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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

If Richard Nixon had employed Russia to hack the DNC instead of having had to burglarize the Watergate Hotel he might still be president. Unfortunately, at least from my limited perspective, Al Gore had yet to invent the Internet.

Tanned, rested, and ready.

Executives are too quick to dismiss what technology can do to improve their business. Those same executives would be outraged if the firms with which they do business didn’t employ that same technology.

And what do the desks of these healthcare executives look like? Healthcare executives have the latest technology at their fingertips, smart phones, tablets, laptops, and large PC monitors. They use all of these tools to manage their health systems. Emails, messaging, reports, systems. Online and interactive. They manage them from their offices and from home and from the country club. They manage those health systems when the call centers are closed, they manage them on the weekends, and they manage them from St. Lucia when they are on vacation.

Health system employees have twenty-four-seven access to their employer from anywhere on any device. What a novel concept.

Health system employees interact with their health system using technology. Patients interact with it by calling it.

Do you know how a health system executive makes a healthcare appointment? I do. They either get their admin to do it for them, or they do what every other person in America does who needs and appointment. They pick up the phone and call.

I call it 8 x 5 access. They can call from anywhere and they can use any type of phone.

These same executives are the ones spending millions of dollars on firms like Disney, Ritz—not the cracker company, and Studer to try to raise the experiences of people who are in the hospital. They are also the people who authorized spending millions of dollars to ensure that when someone walks through the lobbies that their experiences make them feel like they are at a Hilton.

So, what have health system executives done to improve the experiences of people before they get to the hospital and after they leave it?

Almost nothing.

Excluding the ED, ten percent of us visit the hospital each year. Do the math with me. That means ninety percent of us do not visit the hospital during the year. That does not mean though that those people do not use their health system during the year. Almost all of us will have dozens of health-related experiences that do not require a sleepover.

That begs the question—who, if anyone is in charge of designing and managing all of the experiences that happen outside of the hospital? The most obvious answer must be that no one is, for if someone was, those experiences would not be as consistently poor as they are.

To me, the lack of effort to provide a good experience to health system stakeholders leaves me feeling like Dorothy in the Wizard of Oz—We’re not in Kansas anymore. The Emerald City is your health system’s lobby. Do you remember that when they got to Oz the scarecrow was restuffed with clean straw, the Tin Man got oiled and buffed, and the Lion got washed, cream-rinsed, and blow-dried? Great things happen once you get to OZ. the same is true for patients.

But you also may recall how difficult it was for them to get to Oz. The yellow-brick-road was fraught with peril. Trees threw apples at Dorothy. The witch tried to burn Scarecrow. She made the Tin Man rust. Flying monkeys tried to kill them, and a poppy field nearly ended their journey.

That is what people encounter before they get to the hospital. That is what it feels like to schedule and appointment and to dispute a charge. And we do not even have a yellow brick road. We simply use trial and error, knowing that it will be a trial and that there will be many errors.

Nothing about healthcare is easy until after you stand nearly naked in your hospital room trying to figure out how to tie a knot to close the back of your hospital gown. (Every time I take a travel I get on my knees and thank the hospitality gods that Hilton does not make me put on a gown.)

So if health systems hire firms to make the inside experience Oz-like, why don’t they hire firms to make the inside experience equally Disneyesque? They do. Sort of. They hire marketing firms and agencies to create gossamer experiential images of the health system as a whole, images of a health system that will give you the experience you expect.

Digital health agencies create branding campaigns that depict healthy people. The healthy people are shown using all sorts of technology. The healthy people then meet with doctors and nurses at the Emerald City Clinic. The doctors and nurses are using all sorts of technology. Then the healthy people go on a picnic, or they go skydiving, and the doctors grab all of their technology and they go meet with other people who BMIs are too small to measure.

All of those memorable experiences are brought to you by the wonderful people at Emerald City Healthcare. And people do remember those experiences. They remember what happens when they call the system after 6 p.m. They remember sorting through thousands of links on your system’s website without finding a useful link.

And branding your system to get patients to see it as a modern, up-to-date, technology friendly health system is worthless. Patients do not want to imagine that they can access and engage and interact with their health system and have the same experiences and effectiveness that they get from their banks and their airlines.

Until your health system offers those types of experiences, all of your system’s marketing efforts targeted at convincing your patients that your system is customer-friendly and accessible and engaging only work, until like Dorothy, people realize that Oz’s Wizard’s promises were all hat and no cowboy.

Nobody wants to interact with a system which brands itself as a digital health provider. They want to interact with a health system that is a digital health provider.

Some argue that skewed logic is better than none at all. I’m not some people. It’s drawing an errant conclusion from a set of misaligned facts; like 2 + 2 = fish.

