Patient Relationship Management–A 12-step program

The room was filled with the aroma of stale coffee. The anxious looking guests made idle conversation, averting their eyes so as not to look into the eyes of the person next to them. The folding metal chairs were arrayed in a circle. At the appointed time they sat.
A man with a hardened look stood to speak. “Hi. My name is John, and I haven’t spoken to a patient in four months.” As he began to sit, the others responded in unison, “Hi John.”

The rotund woman across from him rose and composed herself. “My name is Mary, and I haven’t spoken with a patient today.”

“Hi Mary.”

This same process occurred until all who wanted had said their piece. Hospital executives. Male and female. Some had earned their stripes caring for patients.  Others, even though they were in charge, had never met one. Recovering clinicians and physicians.

The good news is that the program works. The longer the executive goes without speaking to a patient, the longer they are likely to go. The break-even point seems to be about two weeks, the same amount of time it takes to paint a house. Once an executive has gone two weeks without speaking to a patient, there is almost no chance of slipping into that nasty old habit.

When was the last time you caught one of your executives sneaking a chat with a patient?  Probably never. Old habits aren’t so tough to break, especially when those habits never existed.

Why do witches burn?

Some argue that skewed logic is better than none at all. I’m not some people. What is skewed logic? It’s drawing an errant conclusion from a set of facts. If A and B, then C. For example, in Monty Python and the Holy Grail, there is the discussion to deduce if a woman is a witch.
Why do witches burn?
Villager: Because they’re made of…..wood?
B: Goooood!
Other Villagers: oh yeah… oh….
B: So. How do we tell whether she is made of wood?
One Villager: Build a bridge out of ‘er!
B: Aah. But can you not also make bridges out of stone?
Villagers: oh yeah. oh. umm…
B: Does wood sink in water?
One Villager: No! No, no, it floats!
Other Villager: Throw her into the pond!
Villagers: yaaaaaa!
B: What also floats in water? …
King Arthur: A Duck!
Villagers: (in amazement) ooooooh!
B: exACTly!
B: (to a villager) So, *logically*…
Villager: If…she…weighs the same as a duck……she’s made of wood.
B: and therefore…
Villager: A Witch!
All Villagers: A WITCH!

Let’s depict this like a business problem.


There you have it. So campers, where could we possibly heading with this? Here’s where. We’re starting a hospital; THEREFORE we need an ENR.  Washington is giving away money; therefore we need an EHR.

If that logic was correct, if that logic was both necessary and sufficient how would we know it? One way is we would see a bunch of doctors running towards EHRs rather than away from them. The reason this logic is faulty is that the lifeblood of the EHR is about one thing—the records.

So, if the EHR is made of wood and weighs the same as a duck…

How difficult are EHR, Reform, & Interoperability

My daughter asked me to kill the bug in her room—Super Dad to the rescue.  That got me wondering.  Do most men think we excel at most things?  As I pondered weak and weary, I started to formulate this list.  I ask the men as they read through the list to score themselves on a ranking of one to five, with five being the highest, how they view their abilities in each area.  Ladies, feel free to play along on behalf of someone you know.

  1. Sunday Sports
  2. Getting a taxi
  3. Navigating
  4. Mowing the lawn
  5. Killing spiders
  6. Drawing a straight line by hand
  7. