Abandon Hope All Yee Who Enter Here


I thought those words would make a better announcement for a provider’s call center, or at least, it would add a bit of whimsy for the callers.

I hung a new sign outside of my office; Senior Hallway Monitor, and I added a parenthetical note; “Do you need me to build the watch, or do you just need to know the time?”

Too many providers are trying to build watches to understand consumerism. Unfortunately, none of them have any experience building watches.

The neo-watch-builders have reset their call center IVR to the following:

  1. If you want a single payer system, press ‘1’ and your call will be transferred to Bernie Sanders
  2. If you want to single payer system today, press ‘2’ to be transferred to Canada’s immigration system
  3. If you believe in global warming, press ‘3’ to be transferred to Barbara Streisand
  4. If you want to do something other than schedule an appointment, press ‘4’, click your heels together three times, and chant, there’s no place like home
  5. If you went to our website to do anything other than finding out what hours our gift shop is open, press whatever you wish because we can’t help you
  6. If you went to our website to donate, press ‘5’ and we will send someone to your home to pick up your check
  7. If you want to speak with a clinician, press ‘6’ to listen to the recording that says someone will get back to you within 2-3 days
  8. If you do not want to press ‘6’, hang up and go to the Minute Clinic
  9. If you clicked ‘contact us’ on our website, repeat step 7
  10. If you want to solve this problem, press ‘7’ and you will be connected to the Senior Hallway Monitor

Did I mention that I am the Senior Hallway Monitor?

There are solutions that are better than trying to learn to build watches.  If you are interested in learning what time it is, call me.



Consumerism Nuance: You Did Not Say There Would Be A Math Quiz!

To me, one sentence sums up healthcare consumerism—We don’t know where we’re going, but we’re making really good time.

I can order anything I want online except a healthcare appointment. Why?

There are plenty of healthcare white papers available from the firms who are known for writing plenty of white papers.  They all read the same; lots of facts, plenty of graphs, user-friendly fonts.

These papers should be read and then filed away until the next time you feel compelled to read about consumerism.  Me, I’m going to wait for the consumerism IMAX movie.

There is a significant difference between a white paper and a WHAT paper. A white paper is a collection of facts.  A WHAT paper tells you what to do with those facts.  Most of the facts teeter on the nuances of nuisance; 79% of this versus 81% of that.  Most of those nuances come from data collected from providers, not from their patients.

An example of a key misunderstood nuance is scheduling.  All providers agree that patients want to schedule. Most providers have an 80% or higher level of confidence that their scheduling process works fine.  Patients want to schedule appointments.  Providers schedule those appointments.  Problem solved.  Providers define the scheduling nuance as a slight difference between how patients want to schedule appointments, and how providers schedule appointments. Patients describe that difference as a nuisance.

Providers’ metrics reflect how well providers perceive they are doing on a range of consumerism KPIs.  KPIs for which they collected data and calculated the scores.  Those KPIs are calculated in patient-free vacuums.  A nuance—a subtle difference of meaning.  A smidge.  A skosh.  Provider consumerism nuances are simple to understand—how they do something versus how patients want them to do something.  Providers do not focus on the difference between the how’s, they simply check the box and move on.  Providers are indifferent to the difference between the two scores.

To patients, the consumerism nuance is the numerical difference between the two scores.  If the difference is just a rounding error, we have “much ado about nothing”.  Shakespeare and math all in one blog—I hope there’s not a quiz at the end of this.  If the calculation of the difference between the two scores requires fractal geometry we are no longer dealing with a nuance.  To patients who want to engage their provider digitally, a digital engagement score of 15% is not a nuance, not a smidge, not a skosh.

It is a reason to spend our $310 billion of discretionary healthcare dollars elsewhere.  Providers think about consumerism as access to care—retail care, urgent care, care from a pharmacy.

To patients, access is about doing what they need to do when they want to do it, and on whatever device they want to do it.  Patients want easy access to their provider as they have to their banks and eBay.  Providers give themselves a high score because they are opening urgent care centers.  They think that the difference between having their patients access an urgent care center by phone versus accessing it digitally is a nuance.  Patients think of it as a nuisance.

For those who like to score level of patient dissatisfaction using math, a Nuisance is much greater than a nuance:  Nuisance > Nuance.

And the survey said…the content of white papers, even the white papers of preeminent firms, are written around their own survey data. For example, “97% of providers rely on post treatment surveys.” “More than 80% of patients want electronic access.” “One in three providers get real time information during the patient visit.”  Data is good. How we get it is a nuance.

Borders, the bricks and mortar book store knew people liked to read Tom Clancy.  Amazon knew the same thing.  Borders thought how people purchased a Tom Clancy novel was a nuance.  In a store; versus online.  Borders’ inability to understand the term nuance drove them out of business.  So did US WEST’s understanding of the nuance of which firm people purchased long distance phone services.  And eBay versus Macy’s.  A Netflix versus Blockbuster.