If A is true and B is true, then C must be true. But truth is like poetry, and people hate poetry. Consider and example from the movie, Monty Python and the Holy Grail. This comes from a scene in which the villagers try to deduce whether a woman is a witch.
Leader: Why do witches burn?

Leader: Why do witches burn?

Villager: Because they’re made of wood?
Leader: Good! So, how do we tell whether she is made of wood?
Villager: Build a bridge out of her!
Leader: Ahh, but can you not also make bridges out of stone?
Villager: Oh, yeah.
Leader: Does wood sink in water?
Villager: No! No, no, it floats! Throw her into the pond!
Leader: What also floats in water?
King Arthur: A Duck!
Leader: Exactly! So, logically…
Villager: If…she…weighs the same as a duck…she’s made of wood.
Leader: and therefore…
Villager: A Witch!

What is the skewed logic that has healthcare running in circles? The lodestar is the illusion that states that CMS ratings matter, and that providers should employ digital health agencies to reinforce the illusion. Ratings force providers to take a journey without a map or an exit ramp in site.

Providers have been trained by CMS to follow a Groundhog Day strategy: CMS wants us to do ‘A’, we do ‘A’, and CMS wants us to do ‘A’ again. And that strategy is played liked the game of musical chairs. When the music stops, there are fewer and fewer providers.

Does anyone outside of CMS and those responsible for raising your scores really know how your health system scored? What benefits has the pursuit of higher ratings yielded?

I spent ten minutes trying to find the newest CMS provider ratings report. (See how long it takes you to find out how your provider scored.) And I did not even know that there was a new report until someone told me about it. The vast majority of the collective population of patients has no idea those theses ratings even exist. If you surveyed 100 of your employees, less than ten of them could tell you your firm’s rank, what your number was, and which provider ranked above yours.

There are over six million links to CMS provider ratings. My guess is that all of those links were posted and viewed by a group of people so small that they would fit comfortably in a Hyundai. To quote the Bard, it is much ado about nothing, at least to everyone not involved in their measurement and reporting.

This is a true story. The wife of the chief innovation officer of a large health system needed surgery. He ensured that she received “white glove treatment.” The result? She raved about her experience. Out of curiosity, he read her HCAHP survey, and he learned that she scored the hospital very poorly. When he asked her to explain the conflicting results she told him that it had to do with her expectations. Nobody had asked her what was important to her.

She scored her survey low, but the items in the survey did not reflect what was important to her. Much ado about nothing.

As an industry, we are spending millions of dollars trying to improve experience ratings around issues that are relatively unimportant to the people who matter. If A is true—we need to improve our ratings, and B is true—we spent money and resources to be better, then C must be true—we will get more patients and care will improve.

But nobody has been able to prove that ‘C’ ever happened, and if ‘C’ happened, nobody has been able to prove that it resulted directly from ‘A’ and ‘B’. There is a big disconnection between what CMS and providers believe is important to patients and what patients believe.

Everyone who has ever been a patient will tell you that one of the biggest problems they have regarding how they experience healthcare is how difficult it is to access and interact with every facet of healthcare. Even patients who gave their health system perfect scores on their surveys will tell you how difficult it is to get their provider on the phone and how outdated the methods of access are.

Only a small percentage of what people perceive as healthcare happens inside the hospital. For most people being in the hospital happens only once every few years. The majority of bad experiences have to do with the amount of effort required by the patient before they enter the hospital and after they leave the hospital.

A collection of articles of the top ten technological advancements of the last decade list five advancements that are found on every list; GPS, iOS, Android, social media, and YouTube.

The one industry that stands out in the minds of its customers for having made almost no use of any of the five advancements, let alone using all five of those advancements is healthcare. The combination of those technologies gives every customer in every industry 24 x 7 access and engagement to every firm with whom they do business. Retail—check. Banking—check. Travel—check.

Healthcare—no check.

If you really want to improve patient and customer access, experience, engagement, and satisfaction throughout your organization set high goals for enabling your patients to use those five technologies. Without these five things, digital health does not exist.

You can keep paying millions to a digital health agency. But a digital health agency will not help you make any of those tools effective. Paying a firm to brand your system as a leader in digital health is very different from being a leader in digital health.

Another meeting in the land of skinny jeans and Converse sneakers worn without socks. I need to go shopping. Neatly trimmed pita bread sandwiches made of ground straw and loam. I examined each of the sandwiches in the hope that one of them might have a something with a cloven hoof protruding from the garnish of bean sprouts.

Business problems always begin small, always begin small—like that Watergate security guard performing his nightly rounds and finding a piece of burglar’s tape stuck on a door lock. But problems are never content to stay small. Real problems only remain small in the minds of the individuals overlooking them.

