Sometimes these little blogs write themselves.

Let me begin by explaining the Waffle House Theory of Patient Experience, and by telling you what the acronym IDD stands for.

The Waffle House Theory of patient experience is as follows. If the Waffle House where you live is open, there is a zero percent probability that your provider’s or payer’s call center will solve your problem. You see, the cool thing about Waffle Houses is that they are the restaurant industry’s equivalent of nature’s cockroaches—no, I am not saying that they have cockroaches. I am simply pointing out that neither rain nor sleet nor snow will prevent them from being open. So, if they remain open, no matter what, your chances of having your needs met by calling your provider or payer are zero.

(I’ve even thought that if healthcare firms changed their recorded message to, “Thank you for calling Comcast, that message might help to level-set their caller’s expectations as to what type of experience they should expect.)

IDD stands for Inattention Deficit Disorder. I think IDD is a deliberate collaboration between providers and payers to not meet the needs of patients, members, and consumers. Its premise is simple—if we do not acknowledge that a problem exists, how can we be expected to solve it?

Last week I was speaking with an executive vice president of a large payer. As a courtesy, he asked me not to mention his name because he was trying to protect the guilty party, namely his firm.

The situation is the following. His wife had been treated at a large health system. The names of the system, and the name of the payer, are not important. They are not important because you can substitute different providers and payers and it would not change the discussion.

She received a letter from her provider stating that her reimbursement claim for several thousand dollars had been denied. Two sentences. One dollar amount. Zero explanation. She started calling.

Dialing for dollars.

She called the provider. She called the payer. She asked for an itemization of the denied amount. Eleven total calls. “You have to request an itemized copy of your bill.”

“That is exactly what I am doing,” she told the person. (It does not matter whether she told a provider’s employee or a payer’s employee; knowing which it was would not affect the outcome.)

“I can’t give you that information. You have to send us a letter; something with a stamp on it. And you have to prove you are you.”

“But, I am me. I am the person to whom you are speaking.”

So, back to my conversation with the EVP about this flawed process. “Is there anything you’ve seen that can make this process better?” He asked.

“There are two possible solutions,” I said. “One of them requires that your wife likes to sing.”

“She’s in the church choir,” he replied.

“Well then, since it looks like she will be spending way more time than she wants being placed on hold as she tries to solve her problem, I find it helpful to find an activity that she enjoys to occupy those long periods of inactivity. If she likes musicals, I would recommend that she use all of her time on hold to learn each of the roles of Les Misérables. That is what I do.” (In case you are interested, I will be presenting a one-man performance of Les Misérables this summer at the National Theater in Washington, D.C.)

The EVP did not sound too keen on my first idea. “Well,” I said. “There is another way to solve the problem, and this way works one hundred percent of the time. Tell her to stop calling. Tell her not to reply to any of their emails, and if she receives any letters from either firm, just tell her to throw them away.”

“But we probably owe them money,” he said.

“I’m not suggesting that you do not pay the bill. I am only suggesting that you quit working hard trying to figure out what it is for and how much of it you actually owe. After a few months, she won’t have to call any more. They will call her. And when they call, they will be very helpful. The whole idea is for you to put the monkey on their back. Get things to the point where their whole focus is on convincing you to send them money. You’ll be surprised by how helpful they will be when they initiate the call.”

Dialing for Dollars: Part Deux.

The CEO of a large health system calls to schedule an appointment for himself. He does not know that his health system implemented the Waffle House Theory of Patient Experience in 1947.

He was unable to schedule an appointment.

Pshaw, you are thinking. (Apparently, pshaw is actually a word.)

Many of you are probably thinking that his health system is an anomaly. Once again, my response is pshaw. When you finish reading, call your health system and pretend that you want to schedule an appointment. By the thirty-minute mark of your call you will be screaming epitaphs into your phone—Sic (intentional error).

IDD—Inattention Deficit Disorder. It could also stand for Intentional Deficit Disorder.

If we do not know there is a problem, how can we be expected to fix it?

Well, now you know. Payers and providers make it very difficult for patients and members and consumers to meet their needs. Either they do not know that the problem exists. Or they know it exists, and they just don’t care.

You and I care.

There are a variety of ways for guys to prevent your spouse from adding things to the ‘Honey Do List.” I may have just created a new one.

We have several large, black exterior lights whose color has faded because of their exposure to the sun. Those faded black lights are attached to white boards, which are, in turn, attached to the home’s white stucco exterior.

I should have known better. I was trying to be helpful. Trying to do something without being asked. And so I went to the hardware store and purchased a few cans of black spray paint. Did I mention that the color of the paint is black?

The exterior lights protrude from the side of the house by about a foot. Someone smarter than me might have approached spray-painting the lights with a little more preparation. They may have approached the problem with a roll of duct tape and sheets of plastic to cover the white boards and the white stucco. Did I mention that the color of the boards and the stucco is white?

It would be easy for me to tell you that a sudden gust of gale force wind was responsible for changing the intended path of the spray paint as it left the can. But, there was no wind. The lights are once again black, but

The lights are once again black, but so are the boards and the surrounding stucco.  The refurbished lights look very good. High gloss black accentuated against a white background. Or, as it turned out, a background that is now white-ish.

Trip number two to the hardware store to buy two cans of white spray paint. White boards and white stucco, as I learned after I tried to touch up my overspray of the black paint, becomes a tad less white after ten years. So, try to picture my current dilemma. Black lights. Off-white boards and stucco. And a bright white repair job wedged between two of my new favorite colors; black and off-white. As I look at the results of my work, I am reminded of the Doctor Seuss book, The Cat In The Hat Comes Back, when the pink stain that spreads across everything confronts them.

Enough about cats.

Would you think less of me if I tell you about the voices? I was having trouble sleeping. The sheep-counting thing wasn’t working for me, so I decided to listen to the voices in my head. They gave me a choice between two tasks before they would allow me to sleep; listen to an entire Celine Dion CD, or tie together four disparate facts in a way that made sense. I opted for the facts.

Fact One: Marie Osmond’s never-ending commercial for weight loss. “I’m Marie, and I lost 50 pounds on Nutri-System.” Marie must have been really big.

Fact Two: The never-ending commercial about Mario Perillo advertising trips to Italy. “You may remember my father.”

Fact Three: The spam emails I get from someone named Olga who wants to meet me.

Fact Four: The spam emails I get from Mr. Mumbagi telling me that my uncle left me a large inheritance

And this is what I came up with.

“Can’t wait to meet you, Olga,” I replied. But I wanted to lose weight before I met Olga, so I called Marie, and asked her to tell me about her weight loss secret. Then I emailed Olga, and I suggested that she meet me in Italy. But I didn’t know anything about getting to Italy, so I called Mario Perillo’s son to find out what it cost to go to Italy—it isn’t cheap, even if you bring your own Chianti.   And that left me with no other choice than to reply to Mr. Mumbagi’s email to ask him to expedite the payment of my uncle’s inheritance.

Sooner or later, all of the facts make sense. The circle of life.

The circle of life plays out pretty much the same way in healthcare. Examine these four facts—they happened to the same person who was spray-painting his exterior lights.

Fact One: A patient goes online to try to find the date and time of his appointment

Fact Two: A patient calls his health system to find out what day his appointment is. However, he does not remember the name of his doctor at the specialty practice.

Fact Three: A patient arrives for his hand surgery only to discover that the surgery does not take place at the doctor’s office

Fact Four: A patient calls the health system to ask where he is supposed to be for surgery

But what if our friend, the spray-painter with the bad hand, had an interactive app from the health system that would have made facts 1-4 irrelevant? What would have happened if the interactive app had sent him, or me, a reminder of his appointment that included the date and time and location and a map?

What would have happened is that the surgeon, after asking why my hand was covered with patches of black and white spray paint, would have performed the surgery. And the poor patient would have returned home with his hand wrapped in bandages. And the patient’s wife, who wanted to chastise him for having spray-painted the white boards and stucco black, would have seen the bandages, and she would have been sympathetic to the patient instead of asking why the stucco was black. She would have directed him to his favorite chair, put his feet up on the ottoman, turned on Fox News, and brought him a glass of kale juice.

But there was no interactive app. There was no way for the patient to learn the location of his surgery. And so the patient returned home only to discover that a team of contractors had constructed scaffolding around his entire house, and had removed all of the stucco.

Healthcare’s circle of life.

Design an app.

Save a husband.

There is a huge difference between what healthcare practitioners think is required to schedule an appointment and what actually happens. Take for example, a mother who thinks her child needs to see the doctor. Viewed from the perspective of the pediatrician’s office, I don’t think PCPs believe calling the doctor requires any more work than say calling your mother.

We could extrapolate the example to include how this process may look from the perspective of a single mom with one or more other children that she has to get to school, but that would make my head explode.

PCPs may be surprised to learn that by the time all is said and done, a dozen or so steps are required, and those steps can take the better part of a day for the parent to complete.

