asking an operator to connect you with a hotel other than the one at which you are currently registered.

When that did not work, and after the bellman at your hotel tossed you onto the street, you would make your way to a copse of trees, hope you remembered your Navy SEALs training, and try to build a bivouac with your comb and toothbrush under the branches of a juniper bush.  As the snow fell in earnest you might fashion a pair mukluks from yesterday’s socks.  If you were really fortunate, you might still have a piece of adipose tissue—seal blubber—saved from the last time you were forced to play survivor.  That is how real men did it in the old days, in the days before the entire world started to function around the internet and mobile phones.

Segue.  Hospitals.  Was that a mastodon I saw in your lobby?  I just bumped into someone from IT and she dropped her computer punch-cards—you younger ones may have to Google the term.  In the last five years smart phones and the internet have changed how Americans conduct business; how we buy goods and services.

They have not, however changed how we interact with hospitals.  For those who still have phone books if you look up your hospital in the phone book you will see dozens of numbers to call.

Riddle me this Batman; which of those numbers are you supposed to call if you need to schedule a lab?  It depends.  Which number should you call for a refill?  It depends. For a follow up appointment?  And so forth and so on.

As a prelude to the snow while I slept last night, using the internet, US Airways did all of the following—cancelled my flight, messaged me to let me know the flight was cancelled, rebooked me on a flight, and sent me a message confirming my new seat.  In real-time, all while I slept.

Most hospitals cannot even schedule the original appointment using a phone, let alone reschedule it and send me a confirmation over the internet.  The mastodon model of patient access works as follows.  I call the hospital, am placed on hold, am asked for my referral, my authorization, my insurance.  Then I am transferred to someone else, am placed on hold, am asked for my referral, my authorization, my insurance.  I may get an appointment, I may not.

While I am on hold with the hospital I rebook my hotel, watch a movie on HULU, search eBay for a mastodon tusk, and show my dog a video to teach him how to shut the door.

I’m thinking this whole internet/smart-phone thing may have legs.

As a hospital, are you really comfortable offering less of a customer experience than an airline?

May I take you on a tour of my home?  You enter through the front door.  On one side is the living room, on the other 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 set of china 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.

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

It gave me pause.  The receipt was 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 got to 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 that Thanksgiving, while watching an episode of the Sopranos, I was having difficulty breathing, a lot of difficulty.  I stepped outside to have a cigarette, and to sort out why I could not breath. Collapsing to the floor convinced me that I was having a heart attack.

Less we be distracted, this post is about the 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.

A lot of people are saving their candles for more important occasions.

No occasion will ever be any more important than the occasion of simply having tomorrow.  These days we burn the candles, stain the linens, and break the crystal and the china. Let’s agree to light a lot of candles this year.

Warm regards, Paul

Please be on the lookout for my one-man production, Paul Sings Les Misérables. Those of you who have been on a recent train or plane with me may have heard me practicing.

There are around 4,100,000 hotel rooms in the US. People who study obscure facts recommend pillows be replaced every two months. If we assume that each hotel room has four pillows, the hospitality industry should replace about a hundred million pillows a year. I travel a fair amount, and I have yet to see a pile of discarded pillows at any hotel

It occurred to me that if one measured healthcare’s attempts to improve patient experience and patient access in dog years, we might understand that the expiration date of those efforts have come and gone.

And so I wondered, how might we alter our efforts in order to get a better result?

Health systems, for the most part, have created a generic persona of this entity we call a patient. In almost all of those personas, the persona’s attributes are limited to those of inpatients. In other words, not only are the attributes not tied to any specific individual, they exclude most of a health system’s stakeholders.

And as much as we would like to believe that access and experience have improved, if we look at how hard people have to work to interact with a provider, most of it still happens by phone. The only innovation in patient access over the last fifty years does not come from health systems, it comes from the companies that make the phones—rotary phones to touch tone phones to mobile phones.

Even with all of that innovation, the people who call are still subjected to having to wait to talk with someone, and to having to speak with someone who cannot meet their needs. It is the same old problem, only now we have cooler devices.

Let’s spend a minute looking at whether there is merit in unbundling the attributes we associate with a patient or consumer. Let’s start with a sample group of a million people. We naturally segment people into groups; for example, dog people and cat people. Suppose in a sample of a million people, six hundred thousand of them are dog people.