If digital health is not currently seen as a problem in your organization, it will do until a bigger one comes around. George Orwell had visions of problems like these.

The big word in healthcare for now and all of the foreseeable future is digital. The problem begins when people start to believe that they are already ahead of the curve. Website; check. Mobile app; check. Patient portal; check.

And if your health system has the misfortune of having won an award for its website, your problem is probably twice as bad as the firm which doesn’t even have a website.

Let’s talk about digital agencies for a minute. Digital agencies—A.K.A marketing firms. In today’s vernacular, think Mad Men without the ties and martinis. These firms market themselves to your firm—that is how they got you as a client. They want to help you build your brand in the changing world of healthcare.

How’s that working for you? You already have a brand. You don’t need a new one. You don’t need to become Our Lady of Digital Health—Now With 20% More Healing Power In Every Box.

Providers do not need to be branded as digital. They need to be digital. It is about user experience and about doing stuff; mobile stuff and online stuff.

There is a big difference. If what you have is a website, the only test you’ve passed is your ability to check the box. Most provider websites are nothing more than lipstick on a pig. You see your website as a big victory in the digital war, a war badly in need of  another notch on your success pole.

If you want to figure out just how bad your website is and how poor the advice you are paying for is, try doing these things.

Ask how many individual web pages are on your health system’s website. If the number of pages requires the use of a comma, you have a real problem. Nobody on the planet will ever go to your website looking for whatever tidbit of information is contained on page 5,987. Nobody.

Now, ask your self, “How many questions would you be willing to answer to schedule an appointment online; 0-10, 11-20, 21-30, 31-40, or more than 40? The right answer is not all of the above.

Yesterday I took a website on a test drive. The link’s label was Request an Appointment. As you know, I happen to think words matter. If I am going to your site for an appointment, I am not going there to request an appointment. I took up the challenge and started to answer the questions they felt I needed to know to make my request. I provided an answer to question forty and clicked next. It gave me more questions.  Really.

Guess what it did not do. It did not create me as a user even though I had entered my email and a password. The system never came back to me with, “Congratulations, Dude. Nobody has ever answered as many questions as you did. Just for getting as far as you did, we are going to remove your appendix for free. You are almost ready to request an appointment.”

I have used a phone to actually make appointments and I do not think I have ever been asked even ten questions.

Talk to a patient after you finish patting yourself on the back for launching your new website and watch how they react to using it.

Now, if you want to watch someone’s head explode. download this presentation about how Pokemon GO will make you rethink everything you thought you knew about how digital will really impact healthcare.

I glanced at the woman seated next to me. She was having a bad hair decade. “Is this going to be a difficult meeting?” I asked her.

She looked thoughtful for a moment, which was like watching a beauty contestant tell you she dreams of world peace; even when it’s sincere, it’s the depth of thought that’s scary. “I can’t really say, exactly,” she answered. I was feeling pithy and asked, “Hey, Moonbeam. How about inexactly?”

“You’ll earn your paycheck,” she told me. She looked at me quizzically, as though she thought my mental bolts could use a good tightening, as though I, a consultant, would have a proprietary chromosomal insight as to what was about to happen.

It was going to be the type of meeting that anyone not wearing a Brooks Brothers suit would stick out like a purple banana on a stick. Fortunately, this was not going to be my first rodeo. I’d met people like her before, people who had the biological need to start every day by dancing on somebody’s forehead.

We each brought something different to the meeting— different specialties, different mind-sets, different wardrobes—and the whole becomes greater than the sum of its parts. In an organization, the term for this is synergy, and in an individual, it’s called multiple personality disorder.

“Is that your presentation?” I asked, referring to a stack of thickly stapled documents. “How much time did they give you to present?”

“Eleven minutes.”

“You must have a hundred slides in that deck. I am willing to bet you a dollar that you don’t get past page ten.”

“I could literally give this presentation in my sleep,” she replied.

“How about unliterally?” I asked, but my attempt at sarcasm was lost on her. She looked at me with a look that could have made rocks cry and then said that if I were any dumber I would have to be watered twice a week.

She and I were not bonding. There would be no exchanging of home addresses, and no planning of a future vacation together. Were I given a vote, she would have a special place in the guillotine line when the revolution went down.

I have been to many meetings across the U.S. like the one that was about to start. They were pretty much all the same, the only real difference being the slides that were presented. The meetings were about patient access or engagement or consumerism.

A half-dozen people would be there. They would chitchat about the humidity and mention that it might rain later today. Blank, yellow legal pads would rest in front of each participant. Someone would introduce the topic and everyone would assume the role of attentive participants.