Suppose school starts at 7:45. If your child may be sick, you wait at home until the pediatrician’s office opens at 8; and then you begin to dial. You and dozens of other mothers are all dialing at the same time because you are trying to grab one of the handfuls of open appointments. If the pediatrician’s office is like the one we use, you continue to hit the speed dial until you no longer receive a busy signal. The appointment lottery.

If you are fortunate enough to win the appointment lottery, you then dress your child and take him or her to school. Don’t forget to write the note explain why the child is late. Then the mom heads to work; she also will be late, but she probably doesn’t need a note. A few hours later she leaves work to pick up the child from school to go to the doctor. After the exam, the mom drops off the prescription at the pharmacy, drops off the child at home (assuming there is someone at home to watch the child. If nobody is at home, the mom misses work for the rest of the day.) Mom returns to work, and at the end of the day she returns to the pharmacy to pick up the prescription.

I mapped out the process based on what we had to go through last week to schedule an appointment for our son. This is what it looks like.

It may surprise you to learn, however that there is a simpler solution. A solution that requires exactly one step instead of twelve.

The mom turns to her child and says, “Let’s go to CVS and get doughnuts, and while we are there, we will see what the nice lady at the Minute Clinic thinks is going on with your ear.

The only easy button is the Minute Clinic. If you want to compete, you need to redesign this basic process, and you need to include what your customers go through when you do it

I thought we’d change things around a bit today.

Yesterday I learned that healthcare may be more advanced in its use of technology than I thought.  Twenty percent of the user’s of Google, Apple, and Microsoft access those organizations using voice technology, “Okay, Google.”  “Hi, Siri.”

But, did you know that in healthcare almost one hundred percent of its users access their providers using voice technology?  “Thank you for calling our Lady of Zero Wait Time.  We estimate that you wait time will be long enough that if you have errands to run, you should consider running them now.  If in fact we do speak with you, your call will be recorded for quality purposes.”

So, we’ve got that bit of good news going for us.

Idea 2.  I’ve spent months trying to figure out a simple way to explain consumerism. My effort resulted in the following graphic.  What do you think?

For the most part, CRM is a misnomer. Most CRM systems do what they were designed to do.  The problem is that very few of them do exactly what you want them to do. How can you tell the difference?  Suppose you ask the question, “Does you system do  this?” The moment the vendor tells you, “This is how we get our system to do that,” instead of simply showing you, you know you have a problem.  You have just been shown a workaround.

Most CRM solutions started out as sales force automation tools.  And automating a company’s sales force,is very different from managing customer relationships.

But, that is hardly their biggest problem.

I’ve written many times that if you haven’t reinvented your online and mobile presence in the last three to five years that you may be better served by simply deleting the URL, unless of course, you are satisfied by simply having a digital place where all your customers can do is read about how good your organization thinks it is.  But, if that is your only reason for having a website, perhaps you should simply take your site’s text and photos to a publisher, have them print and bind the material, and offer it to your customers as a gift.

I met last week with a health system executive who told me that their website had more than twenty thousand pages. If you read a page a day, it would take you sixty years to read every page.  As a point of reference, most people who track this kind of data would tell you that the longest book ever written is Marcel Proust’s novel, In Search Of Lost Time.  His muse only covers 3.031 pages, and there is no record of anyone reading the entire book.

Why not turn your health system’s website into a coffee table book.  “Our Lady Of Healthcare: An illustrated History.”  Need some ideas for the table of contents?

1. The Early Years
2. Fun Facts About Our Staff
3. Pictures To Color While You Are In The Waiting Room (Bring Your Own Crayons)
4. 5 Favorite Menus From Our Hospital Cafeteria
5. People Who Gave Us A Lot Of Money
6. Silly Gifts From Our Gift Shop

The world has changed, and most firms have not changed with it.

In the same vain that your health system has not kept up with change, neither has your CRM vendor.  Mark my words, in the next three to five years, if you understand what is going on around you, you will be discussing closing your call centers, or at least making them significantly smaller.

Why? Because nobody wants to be forced to call a company; ever.

Look at your desk. Within reach rests a thin black or white device. It is about two and a half inches wide and about five inches long.  It is an electronic Swiss Army box.  It does photos, texts, emails, banking, music, books, documents, and a hundred other things. It can be a flashlight and a shopping cart.

You can even use it to call people.  My children have one of these.  I do not think they have figured out how to use it to call anyone.  Half of the people who own phones do not use them to call anyone. The other half use them to make calls, but they want to call friends, not vendors.

CRM Vendors. Have you been paying attention? Here is my denouement. It’s French, like “la plume de ma tante.”