The real nuance, the one to which providers pay lip service, is not the nuance.  Nuance implies scale. A small change yields a small and different outcome.  Nuance, in today’s vernacular, means that firms that were created out of thin air knocked all the air out of industry stalwarts.

Nonsense > Nuisance > Nuance.

And the driving force of all this change was the customers and patients.

Patient surveys tell you nothing about what patients want.  Patients tell you what they want.  And there is nothing nuanced about what they say.

The average patient does not care about your 37 KPIs.  They care about whether they can do what they want when they want, and on whatever device they want.  Give them those three things and the other 37 will take care of themselves.

Healthcare: What is the difference between a nuance and a NUANCE?

I read a McKinsey report on Healthcare Consumerism.  A great study if you are interested in facts.  A less great study if you are interested in the application of those facts.

McKinsey concluded, correctly in my opinion, that what providers and payers provide, and more importantly, how they provide healthcare differs widely from what patients and consumers want.  And that difference is growing.

For example, around forty-percent of people prefer to get care, both urgent and primary from either urgent care, a pharmacy, or a retail store.  And the reason for this is a simple nuance.  It is not related to the quality of the care, it is related to the ease of obtaining care.

Providers and payers look at that nuance as a digital disruption to their way of doing business.  Patients and consumers view the nuance as ease of use, the same quality of care, the ease of access, and the level of engagement.

Healthcare views the difference as a set of nuances. Patients view the difference at a set of NUANCES.  Ease of access, engagement, and care management.  You can reserve a spot in line at the Minute Clinic versus you can schedule an appointment by phone for next Tuesday.

Eighty-percent of people want to interact as much as possible electronically.  Only twenty-percent are satisfied with healthcare’s current way of doing business. Healthcare executives still believe patients want a brick and mortar solution.  Clearly, they are not asking patients what they want, or if they are, they are ignoring what patients want.

Providers believe scheduling an appointment as a singular goal.  Patients believe the ease of scheduling an appointment as the goal. A phone call versus a digital experience. A nuance versus a NUANCE.

Amazon is a NUANCE company.  Bookstores believed that buying a book was the goal of its customers.  Amazon discovered that the ease of buying a book was the deciding factor.  Nuance versus NUANCE.

There was a time when ninety-percent of long distance phone calls were placed through large companies like AT&T and US West, and those firms charged on a call by call basis.  Sprint and T-Mobile changed that business model.  They delivered the same phone call.  Call someone from point A to point B.  The quality of the call was the same.  The person with whom the spoke was the same. The NUANCE was the fact that they discovered an easier way to charge for the same service that delivered the same product. They reinvented long distance calling.

Sprint and T-Mobile put mammoth firms out of business by simply adding a nuance to the business model.  Netflix delivered the same business model.  If you wanted to watch Top-Gun, you could make two trips to Blockbuster, or you could click on a link and have it delivered to your television or mobile device. You could pay-per-movie, or you could pay a monthly service charge and watch all the movies you want.

HBO, and movies on demand firms like FIOS and Comcast, offered a fixed number of movies for either a subscription fee or a pay-per-movie.  Watch a movie from a library of thousands of movies—Netflix—or watch a movie from a small library of on-demand movies.  Nuance versus NUANCE.

Ease of use matters.  It matters in television, banking, retail, and telecommunications.  The firms that failed believed that the product was the defining factor.  The firms that beat them, the firms that were created out of thin air—firms that did not focus on the product –put their would-be competitors out of business by simply rethinking the delivery model.  A nuance to the winners, an absurd idea to the losers.

Healthcare is in the throes of being out-nuanced by firms who understand their consumers.  Deliver a product that is on par with the product delivered by the incumbents, but do it in a way that meets or exceeds the expectations of their consumers.

By the time healthcare catches up to today’s nuanced delivery model, they will have already been surpassed by the firms which had already out-nuanced them.

For the bricks and mortar healthcare firm to succeed they need to reimagine how they do business.  How they deliver care. How they provide access to care. And how they engage patients.

Healthcare’s biggest advantage is that they have nicer lobbies.  Healthcare’s biggest disadvantage is that patients don’t care how nice the lobbies are.  When healthcare executives understand the difference between a nuance and a NUANCE they will compete, until then they will be fighting the battle between Borders and Amazon.

Why Does Healthcare Not Understand Big Data?

What is big data’s big problem?

Too many companies think big data is one of two things; big data is a big amount of data, or it is a really big number.  It is neither of those.

Big data is a myth. A myth on which companies spend millions of dollars.  They spend millions of dollars trying to convert big data into some form of information.