The problem seems to be that everyone thinks that they already know everything there is to know about the topic. They have outsmarted themselves. Nobody is prepared to say that the emperor has no clothes for the simple reason that they know that the organization’s leadership does not have anyone interested in changing the status quo.

There is no definition of patient experience. No access strategy. No written vision of how things should be.

So when the meeting ends I look around the table. The yellow legal pads are as blank as they were when the meeting started. That is because nobody was told what they need to do tomorrow to move the issue forward. Other meetings will yield the same result.

My dad asked recently, “What exactly do you contribute as a consultant?”

I replied, “I am the guy who knows what to do tomorrow, and who rides the elephant into the room.”

I did notice, however, in today’s meeting that one of the attendees seemed to be a little less bored with the proceedings. I asked him in the elevator what had captured his attention. He told me that the Magmar Pokémon character was sitting behind the bagels on the room’s credenza.

Knowing that I still had two more meetings to attend that day I decided to download the Pokémon app just to make sure that the day wouldn’t be a total loss.

Perhaps I should set the stage. I went for a run this morning in a beach town on the Jersey shore. I would tell you the name of the town, except for the fact that this morning I met most of the town’s police officers, and since I still have another week at the shore, it would be silly of me to write something to make the other officers want to engage me.

I was nine miles into my run. Ahead of me was a bridge that would lead me back to the house where we were staying; three miles from here to there. There was a lot of construction on the bridge and a lot of cars. One officer may have later mentioned something about a large sign printed with the words, No Pedestrians.

I came to the apex of the bridge that crossed the bay. I was drained, and I was leaning way over the guardrail to catch my breath.

To my surprise, a state policeman, kitted out smartly in his pressed uniform, pulled alongside of me. “What are you doing on my bridge?”  He asked from the cool confinement of his air-conditioned patrol car, an undisguised tone of concern in his voice. To hear what he was saying I removed one of my ear buds.

I saw my face reflected in his Ray-Ban Aviator sunglasses. Since I was trying to cross the bridge, I thought about asking him if his question was rhetorical, like why did the chicken cross the road, but he did not look like a chicken crossing the road kind of guy.

“Are you okay?” He asked. “You don’t look okay.”

He came across as highly educated, and someone with great elocution and diction. He was impressively well mannered and well behaved. He was like the human version of a Great Dane. I thought we were getting ready to bond, but then it occurred to me that his version of deep, long-lasting friendships was probably an exchange of business cards. “I’m fine. Why did you pull over?” I asked.

“We got a few calls about a guy on the bridge who looked depressed and might be thinking about jumping.” Several other police cars arrived on the scene. The officers looked at one another, the way lions look at one another when there’s only one carcass to go around. My little section of the bridge had become standing room only. I thought they should post an officer down by the tollgate to issue tickets and bathroom passes.

Most of the officers kept their distance, I guess because they sensed there was something special about me, and they did not want any of that specialness to rub off.

“I haven’t seen anyone,” I replied. “But if I do, I will flag someone down.”

“Are you thinking of jumping?” He asked.

“Jumping what?” Only did then I realize that he thought I was his potential jumper. I may have mentioned that I have a bit of a cynical streak, and the beast was demanding to be fed.

“Jumping off the bridge. Are you sure you are okay? You look depressed.”

“I think I look like I just ran nine miles.” I placed my right leg high on the guardrail to stretch my hamstring. Below me a small armada of boats had dropped anchor and the passengers appeared to be having impromptu tailgate parties in the middle of the bay.  Everyone was looking up at me, and some appeared to be filming, so I waved. A few of the people were yelling for me to jump.

“Take your leg off my bridge,” he commanded. “I was about to call for a helicopter. Are you sure you are okay?”

To me, the entire dialog was starting to sound like a bad country and western song. If I continued across the bridge, home was only three miles away.  If he did not let me cross I had to double-back those same nine miles.

“May I continue across?” It was a stupid question, made worse by my insouciant expression. I was going to lose the battle to cross the bridge. Losing gracefully is an acquired skill. Defeats pile up on top of defeats and eventually you lose the urge to fight back. I hadn’t built up that immunity yet.

I realize it was time for plan B. Which was a bit of a problem because there wasn’t any plan B. I was going to ask him if his helicopter would give me a ride back to our house, but he didn’t look like a give me a ride back kind of guy. “May I continue across?” I asked again.

A chorus of jump, Paul, jump was rising up from the boaters. He’d had enough of me. I started to appreciate that there were so many people watching, because if there hadn’t been he may have helped me jump.

My son asked me why I ran eighteen miles. I said it was because the policemen wouldn’t let me run twelve. That was my day.

More than five hundred of you read my post on Pokémon GO. Several of you asked me to explain how that type of augmented reality could play in healthcare. Let me being by saying, augmenting reality is far better than arguing with reality.