If you are in a planning meeting, mute your phones and pay attention. Forget about defining requirements for release 5.09.17. Nobody really needs the update. Your customers’ customers certainly are not holding their breath for it. I have seen the future, and CRM ain’t there. At least not one that can be accessed by calling an organization.

At HIMSS this year, I had the following conversation with a CRM executive. He had asked me to share my thoughts about what long-term strategy they should be pursuing. This is what I shared.

• You have what was an essential tool when the only access to an organization required using a phone
• They had to call an organization during the hours the call center was open
• Decades moved on. You added functionality for the people who had no other choice but to call an organization
• Organizations started to learn that their customers did not want to be forced to call them; they wanted a choice of access channels
• Oops! CRM vendors do not offer a choice of access channels to their customers. Voice only; nothing digital

No amount of added functionality is going to change the paradigm.

But what would happen if the CRM vendor asked the question, “How could we design an online experience the was direct-to-consumer? Bypass the organization. Skip the call center and meet the customer’s needs interactively online. Design it around a mobile-first strategy that featured user-centered design. And add a natural language processing feature.

The upside is huge.

• 24 x 7 access
• Zero wait times
• Zero abandoned calls
• Zero repeat calls
• The right answer every time, at any time, on any device
• No personality conflicts between customer and agent
• The marginal cost of the next contact is zero
• Customer acquisition and retention increase

(Big Hint) The winning CRM solution will be a cloud-based, cognitive, interactive customer portal.

The first CRM vendor to market with this wins.

Each of us spends an inordinate amount of time on hold, reassured that when finally speak with someone that the call will be monitored for quality.

The offerings of every customer experience (CX) consultant on the planet include the ability to reduce waiting time; time the caller spends on hold.

But hold on Skippy, are there better ways to address waiting times, ways that add those minutes back into the caller’s day? Being placed on hold does not have to be a negative. It is only a negative if all you do during that time is wait.

What if you could put that time to good use? When I find myself running out of time to complete a project, when I need twenty minutes of uninterrupted time to work on the open items on my task list, I pick up the phone and call someone. Not because I want to talk to them; in fact, for just the opposite reason.

I know from experience, that when I call these firms, they will put me on hold. They provide me with I need the most at that very moment. Quite time. A time-out from the fires burning all around me. Who do I call? My two favorites are Comcast and Verizon, but I am usually rewarded with just as much time by calling my provider or payer.

A few months ago it occurred to me that I did not have to limit myself to just working during these time-outs. I could actually turn the time into more of a Zen experience. I tired counting backward from infinity; twice. Completed an entire volume of Sudoku puzzles. I wrote an algorithm to help me figure out how to fold a fitted sheet. (The first time I tried the algorithm I invented a new art form—cloth origami. My bed sheet-cum-swan is being exhibited at the Museum of Modern Art.)

But then I discovered how to turn those sixty-minute blocks of wait time into a fun activity, and that discovery proved to be so enjoyable that I am writing to share it with you.

Spam.

We all get it. Most of it is nonsense, but there is a way to turn it into unparalleled entertainment. I discovered that certain types of spam emails are just begging for a response, if for no other reason than to mess with the mind of the person who emailed it. I am not referring to the emails telling me that I may have won a million dollars. I like the emails that tell me a relative died and left me his or her inheritance.

They usually begin like, “Dear Mr. Paul. My name is Felix Undambi. And I am the barrister of your late uncle Bill.”

Without reading the rest of Mr. Undambi’s email, I fire off a reply. “Thank you for contacting me. What happened to uncle Bill?”

“Dear Mr. Paul. Your uncle Bill was studying infectious diseases in Botswana, and he became very ill. I was with him, and his last wish was that I contact you, his favorite nephew.”

“That is great news,” I write.

“Dear Mr. Paul. I do not understand. He is dead.”

“I understand. But uncle Bill was the black sheep of our family. He never even finished high school, and yet he became a scientist! I thought he had moved to Iowa”

“Dear Mr. Paul. What is an Iowa? He was very proud of you, and he left his estate to you. Unfortunately, for me to send you the funds I am required to pay certain in-country taxes first. If you send me fifteen hundred dollars, I will pay for you”

“I understand. Pay the taxes. And then send me what’s left. But I don’t want to pay taxes in the US. So I want you to use my other email address.”

This is where you can get very creative with Mr. Undami depending on whose email address you decide to give him. I will leave the rest up to you.

Anyway, just an idea. If you want the fitted sheet algorithm let me know.