Big data; little information.  Big Data multiplied by No Information equals no data.

And you can’t blame the data.  It is inanimate.

Knowing how many people visited your website is not big data, it is counting.  Two hundred people visited; one more visited, 201 people visited.  Zero value add.

One thousand people liked you on Facebook.  One more person liked you on Facebook.  One thousand and one people liked you on Facebook. Cool. It’s almost as valuable as collecting U.S. commemorative stamps.  Only you can’t mail a letter with Facebook likes.

And so on and so forth.

For most companies, big data equals not data, at least no data that has any value.

Let’s look at a few companies that failed at using big data and those which succeeded.  Does anyone remember MySpace?  MySpace used to be a big deal.  But then again, so did Sears.  Firms that don’t know how to use big data had the half-life of a fruit-fly.

Facebook, that little start up, paid attention to big data.  The adoption base of that little start up is connected to one of every two people on the planet.

And then there are Amazon, eBay, Netflix and LinkedIn.

If you belong to any of these sites, one thing will jump out at you.  They know everything about you.  They know what you did, and here’s the kicker, they know everything you may want to do next.  Based on your prior behavior, Amazon recommends what book you may want to read.  Based on your prior behavior, eBay recommends what you may want to purchase next.  Based on your prior behavior, Netflix recommends what movies you may want to watch next.  And, based on your prior connections, LinkedIn recommends who you may wish to connect with next.

One might infer that these sights are pretty prescient. They are not.  These sites use Google Analytics to tell them, based on the behavior of their members, how to shape the next interactions of their members.  Google Analytics tells them, based on their members’ prior behavior, what drove more adoption and what did not.

Amazon’s goal is not to sell you another book.  eBay’s goal is not to get you to buy one more item. Netflix is not to get you to watch one more movie.  And, LinkedIn’s goal is not to get you to connect to one more person.  The goal of each of these firms is to get their site to be your daily go-to site for everything they do.

They grow and maintain membership and adoption by making it valuable for their users to use their sites as often as possible.

This approach works in every industry except healthcare.  Healthcare has lots of data about its patients. It has no data about its prospective patients.  It knows nothing about the behavior of its prospective patients—its consumers—and it knows very little about the behavior of its patients.

It could.  But it doesn’t.

It knows how many people go to its websites.  It does not know if those people are patients, it does not know why those people went to those websites, or what they hoped to do.  It does not know what they wanted to do when they used the app.  It does not know what would make them come back to their websites or apps.  It does not know how to shape their behaviors, or how to create value for their visitors.  And worst of all, it does not have a clue how many prospective patients tried to access them using some form of digital media.

It could.  But it doesn’t.  Why bother having a digital presence that has no value?

Suppose a new patient goes to your website to schedule an appointment.  They go and they leave because there was nothing to do.

But what if it worked like this.  You could track the number of people who found your website through Yelp or Facebook.  Then you could track what percentage of those people created a patient profile since they are not in the EMR.  You could track how many of the people who created a profile searched for a doctor and scheduled an appointment.  You could track what type of appointment they scheduled.  You could track what percentage of those people made it to their appointment. And you could track, by service, what the revenues were for those people.

If you did that you would know where new patients came from.  You would know if they set up a profile and scheduled an appointment, and you would know the revenues they generated.  You would capture all kinds of data about prospective patients.  You could then tie that data to your legacy systems, systems like the EMR and billing and marketing.  You would know about patient acquisition and retention.

You could but you don’t.  Instead, you rely on erecting billboards, advertising on NPR, and having a dysfunctional call center.  Do you know what it costs to acquire a patient?  Of course not.  Do you know what services new patients buy? Of course not. Do you know what revenues new patients generate? Of course not.

Google Analytics and an integrated analytics platform would allow you to know all that.  Those tools would give you free external data about all your consumers.

Google, Amazon, eBay, Netflix, and LinkedIn know how many people used their service.  They know what made people use their services more frequently.  They know what they did to shape behaviors that worked and what did not work.  Using analytics, they change their platforms in real time to improve their ability to change the behavior of their users.

Search on the analytics for these firms and then search on the analytics for your firm.  The number of hits differs by orders of magnitude.  If ten thousand people go to your website, what do you have to show for it?  If ten thousand people go to Amazon, Amazon knows to the penny the value of each of those visits.  The same with eBay and Netflix.  They also know how many times those people went to their site each week, and they have a good idea how to increase that number week after week.

Healthcare can shape consumer behavior.  Having the ability to do something and doing something are different things.  Dorothy had the ability to go back to Kansas, she just didn’t know how to do it.

What healthcare needs is not more big data.  It does not need a data warehouse. It needs a way to capture external data and marry it to internal data to shape and modify patient and consumer behavior.