I think the idea is simple. Pokémon GO captures a player’s geo-location. Based on its knowledge of the player’s location, the game then spawns (places) different Pokémons

In the same general location. The player then collects the Pokémon and moves on to collect the next one.

Now, imagine a health system that new someone’s location, and knew what service the patient needed to access. Admittedly, this is a huge step for an industry that does not even provide online chat.

Suppose that you need to speak with a nurse. A virtual nurse from your system, or perhaps an independent system alerts you. You make the connection and talk with the nurse. Or suppose you are fighting depression and are having a bad day. You let your healthcare Pokémon app know that you need to speak with a behavioral health professional, and someone connects the two of you.

I think it would work like Uber Healthcare. You make a health request, and you are connected to someone without an appointment. The app will tell you the cost of the virtual meeting. It could be designed to connect you to professionals that accept your insurance. If a follow-up visit was needed, it would schedule it. If a prescription were required, it would order it.

One of the neat features of this approach is that instead of spending millions of dollars to improve outdated processes, this type of thinking would simply eliminate those processes.

What do you think?

Innovation scares a lot of good leaders. Many are attitudinally challenged. “Into the valley of death rode the six hundred,” Alfred, Lord Tennyson wrote in Charge of the Light Brigade. The scary part is that none rode out. Staying the course tends to ensure continued employment.

Staying with the literary theme, I tend not to go gently into that good night when I talk about innovation—Dylan Thomas, not Bob Dylan. Sometimes I get this weird impulse to leap into the room and scream, “Juan, Paco, José, grab those machetes and shears . . . Viva la Revolución!” You see, I don’t mind looking like an idiot; I just like to do it on my own terms.

It is easier to spend your year counting how many paper clips it takes to run a health system. That tends to be their excuse. My dog ate my excuse. They also have a tendency to believe that curiosity is what killed the cat, curiosity about new ideas. Curiosity is why I get up each morning; besides, I am a dog person. I seek out opportunities to kick the scaffolding from under their feet.

The biggest problem leaders have when assessing innovation is that their nonnegotiability never becomes negotiable.

Have you ever sat through a strategic planning meeting? I have, and flies are dropping out of the air, dead from boredom. It is rare that I find a firm that actually has a defined strategy. What they usually have is a budget, and they leave no number unturned in their ability to explain why they cannot afford to do something that even hints of being innovative.

“So we beat on, boats against the current, borne back ceaselessly into the past.” The final line from The Great Gatsby.

Borne back to the past. Just like healthcare consumerism. The past tends to be a prologue to the future.

There are literally hundreds of health apps you can download that purport to have something to do with your health.

Most of them measure something; what you ate, what you did.

They are ineffective because if you didn’t eat right, or did not do anything, they have nothing to measure. And if you did not do anything—think exercise—you go to bed being no healthier than you were when you awoke.

You see, none of the apps can make you do anything. Samsung’s health app is called S-Health. Samsung extols S-Health as a fitness coach. It has “intuitive charts and helpful tips.” I felt healthier just reading that. It monitors things, a lot of things. Its pedometer feature tracks your steps.

For it, or any health app, to be effective, though, you have to give it something to monitor.

My children and probably many of yours live in what I call a step-free zone. A snail lapped one of them. They do not move unless food is involved. Or, at least until Monday they didn’t.

Enter Pokémon GO. One of my sons logged 9.4 miles on Monday. In a meeting yesterday, a very senior healthcare executive announced that his son walked 8.5 miles on Tuesday.

It’s not a health app. It’s not Bluetooth. What it is is something that changed behavior. The location-driven game conquered the planet in a week. Pokémon GO got more kids to exercise in twenty-four hours than Michelle Obama’s “Let’s MOve!” program did in eight years.

Fifty-three percent of smartphone users have an Android. On Monday alone, six percent of Android users opened the Pokémon GO app. It is estimated that by the third day, that there are 9.5 million daily active users.

What does all of this have to do with healthcare?

• Your health system probably doesn’t even have an app
• If it has an app, what percentage of the people in your service radius are daily active users? I bet it is way, way below 1%
• Why don’t they use it?
  • It is not fun
  • It doesn’t create a great user experience
  • There is nothing that makes it habitual
  • There are no rewards

What would happen if all of the children’s’ hospitals threw together a Pokémon GO gym for its patients? They won’t, but they should.  If you think this idea has merit, don’t call on your marketing department or IT to do it.  Call a kid.

So, this is how the world works. It is not how healthcare works.

People are getting hurt playing Pokémon GO. They have fallen off of cliffs, been hit by cars, and one was bitten by a snake. Who are these people? What do we know about them? These are the people your marketing department is trying to reach.