A recent Pew study of 813 men showed that three times as many men correctly identified the geometric shape on the left, a torus, than the number of men who correctly identified the shape on the right as that of an iron. Admittedly, many more men actually thought the shape on the left was called a doughnut, but the judges ruled that those men deserved partial credit.

A torus is a surface of revolution generated by revolving a circle in a three-dimensional space about an axis coplanar with the circle.

Guys, an iron is a three-dimensional shape that is pushed and pulled across a two-dimensional space that is coplanar with an article of clothing.

Most single men do not own an iron. Most married men know that there is an iron in their home, but it is not there by choice. Most guys, given the chance to examine an iron, if asked what design improvements they would make to the iron, would reply that they would begin by spackling the holes in the bottom—many of those same men would spackle the hole in the doughnut.

A few men may have tried to use the iron once. Some may have even given it a second go. But sooner or later every man compares the level of effort required to iron a piece of clothing to the level of effort required to call the dry cleaner. And then they remember why they never owned an iron.

Dry cleaning offers a simpler solution, and it provides a better user experience.

I cannot remember how long it has been since I sent a fax. There was a time when the ability to fax was a survival requirement for everybody who worked from a home office. I placed my fax machine right next to my printer. I set up a dedicated phone line for the fax. Ink and paper for the fax and the printer, and I modified my business cards to include my fax number. There were no Wi-Fi downloads of functional enhancements; what you bought was what you got.

The phrase, green side up, comes in handy if you are laying sod. I never learned which side of the page being faxed was supposed to face me. I probably destroyed more faxes than I sent. I’m sure I also had dozens of my faxes stored in the cache, never knowing why I did not hear back from the recipient. I got to the point where I found it easier to overnight a document than to fax it.

Then somebody much smarter than me created a phone from which I could take pictures of what I would have faxed. Through trial and error, I was able to learn how to email or message my document to a second party.

My fax has been in the closet for years. The printer is about to be relocated as well, both awaiting their fate at a forthcoming garage sale.

It turned out to be simpler solution, and it provided a better user experience.

Hardly any industries use faxes anymore; hardly any industry except healthcare.

Faxes are still survival equipment for healthcare, especially for providers. It surprised me to learn that many health systems receive and send thousands of faxes a week. I felt obligated to discover why people chose to fax their health system, especially since there seemed to be a simpler solution—calling.

As we both know, calling is not a simple solution. Hence, the high number of faxes. The more I studied the idea of faxing the more sense it made. The benefits, from a patient’s perspective include:

• I can contact you 24 x7; not just when the call center is open
• A fax provides an audit trail of our communication
• It requires very little interpretation
• It removes tone and attitude and focuses on the issue
• I will never be placed on hold or transferred
• I will never have to wait on hold

So, from the perspective of a good user experience, faxing checks off a lot of the good requirements. The most negative factor seems to be the lag time between when you send the fax and when you receive a reply. Tasks that actually require 5 minutes of work to complete can cover an elapsed time of 2-3 weeks. But remember, we are talking about healthcare were the term ‘lag time’ seems to be every organization’s middle name.

“Our Lady of Lag Time Medical Center.” Need to speak with a nurse? Leave a message. Want a refill? Call back during normal business hours. Complete the Contact Us section on our website—someone will reply to you in 2-3 days.

Do the benefits of faxing seem familiar to you? They should. They map almost one-to-one to the list of customer benefits that are the result of a good user-designed, mobile-first customer experience strategy. A remarkable experience, every time, at any time, and on any device. If you delete the word remarkable, the experiences are pretty similar.

The users created your fax strategy. If you do not come up with a better experience than a call center, do not be surprised if your customers create it for you. If all of a sudden you begin to receive a bunch of requests to schedule appointments using Palm Pilots, take that as a signal that you have lost the war.

A few of you wrote asking where you could purchase my red baseball hats—the ones embroidered with the words, “Make American Healthcare Great Again.” Stay tuned.

I drove past a Mini Cooper dealership today and learned that not all Minis are created equal. Minis come in different sizes—small, medium, and large; one for the papa bear, one for momma bear, and so on.

Then I pulled into a Starbucks. And my mind put Minis together with Starbucks and led me to think about how fans of Starbucks might order a Mini. Tall. Grande. Venti.

“I’ll have a Grande with mocha leather seats.”

I settled for an iced coffee. While I was looking at all of the ice cubes in my drink, my mind immediately jumped to the fact the a Chicago woman, who has apparently missed way too many Mensa meetings, is suing Starbucks for five million dollars because she used string theory and discovered that adding ice to her iced coffee used up some of the space where the coffee would have been had she ordered an iced coffee with no ice. Perhaps I could join the lawsuit.