Of those six hundred thousand, suppose seventy percent are coffee drinkers and thirty percent prefer tea. That gives us four hundred and twenty thousand people who like dogs and drink coffee. Of that group, half favor football and half favor baseball; two hundred and ten thousand dog-loving, coffee-drinking football fans. And of those who like dogs, drink coffee, and favor football, ten percent are fans of the Dallas Cowboys; 21,000. Five percent of those people live in Seattle, and of them, twenty percent hate the fact that rains often in Seattle—that gets us to a group of 420. Of the 420 dog loving, coffee drinking, football loving, Cowboy fans who live in Seattle and that hate the rain, thirty percent of which refuse to carry an umbrella—123 people. Seventeen of the 123 have red hair, nine of the seventeen are married, three of the nine do not have children, and one of the three is a republican.

Sooner or later segmentation comes down to the preferences of one person.

What if the sample was population one million people who at some point have been patients, and all of who will be patients again? They do not fit easily into a homogenous group. Some of those individuals are patients, some were patients, and some will be patients. Some battle chronic diseases. Some have children. And some, for reasons understood only to them are Dallas Cowboy fans.

They have their own experiences, and they have their own expectations of what those experiences should be. To be blunt, an individual does not care about how great everyone else’s experience were. A person cares about how great their experience will be.  Their is not a patient or a consumer in the US who can tell you the HCHAPS score of their provider.

Healthcare is not eCare, heCare, or sheCare.  It is meCare.

Measuring patient experience using just HCAHPS assumes homogeneity. That approach relies on the fact that creating a homogeneous experience will keep everyone happy. Try that same approach on a married and childless, wet Dallas Cowboy fan and his dog that live in Seattle, and who voted for Mitt Romney in the last election.

Improving patient access and experience requires making it feel like it was designed to meet the needs of each individual. And since the only thing that seems to change is the type of phone being used, if you want to really improve access and experience, get rid of the phones and let people interact with your health system online.

“You can’t write that!” If I ever needed motivation, telling me what I cannot do is usually sufficient.

What if you threw a party, and a bunch of people popped their head in the door, looked around, and decided that their best option was to go to the Laundromat? What if ninety-eight percent of the people did that?

The new and improved healthcare.gov 2.0—or 0.02 depending on your perception—launched today. One million visitors—there was no information regarding how many of the visitors were from the CGI Group (the Canadian firm that sort of developed dot-gov-1.0.) Twenty thousand applications. Two percent of the visitors, .02. If only two percent of any organization’s potential buyers, or visitors to an organization’s website buy, it could suggest one of three things:

• The visitors found nothing that compelled them to part with their money
• The visitors had a poor user experience
• The visitors believed their other options were better

According to reports, the number of uninsured Americans dropped five percent last year. In order for the government to be the country’s only payer, if in fact that is their goal, they need a plan that does not rely as much on attrition. Those same reports show that the fine for being uninsured has been quadrupled, from $95 to $395.

While it seems one can make a compelling argument to recast healthcare, I am not convinced that the current approach is the compelling argument; especially after hearing repeatedly that the Affordable Care Act’s architect, the mountebank from MIT, boasted about how the success of the Act depended highly on the stupidity of the American voter. Based on the Act’s adoption metrics, perhaps Mr. Mountebank overestimated our stupidity; at least I can hope mine was.

But then again, I digressed. The one teachable moment from last year’s launch of the ACA is that user experience matters. People do not want to work hard to do what you want them to do on your website.

Now I would be remiss if I did not segue directly to the website of any of the health system, remiss if I tried to compare the functionality of healthcare.gov to the functionality of any health system’s website. And why would I be remiss? Because the healthcare.gov site, despite its inadequacies, no matter how dysfunctional it was, still had a degree of functionality.

Not so when it comes to the functionality of the websites of most health systems. At least healthcare.gov presents the idea, no matter how illusory or gossamer it may prove to be, that the people who go to the site can acquire an insurance policy that will benefit them.

Permit me to beat or re-beat a dead bovine with a stick. Health system websites. Your health system’s website. Repeat this mantra after me. Once someone has visited your health system’s website once, is there any compelling reason for visiting it a second time?

Once you have read what the site’s authors want you to read, is there any reason for you to read it again. For those who may be reading my little missive for the first time, thank you for having made it this far. Before you write me off, go to the website of your health system, and try to do something…anything. After a minute or two it will occur to you that the only thing you can do online is read what the health system wants you to read. And once you’ve done that there is no reason to revisit the site.

And so your point is….? My point is this. Healthcare.gov, no matter how inadequate its offering, at least it has an offering…do this, sign up for that, enter your data. At least it has a call to action, at least it asks its visitors to commit to doing something.

What do the websites of most health systems ask of their visitors? They ask them to read. Read something. Please. Sort of like the book-of-the-month club, only without the benefits and discussion group.