And what do those people do when they get hurt? Do they pull up one of your apps and schedule an appointment? Nope. Do they go to your website and schedule an appointment? Nope.

Assuming they can find the number for your health system, maybe they call your system’s call center—the very idea of that just made my head explode. It should make the heads of your executives explode.

I bet a lot of them go to the Minute Clinic. And while they are waiting to see the nurse, and ignoring their broken leg, they are probably hunting for Pokémon over by the shampoos and in the Gummy Bear aisles.

So, if your reaction to Pokémon GO is that it is just a game for kids you should think about hiring your replacement.  It is called augmented reality, and yes, it already has its own acronym, AR. patients are already lining up–virtually–for e-clinics instead of brick and mortar locations.  They will expect doctors and nurses to make virtual visits to their homes.

The firms that will fall out of favor the fastest are those with the most outdated processes–alarm bells should be going off in the heads of providers and payers, especially since many of their employees are adverse to using newer technologies in their lives.  We are not talking about upping your use of Facebook and Snapchat, or updating your blog.

I mention this because healthcare is woefully behind planning and deploying anything that even hints of its interest in innovating through consumer technologies. Heck, most providers do not even have a CRM in their call centers.

I’d be willing to bet my neighbor’s BMW that nobody in your organization has even mentioned the term augmented reality.  So, if you are so smart, you are probably thinking, what should we be doing? 

Start with these two things:

1. Develop a strategy that allows you to close your call centers within the next 3-5 years
2. Hire your receptionist’s sixteen-year-old nephew as your Chief Augmentation Reality Officer.

And in case the director of the FBI is trying to track down who wrote this post, he won’t be able to figure it out. (I arranged to have my email server kept in a friend’s bathroom.)

Several of you know that it is best to ignore my sarcasm; encourage me and it only gets worse. The rest of you may be waterlogged with ambivalence. There are a lot of other healthcare blogs. You should read those if you are into the opinions of people who are experts at watching water freeze, people who are pinning the tail on the wrong donkey.

If you are in habitué to learn about consumerism from an author whose ideas are presented like a sprinkling of dew on a rose petal, my blog may not be the best choice for you. I don’t sprinkle. Nor can I turn Coke into Pepsi, but I have been known to make rocks cry.

Healthcare consumerism is a walking enigma on stilts.

The fact that I’ve spent my career in consulting may have something to do with how I approach issues. Consultants, for example, are the people in the movie theaters who get dreamy-eyed when the Titanic goes down. I cried, not because I was moved, but because it was such a bad movie. When bad things happen consultants are thinking, I have a PowerPoint somewhere that told you it would sink. And we tend to make that point with all of the generosity, grace, and selflessness of Jack the Ripper.

After all, ships that aren’t likely to sink do not need consultants any more than we need another album by the Village People. Some business leaders wait to glom on to an issue until it has enough cachet. Those are the same people who will tell you that they were only responsible for sinking the lower decks of the Titanic. Getting insight from them is like reading cartoons that do not have captions. They leave the thinking to you.

Unlike HCAHPS, I am not big on nuance. I wouldn’t know a nuance if it hit me in the face. I prefer to keep equivocations about HCAHPS out of my inbox, because if you think you have a fifty-fifty chance of getting it right, there is a ninety percent chance you will get it wrong.

People who believe consumerism is linked to HCAHPS see straws and immediately reach for them. HCAHPS are to patient experience and consumerism what Oliver Stone was to the Kennedy assassination. Only a handful of us has a license to interpret the universe.

For those who think I may be out of my depth when it comes to addressing matters of customer experience in healthcare, customer experience has no depth. At least beyond the mindset of a sixteen-year-old. And that is why I pretend to be the ringmaster when it comes to the circus of egos who are trying to tell you that you are already doing everything possible to understand what your patients expect from your organization.

Healthcare’s consumerism circus has started, and it’s going to be a three-ringer. Maybe I should be wearing a cape. But, I am a consultant; trust me. (You do not need to comment on the oxymoron.)

I find it helpful to present issues using my illusory charm and mythical footwork, and to disperse profundities to both the washed and the unwashed. Maybe that is why consultants have half-lives of fruit flies.

There are those who will tell you that when you fall off the horse, you need to get back on. I disagree. I think you need to learn to walk or to drive.

There are around a hundred and fifty million people in the U.S. who drive. They live among us. We see them driving, and we think we know how they do it. We think we know what they are doing.

I mention that because I am teaching my daughter to be one of those drivers. She has spent about twenty hours practicing, and other than backing out of the driveway, she seems to be getting the hang of it—way to go, Dad!

During yesterday’s driving lesson with her favorite dad ensconced in the passenger’s seat, she told me about a friend of hers who just passed her driving test. And she remarked, “Sally only uses one foot when she drives.” Her statement was so innocuous that I missed it.