Part of me wishes she had tried to order a caff, half-calf, decaf Venti, latte with skim soy milk. Her head would have exploded.

Let’s discuss population management. We’ll get to population health management in a minute. Population management and The Wall. It occurred to me that one way to solve this problem, and to pay for it, would be to make the wall a tourist attraction. Like the Great Wall of China. Did you know The Great Wall is the 26^th most visited site in the world, and that is it visible from outer space? I am betting that The Donald would not settle for just building a wall. His too would have to be visible from space. And can you imagine his reaction if his wall was only the 27^th most visited site in the world?

Maybe he could manage the populations on both sides of the wall. Build Trump Casinos right into the wall, have a two-drink minimum and sell my red baseball hats to help pay for the wall.

So, that is how my mind works. Red hats to Minis to Starbucks to the wall and back to the red hats. The circle of life in Paul’s world.

Now to population health management. No wall required.

The most important requirement to being able to effectively execute population health management is knowing something about the health of the population. I do not mean that in a frivolous way. How do we define the term “population”, and what do we mean by the term “health?” (I cannot remember whether the quotation mark goes before or after the question mark; hopefully, that will not undermine this post.)

Does population refer to the people within a provider’s radius of service? Or does it just refer to their patients?

If population refers to people who simply live in a provider’s area, who are not currently under the care of that provider, people whose health history is not stored in the provider’s EMR, can we agree that the provider knows nothing about the health of those people? If the population refers to patients whose health data is stored in the EMR, what does the provider actually know about the health of those people? Knowing someone had his or her gall bladder removed three years ago tells the provider nothing about the health of that person today. Having the person’s gall bladder data also tells the provider nothing about whether that individual might have been dealing with hypertension or depression.

If those statements are even partially correct, does spending money analyzing big data through analytics make sense? To analyze big data you have to have big data. Having a lot of data is not the same as having big data.

The same questions can and should be raised about payers. How much to they really know about the health of their members? (To me, the term members seems a tad too convivial.) A payer’s knowledge about an individual’s health is limited to what they can ascertain from the claims that individual files. Just because millions of their members are not filing claims does not mean those members are healthy; it may just mean that neither the member nor the payer knows anything about that member’s health.

What about retail pharmacies? What do they know about the total health of their customers who have taken or who are taking medication? Do they know if the medication made the person better, or if the medication is helping the person manage their illness? Or, do they only know that the person refilled their script?

Is the healthcare community actually trying to manage big data while only having very little data on a person-by-person basis? Is it possible to execute population health effectively when the current health of most of the individuals in the population is unknown? Knowing how someone was is not the same as knowing how someone is. Can you name a single healthcare organization that has a current, accurate, and complete picture of your health?

Population health management has its own wall. Millions of people in the population collect data about their health. They do it with smart apps and by using wearable devices. And they do it every day. They will do it again tomorrow, and the day after tomorrow.

And what do they do with that data? Pretty much nothing. They may look at it.

So here is the big question. Has collecting and storing that data improved anyone’s health? The part that is needed to turn a single person’s data into relevant health information is to have someone who understands how the disparate pieces of data fit together assess it. And that is the wall. The population health wall stands between what is possible to know about a person’s current health and what is known about that person’s health.

People, people in the population whose health and wellness the healthcare community is charged with managing, cannot find an organization capable of managing their health and wellness proactively. The data is there. Big data. And the amount of big data gets bigger every day.

If the big data falls in the woods, and nobody is there to assess it, does it make a sound? It could if someone was there to hear it.

Population health management. And the wall.

The circle of life.

HCAHPS. The patient is the object of the service.  They are the subject of the experience.

Most health systems focused highly on improving the dogmas of patient experience well before CMS came down from the mountain carrying the stone tablets engraved with the thirty-two statutes.  Trying to channel CMS will not improve your PX score, but it probably won’t make it any worse.

There are two amaranthine rules about Healthcare Customer Experience.

Rule 1: CMS invented the patient experience (PX) rules from whole cloth, without regard to the experiences or expectations of prospective patients, caregivers, family members, referring physicians, and without regard to the experiences that occur outside of the hospital’s four walls–some hospitals may have more that four walls, but the rule still applies.

Rule 2: Consultants cannot change CMS’s definition of PX, but we sure can raise a lot of questions about its shortcomings.

If a health system wrote their annual scores on a whiteboard almost every system’s scores would show improvement year-over-year.  They would also show the degree of improvement decreased year-over-year.  Diminishing marginal improvement.  Once you have fixed the large errors, the low-hanging-fruit, it becomes more and more difficult to gain the next bit of improvement.