You know better than me, that the likelihood of you learning anything profound from having read my little rants is small. That is because the reading level and the points I attempt to make are tailored at a ninth-grade reading level—and before you take umbrage with those words, that is the level to which the New York Times writes.

I hope what it really means is that there are many measurable, achievable, and cost-effective ways to improve patient access, engagement, and experience that do not require an MD or a PhD. All they require is someone willing to lead who is willing to say, “We make it way too difficult for people to do business with us.”

The great thing about being a T-Mobile customer is that you can get a new phone without ever having to wait for an upgrade. And their rates are low. And I think the rates are so low because only three people in the country are able to make a call at the same time.

So, I’m driving to pick my daughter up at her friend’s house, a friend who lives nine miles away. I fire up the GPS on my aforementioned T-Mobile; estimated drive time of seventeen minutes.

The route is mostly back roads, and as soon as I reach the backest of the back roads I am informed, “GPS signal lost.” After having my way with the recording, I continue to drive. And drive. And you know the rest. I head to places with higher elevations, find a signal, and am directed to roads that even I know have nothing to do with where I am headed. My route is again transferred to another, and so forth and so on.

I am talking to myself, and yelling at drivers who look like they know where they are going. Squirrels on the side of the road point at me, and double over in laughter—I hope they choke on their acorns. After an hour and two minutes I arrive at the house, upon which my phone chirps, “You have arrived.” I started screaming epitaphs in front of the squirrels.

An hour and two minutes is four minutes longer than I spent the other day trying to schedule an appointment with a large east-coast health system. The person with whom I spoke the longest seemed to have a pulse equal to that of a hibernating bear, and had he been a household pet he would have been put down purely for aesthetic reasons.

I find it helpful to trace everything back to a seminal point like just prior to when the random swirls of gases in the chartless universe got together and formed the earth; or not, depending on which side of the Darwin bed you sleep.

From the side on which I sleep, the seminal point for patient access can be traced to the phone. If the people manning your health system’s phones cannot meet the basic needs and solve the problems of its callers, very little else matters because the callers will call somebody else.

Hammers, like phones, are very evolved tools. They haven’t changed for years. And why would they change? Nails haven’t changed. Nails have been the same forever. Therefore a hammer’s necessary features were worked out long ago. A heavy metal head, and a handle. All you need, and nothing you don’t. Phones are also very evolved tools. The primary difference between a hammer and a phone is that if you do not have able people on both ends of the call, the phone is useless.

Transferred calls, dropped calls, callers placed on hold, being told my call would be recorded for quality purposes—an illusory promise of something unseen. When I heard the recorded voice inform me of that tidy bit of news I yelled back, “Wouldn’t I actually have to speak to someone to make the recording worthwhile?” The entire scheduling process—I am overstating the concept as there was no process, just a series of random interactions—reminded me of a series of cattle pens at a slaughtering house, and the only thing that saved me was my refusal to be herded. By the time the process had concluded I had developed nictating membranes over both eyes and recessed to the lizard part of my brain.

Maybe the process was designed to wear people out, to get them not to call back. Sort of like the customer experience models used by payers.

Just to be clear, there are no catastrophic patient access failures. The failures people suffer through are made up of a series of small things that become big things, much the same way that individual snowflakes become an avalanche.

Health systems should bear in mind that even though the people who work there may know the number to call to get an appointment, nobody else does. In most cities only six people have a phone book or the Yellow Pages. Chances are good that even if they could find the listing for the health system they would not know which of the dozens of numbers to call.

Here is how real people—patient people and consumer people—figure out how to call a given health system. They go online; they see a number, cross their fingers, and dial. They do this process again and again until they either give up, or until they declare themselves cured and no longer need to purchase healthcare.

The chief marketing officer of one of my former clients, a large academic medical center in Philadelphia told me her health system had more than 1,200 URLs. That probably gives the average consumer more than 1,000 different numbers to call to have their needs met.

The most functional feature of any health system’s website, if viewed from the perspective of someone wishing to schedule an appointment would be a big, flashy display of the single phone number they need.

Your website’s home page has become the digital phone book for everyone wishing to interact with your health system. I estimate that more than fifty percent of the people who visit your system’s website do so to figure out which number they should call to have their need met. My experience suggests that almost one hundred percent of the people who are trying to call your health system have to call more than one number to speak with someone who can help them.

If one thousand people go through this exercise each day, the health system receives an extra thousand calls simply due to the fact that everyone has to call more than once. If each call’s fully weighted cost is thirty dollars that means thirty thousand dollars a day goes up in smoke. That means the health system spends more than ten million dollars each year because people must call again and again.