A few miles later I asked, “What did you mean about using one foot?”

“She uses the same foot for the gas and the brake.”

By having spent years observing what is commonplace, we think we know everything about that which we observe. I watched my daughter and assumed she was using the same foot for the gas and the brake. She had spent sixteen years watching us drive her. She saw two pedals, knew she had two feet, and put two and two together and got an irrational number. We gave her the keys. It never occurred to us to tell her that even though there are two pedals that you need to use only one foot. And the reverse never occurred to her.

We learned quickly that our assumptions were wrong; mine about how she was driving, hers about how everybody else was driving.

We make the same errors every day when it comes to our knowledge of patients and customers. We assume that if someone needs an appointment, they simply call and get one. Or a refill, or an explanation about their bill, or a referral, or whatever. Only it ain’t that simple. Nothing is. Never was.

But if everyone in your system believes being a patient or a customer is simple, then why would they be concerned about fixing it? We fix things that are broken.

Instead of operating a health system based solely on assumptions, why not ask your patients and customers whether your assumptions are valid.

The real bad news is that assumptions are driven by expectations. And chances are high that nobody in your system has ever asked them about those either. As a matter of fact, health systems and payers probably have not asked their patients and members about much of anything.

If you haven’t spent much time with people of my métier—consultants, we aren’t real high on anybody’s be-sure-to-invite-to-the-party lists. Maybe it’s the shoes. My counsel has always been, we’re okay if you paper over the rough spots.

You may think consultants are business’s Robespierres. During the French Revolution, Robes—I am the yin to his yang—backed the execution of Louis the XVI. (What I love about Google is its ability to make it seem that you have a PhD. in French History even if all you know about the French is how to make a decent Béchamel sauce.) Robes, as good as his leadership was, was guillotined a year after Louis. His fate makes me glad that we do not favor the guillotine for thought crimes that may have been committed by consultants.

If you will allow me another moment of your time and allow me to pretend that I am a historian on par with Thucydides—you can also Google him; I did—you could infer that consultants are like Torquemada, the Spanish cleric who in his spare time founded the Inquisition.

I could not help myself, and I offer an apology to those of you who have made it this far without clicking over to eBay. If you have been a reader of my blog for longer than a few months, you know that I think most business problems can be illustrated best by a reference to something written by Mel Brooks. (For information on Torquemada see History of the World, Part 1—there is no part 2.)

I try to bring a certain bon homie to your day. In the world of consulting, some would say I have what is called the Pope’s Gift. What that means is that if the Pope walked outside on a perfectly cloudless day an opened his—I’m not being sexist with my pronoun—umbrella, that every Catholic for miles around would open theirs, too. Some believe that if I opine that you have a problem, chances are pretty good that you have that problem.

I tend to raise the issues by screaming epithets—wrong word, but I like it—because I believe there are many organizations delivering lip-service about how important their customers are. The catch is that there are executives in those organizations with their hand in the cookie jar, and their first inclination is to point at the refrigerator—doesn’t it seem like the word refrigerator ought to have a ‘d’ in it somewhere?

Fixing consumerism has a lot of low-hanging fruit. The problem is that many of the people in charge of fixing consumerism and access and engagement cannot tell the difference between fruit and cannolis.

As I wrote previously, an executive vice president of a huge health system moved to a certain city to start his new job. The city is irrelevant. It could easily be your city. He—without throwing aspersions to the politically correct crowd, because he was and is a he—called his employer, to get an appointment with a PCP—primary care physician—to those of you who are still playing. And he was unsuccessful in his effort to get an appointment.

This happens hundreds of times every day. It happens at your health system.

But it happens ‘in camera.’ In camera is a legal term. The term refers to a discussion that happens in the absence of others—the people at your health system who should know that these attempts to access you health system are happening—but who do not have a clue.

Imagine you are that executive and you are sitting in your office. I am going to employ a little literary license to set the stage.

Your two hundred gallon salt-water aquarium is bubbling away on the far wall. Your desk is uncluttered. You Mont Blanc pen and pencil set sits front and center on your leather desk pad, poised to sign whatever strategic document appears on your blotter.

Three hundred square feet of polished glass walls afford you a view of whatever river happens to flow beyond your parking garage—you can pick the city and river of your choice without affecting the outcome. A nifty Degas print, uplit by an LED lamp embedded in the hand-stitched Oriental tapestry, whose colors that happen to match your socks, colors that were hand ground by lama-farming urchins in Nepal, hangs on the far wall.

Your kingdom awaits your leadership. So what do you do? Feed the fish? Adjust the Degas print?