It can do all of this by using a simple platform that collects external data and analyses it against its internal data.

Think of Uber.  What does it know from its analytics? It has the most data of any firm on the planet about individual driving patterns and more data about who wants to go where and how often.

Healthcare does not even know how many new visitors went to their websites.  Had those people created new profiles that would open the door to millions of pieces of big data that here-to fore did not exist.

That solution exists. Email me if you want to learn more.

Why Can’t Healthcare Spell Convenience?

I had a meeting this morning with two very well-known healthcare executives. I had a meeting this afternoon with my dentist. It is unfortunate that the timing of the two meetings could not have been reversed. A tried to multiply my calendar by negative one, but that does not work with time travel.
You see, I have, or to be more accurate, I had four temporary crowns; my four front teeth. The crowns met a sandwich and the sandwich won. So, there I was meeting these two executives for the first time, and I was wearing a smile that made me look like I could have been the grown version of the banjo-playing boy sitting on the bridge in the movie Deliverance.

Affixed to the back of a bus I read an advertisement from TD Bank—America’s Most Convenient Bank. Back in the day that Deliverance was just a dream in some producer’s eyes, banks were prohibited from crossing state lines for fear that they would evolve into what they are today. As a result, banks started making baby banks—brand banking.

Back then, banks were like gas stations and convenience stores—hence the name—and they had to be close to where you lived. Location, not services, defined convenience.

Like healthcare.

The only thing healthcare has in common with the term convenience is the letter ‘c’.

Today convenience in banking means the ability to do what you want, every time you want to do it, at any time you want to do it, and using whatever device you want to use. So that is what banking did. Banking transformed itself from bricks to clicks and from mortar to bits and bytes.

They did this because they knew that once they made it easy enough for everyone to enter all their financial data on an electronic platform, and deliver services from that platform that people would not change banks.

Healthcare should be doing the same thing, but it isn’t. It could. It could also have big data if it collected all the data people store on their healthcare apps and wearables, but they don’t. Whichever providers and payers are the first to collect and analyze everyone’s health data will not only win, but those firms will be the first to truly manage the health of the populations they serve.

But until then, if you are looking for convenience think about going to 7-Eleven.


Consumers Want To Smell The Bacon

Why are so few healthcare executives willing to lead?

There’s a world of difference between a strategy and implementing a budget.

Consumers and patients want to smell the bacon.  That is because the smell of bacon is a good thing.

In 1775, America’s David Bushnell invented the first submarine. 1774—no submarines. 1775—submarines. Why? Because David 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.

Yada, yada, yada. America has 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.  In two hundred years, 72,730 days, healthcare has yet to deliver consumerism. Nobody is smelling the bacon.

Lockheed’s 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 recently delivered the Air Force’s newest jet fighter, the F35-A.

I recently heard a story about a problem the Dallas 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. Jerry 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 list of Most Wired Hospitals. I read the list. And those hospitals do use a lot of wires. And then I researched several of those hospitals to see what they do with all of those wires. It turns out; the wires are used for and by the hospital and its employees to communicate. 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 was 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 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. Nobody is cooking the bacon.  Is that because healthcare executives do not think that there are any big ideas that require innovation?

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.

Nota bene: Healthcare executives: create a Skunk Works group to deliver unwired, patient-centered solutions. Patients and prospective patients want to smell the bacon.

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

If You’re Not Seated At The Table, You’re On The Menu

If you, as a patient, are not seated at the table, you’re on the menu.

I received an email asking if I would consider presenting at TED Talks this winter. 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 non-existent. Gartner estimates that 275 million wearable devices will be sold this year.  I estimate millions of people will still not know any more about their health than they did before they bought their wearables.

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 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 additional 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 my health except for my claim, but I am giving them a temporary hall pass because they are way too busy raising Obama Care premiums. My pharmacy knows nothing beyond whether I picked up my medication. And the firm that made the medication does not know 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 must have relevant information about current state of my health regarding the treatment I received. Without that information, they are managing air.

Issue 2.

Still focusing on the patient in Issue 1, other than the condition for which he or she was being treated, what else may be going on with that person’s 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 that data; he has been collecting it for two years on his wearable or health app. 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 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 of all apps. There is no tool that marries the data from someone’s smart watch and the apps collecting all their health data and sends it to someone who could assess it.

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, like Elvis, leaves the building
  • We have no knowledge of whether that person has other health issues
  • We can 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 if they are healthy. The best information they have is that they do not feel ill and nobody told them otherwise.

I have a lot of data about my factors, that when aggregated, could tell me a lot about my health. But until someone who knows how assess my data assesses it I am left to judge my health.

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 build a solution.

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.

Patients are the ones not seated at the healthcare table. They are on the menu.

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