A few years from now, if you and your child happen to stay at hotel—could even be a Holiday Inn Express if you have savant-like tendencies—your child will look around the hotel room and ask you to explain some of what she sees.

For instance, that thing on the nightstand with the buttons on it, “What’s that for daddy?”

“In the old days, people would use it to make telephone calls.”

“And the box by the TV, what does it do?” She asked.

“People used to pay to watch movies using the box when they stayed at the hotel.”

“After they made their phone calls,” she stated as the concept became clearer.

“What do you want to do now?” The father asked.

“I am going to text my friends and tell them about these silly things, and then I am going to watch movies on my iPad on Netflix.”

For those who remember traveling when Bush the First was president, you probably remember using those phones. To use them you had to dial and 800-number, enter a lengthy PIN, and then enter the number of the person you wanted to call. That was the only way to stay in touch with your loved ones. After calling home, you would watch the national news on ABC or CBS or NBC to get updated on your world. In the morning you would read the newspaper that had been left in front of your door overnight.

Things have changed for everyone about how we learn of and interact with our world. Well almost everyone.

Today, the only way to access the vast majority of health systems is by phone or in-person. I met recently with the person who oversees patient access at a large academic medical center. Their end-to-end definition of patient access started at registration and ended at admissions. They only considered access a function of inpatients. Access consisted of many steps, some of them redundant. The final steps required the patient to be face-to-face with an access team member, a requirement that resulted in the patient making at least two trips to the hospital.

We were told that the process worked, which by default allowed the access group to conclude that it was efficient and effective. We were told that the processes that would be done by telephone were very, very effective—more on this in a second.

I asked why the in-person tasks couldn’t be done on the phone or online, and I was told that they had to be face-to-face because they needed to verify the patient’s driver’s license, and because the patient needed to sign the forms. I wanted to ask what would happen to the process if the patient did not have a driver’s license. I thought about asking why since the IRS allows people to file taxes online, why the hospital could not figure out how to get a patient’s license information and signature without a face-to-face meeting.

My colleague kicked me discretely and I demurred. Instead I asked the access director to describe the patient access process for outpatients, former patients, and prospective patients. “That is not how we define access,” is what I was told.

I was in the process of asking how her patients define access, and I moved my shins away before the next kick struck home.

Robert McDonald, the Veterans Affairs Secretary, was quoted in an article in yesterday’s USA Today saying, “The VA experience should be less like the broken bureaucracy it is currently, and more like an Apple store.”

Bingo! I wanted to hug him. If you want to improve access for your health system, remove the word ‘VA’ in Secretary McDonald’s quote and insert the name of your health system. The substitution is equally effective if you replace ‘experience’ with either ‘access’ or ‘engagement.’ Now you have a vision you can work with.

A remarkable experience for every person every time on every device.

My DC hotel room last week was about the same size as a prison cell. But the towels were better, and they had an open wine bar at night, so maybe it was like a California prison.

One of the recent news shows has a healthcare-cum-fashion piece about women’s fall footwear; boots. Apparently, not all women can fit into the particular pair of boots they want to buy. My reaction was that the women in question should consider buying a different pair of boots. Apparently, my mind is too limited.

All was lost for these poor women until one group of healthcare professionals jumped in with a solution. If the shoe fits, wear it. If the shoe does not fit, it is because their calves are too large—I would never consider writing that their calves were too fat. Even someone as disdainful as I am about being politically correct does not need to go looking for trouble.

So the news reporter did her piece with the physician and the woman who wanted the boots, drew little red lines all over the woman’s calves, and yada, yada, yada, by the end of the piece the woman was able to fit into the new boots.

The question that immediately came to mind for me was, what if she finds a jacket that matches the boots, but whose sleeves are too short? Does she have her arms shortened?

For most problems, at some point we will encounter an easy answer that is so simplistic that our natural response is to disregard it.

For example, when people call your health system they call because they want a piece of information or they want to be able to accomplish something or they want to make a complaint. If your health system receives a million calls a year, ninety-seven point two percent of them will fall into one of those three buckets.

The easy answer would be to design your call center to be able to respond to those three types of calls. The more difficult solution would be to make your callers feel like you were telling them that the best solution you could offer them was to shorten their arms.

After your call center has shortened their arms, the callers may not be able to reach their phones, or if they can, they may just decide to call someone else.

I would write more about this topic, but I just saw an advertisement for a pretty dapper pair of boots—I hope they are not too snug.