Try this? Take off your jacket and tie—the fish won’t mind. Take the elevator to the third floor, and sit in the surgical waiting room. Talk to the person sitting under the television who happens to be reading a dated copy of the Latin American Economist magazine. Just talk and listen.

And then go to the first floor. Keep talking and keep listening. Spend the next hour in admissions. Spend another hour in the ED waiting room. And another where you do the lab tests—and bring your magazine to keep yourself from going nuts. Then go back to admissions. A lot of the people you saw earlier are still there. And leave the magazine because you don’t understand economics and you don’t speak Latin American.

Then go back to your office. Put on your tie and your jacket. Have your admin get you a cappuccino. And create a new to-do list of all of the things you learned about what you need to do to improve patient access, experience, and engagement.

And if after twenty minutes of thinking about what you need to do, and you look down at your list and realize that you have not written anything, write this:

“Feed the fish.”

That way, you will leave the office knowing that the day was not a total waste of your time.

This weekend I watched the movie, Eye In The Sky, a modern wartime political thriller. The movie deals with the ethical and moral implications of eliminating terrorists through the use of drones, while minimizing collateral damage—their phrase not mine.

Most of the film involved what might best be described as a game of hot potato, as each of the people responsible for approving the strike order passed the buck to someone else in their chain of command. The drama centered on whether the bad guys would get away before the decision was made. The holdup in the decision process was because the drone’s camera showed that a young girl might be killed if the drone’s missile was fired.

I turned to my wife and remarked, “How cool would it be if Donald Trump walked into the mission planning room and taught everyone how to make a decision?”

When it comes to business, very few executives like to shake the trees. That is because gorillas are often found in trees. I tweeted last week that a woman had asked me to explain what I do. My reply was, “I am the guy who drags the elephant into the room.” Your room. And I like it. Gorillas and elephants.

One of the first things you learn in business school is to trust facts and only facts. Do your best to avoid deductions, and run away every time a hunch comes within ten feet of you. I tend to do the opposite. I rather enjoy doing a swan dive off a deductive highboard even if there is not a single drop of factual information in the pool. (I try to make the most out of being underestimated.)

In business, when a senior executive comes up with an insipid suggestion, the rules of decorum dictate that it be treated like Einstein’s theory of relativity. Sometimes there is no suggestion, there is only silence. People came knocking at the idea door only to find that there was nobody home. No ideas can be as detrimental as bad ideas.

When someone tells you, “We’ve got our arms around consumerism,” don’t believe half of it. Believe the other half.

Think back to the last important business meeting you attended. Sooner or later you realize that nothing that is being said is making sense.

“The time has come,” the Walrus said,
“To talk of many things:
Of shoes–and ships–and sealing-wax–
Of cabbages–and kings–
And why the sea is boiling hot–
And whether pigs have wings.”

Sound familiar? When someone doesn’t know what to say almost anything will do.

I’ve been in many meetings on consumerism, access, experience and engagement. And when the most senior person in the room discovers that his or her organization as been missing in action on those issues, everyone knows it. That individual stands there like Captain Queeg, rolling ball bearings around in their palm and ranting about who stole the strawberries.

Today I spoke with a very knowledgeable, senior clinical executive at a very large and respected health system. I learned that the health system we were discussing had spent months researching and updating its website to reflect what people want from their healthcare provider.

After my call, I went to the website to see what their research told them people wanted from their healthcare provider. They must have concluded from their research that people really, really like the color blue. The aesthetics are nice. Aesthetics are usually the final task in design thinking—make sure it looks nice.

However, all of the tasks that take place prior to aesthetics involve making sure that people can actually do something on the website—your digital representation of your brick and mortar facility.

Since I was already at the site, and since I like blue, I decided to stick around for a while and give the website a test drive. I began with the Contact-us box. I wrote a very nice note. I received an immediate response; 500 Error. Check back with us later. I may not need a doctor later. There is a link for Donations and Pay Your Bill. Both of those links seemed to be working very well.

I clicked on Locations. They have a lot of locations. I tried Patients and Visitors. More blue. Lots of words. Nothing actionable if I were a first-time patient other than a link to share the page with a friend who also likes blue. I registered as a new user. A nice touch. But I did not receive a confirmation, nor did it come back with Hi Paul, what would you like to do next?. In fact, it did not come back with anything.

Consumerism 101: Patient Acquisition. Registering online does not have equal value to having someone do something; set up a profile. Do you want to add family members? Do you want to schedule an appointment? Do you need to speak with a clinician? Add your pharmacy information? List your doctors? Complete a health history?

This system is also in the process of centralizing its call centers. Since offering a seamless omnichannel experience is so important, the best advice I can offer them is to make sure that the carpeting in the new call center is blue.

BTW: I took the strawberries.