Curiously, one question unasked in the patient experience survey could have the biggest impact with regard to how a patient scores their experience. Were you able to fall asleep when you were tired?  How would you feel if you stayed at a hotel, a hotel with excellent amenities, but you could not sleep?  Your survey answers would not reflect the excellent restaurant or the promptness of valet parking.  You would downgrade your experience score of the hotel because you could not sleep.

Several months ago a health system was featured on the cover of one of the trade journals for its innovative approach to improving patient experience.  What did that system do?  It added a screensaver to the desktops at the nurses’ station.  Appearing on the screensaver was the word Quiet.  Maybe Webster’s had dumbed-down the definition of what is and is not innovative.

The difficult part of tweaking out another tenth of a point across any of the thirty-two survey questions is that there are no more easy buttons left to push.

You could add the screensaver.  Or, you could bubble-wrap the Jell-O on the dinner trays to try to keep the noise down.

Or your health system could spend a dollar; one dollar per patient.  And with that dollar purchase two items.  A sleep mask, and a pair of earplugs.

In addition to their diminishing marginal returns, there are those who would suggest that the importance of HCAHPS to patients is of no more importance that the study of ornithology is to birds.  I am one of those people, in part because every health system had been working to improve all of those things well before CMS got involved.

Each of the survey questions, with regard to the calculation of a health system’s score, are of equal weight.  This implies the health system can benefit as much by having cleaner bathrooms as it can from reducing pain.

Now assume your health system had thirty-two patients.  What if each patient scored a different one of the thirty-two questions the lowest—patient 1 scores question one the lowest, patient 2 scores question 2 the lowest, and so on.  Now, if you are a member of your health system’s HCAHPS improvement committee, you are faced with quite the conundrum—what do you fix?  Where do you spend your PX capital to increase your system’s total score?  No matter where you focus your scarce resources, to improve your total score your will always have thirty-one areas that also require your attention.  In short, no matter what you fix, the fix will only meet the needs of a select few.

It is difficult to raise all boats because all of your patients are in different boats.

So, what can you do to raise everyone’s experience?  Is there a way to raise everyone’s experience all at once, or do you have to do it patient by patient?

There is indeed.  To raise everyone’s experience the first thing you must do is to define who belongs to the group everyone.  Why not agree that the group everyone consists of every one?  All of the health system’s stakeholders who have an experience with the health system.  Inpatients, outpatients, former patients, consumers, family members, and physicians.

Now that we know the answer to WHO has the experiences, we should answer the question WHAT.  What are those experiences?  Find out which experiences are the most common among your stakeholders, and which experiences have the greatest impact on their satisfaction.  That way to do that is very complex—you ask them and you observe them.

There are those who believe if a patient reports that the nurse in radiology is a grouch, writing checks to firms like Studer will improve the overall experience.  If you really want to raise all boats, ask yourself before you write that check what percentage of your stakeholders will actually interact with that specific nurse in radiology.

Improving WHO and WHAT is underway.  Let us address the question of WHERE.  Begin at the beginning, when your stakeholders have their first experience with your health system.  If you start fixing things at the wrong end, hundreds, perhaps thousands of your stakeholders will have already rated their satisfaction with their feet; they will have left your system without ever having had the chance to see how well you fixed the parts of the experience they never experienced.

All of your stakeholders, every single one of them will experience your health system before they ever set foot inside one of its facilities.  And based on their satisfaction with their first experience they will decide whether they will have another experience.  Their satisfaction with your health system is cumulative—Experience A + Experience B + Experience C, and so forth.  A bad initial experience taints the whole experience.  I am sorry there was a fly in your salad, but how was the entrée?

Seventy to eighty percent of your stakeholders will visit seven websites before they try to access your health system by phone, and half of those stakeholders are not currently your patients—they are consumers, consumers shopping for healthcare.  Assuming your health system’s website was one of those seven sites, what kind of experience did your stakeholders have?  Unless the reason for their visit was to pay their bill, they had a poor experience.  That means your health system is oh-for-one. (Fortunately, almost every health system’s website offers nothing more than yours.)

I saw a television commercial advertisement for a large Philadelphia health system.  Its message was, “To schedule an appointment visit us online.”  Guess what?  I visited.  The word schedule did not appear on the homepage.  I clicked on the patient link.  It did not appear there either.  I entered the term in their search box.  No luck there either. There was the ubiquitous link to pay your bill.  I would bet dollars to doughnuts ninety-eight percent of health systems are no better.

The reason stakeholders go to your website is because they do not want to have to call your health system any more than they want to call Verizon.  Did you know that twenty-five percent of the people who call a company (your health system is a company) are likely to change to another company simply because they had to call?

What do we know so far?  If you measure the experience by whether it provided value to a stakeholder, the online experience was of no value.  And how good was their phone experience? Not much better, but don’t take my word for it. Go listen to some calls.  The average person has to call almost three times to complete a single activity.

If a person has a bad online experience and a bad phone experience, what is the likelihood they will ever go to your website again? If they had to call three times to get an appointment, are they really going to care that you hired someone to coach the nurse in radiology, or will they have purchased their healthcare from someone else?

None of this is difficult unless you don’t think you have a problem.  You can try this approach, or you can install the screensaver, buy the earplugs and sleep mask, and hope people who visit your website pay their bill.  Who knows, maybe your HCAHPS scores will increase.

My son and I were binge-watching “Breaking Bad.” After several hours, I developed a hankerin’ for fried chicken and last night at 10 P.M. I quenched my hankerin’ at Popeyes. Unable to put two and three together, it did not occur to me that dozens of the Breaking Bad episodes were centered around the fried chicken franchise, Los Pollos Hermanos.

So, this morning, my adroit brain put two and three together in a Pavolvian manner and I discovered that while watching a show that relied on fried chicken made me want to eat fried chicken.  I was encouraged that I hadn’t lost my ability to grasp Pavlo’s signals. The twelve hour lag time I am trying to attribute to the humidity.

Let’s start with a few questions just to see if we can up the angst factor.

Did you ever wonder why your firm has something called a contact center or a call center?

The question nobody is asking is, why doesn’t your firm call it a help center?

The reason is obvious; at least to the callers. The one thing that is known for certain by the callers and by your firm is that every call can be resolved to meet the callers’ needs. What is not known is why aren’t those needs are not being met.

That is why the term customer experience is healthcare’s biggest misnomer or oxymoron.

“Customer experience. It’s a mess, ain’t it?”

“Well, if it isn’t, it’ll do until the mess gets here.”

These numbers may make you wish you were sitting down when you read them.

I met with one of your colleagues today who told me his health system implemented an online scheduling system. The two key performance indicators you should stew on for a few minutes are:

• People scheduled 37% of all new appointments during the evenings and over the weekends
• Two-thirds of all online appointments were scheduled for either the current day, or within the next two days.

These numbers are important for the following reasons—hopefully you know these already, but in case you don’t…

• Everyone who has an appointment has the potential to have a second and third appointment and yada, yada, yada
• Appointments and subsequent appointments generate revenues
• Not being able to schedule an appointment generates zero revenues
• If two of every three people who want an appointment want it within 72 hours, what percentage of them go somewhere else if they cannot get it from your organization
• If your organization does not allow people to schedule an appointment on weekends and evenings, how many of those appointments does your health system lose

Let’s play with the numbers, and let’s eschew altruism. Let’s look at the numbers in a way that has nothing to do with improving the health of the people who call for an appointment. Let’s be selfish and simply focus on the revenue impact of not being able to schedule an appointment with everyone who wants an appointment.

My first assumption is that the reason your system has a scheduling center is to schedule appointments. My second assumption is that your top key performance indicator (KPI) for that scheduling center is that you want to be able to schedule an appointment for every person who wants an appointment.

So what happens to your KPIs if your employees cannot even answer the phone? What happens to your KPIs if they cannot schedule appointments on weekends and during the evenings? What happens to your KPIs if they cannot schedule appointments during the 2-3 day window when two of every three people want them?

Your health system designed its call center to miss all of the most important KPIs that are essential to your callers. Your health system’s processes are designed to miss the expectations of at least one out of every three callers.

Clearly that was not the intent of the people who authorized building the call center. But how did it become the result?

If your health system looks at these questions from the perspective of losing the marginal revenues of a single appointment, it is missing the point. It is missing it in a big way.

Thinking that every missed appointment costs your health system a hundred dollars is the wrong way to assess the opportunity cost. One appointment leads to a second appointment, and a second appointment leads to a third. And yada, yada, yada.

If your health system misses twenty-five years of appointments and treatments and procedures because it could not make the first appointment, what it really lost was an asset worth $250,000.

That is a really big cost for not being able to answer the phone. People, your patients, buy houses for less money than that.

Get rid of your call center. Get rid of your contact center.

Build a help center.

And once you’ve built that, build an online, mobile platform that makes your help center irrelevant.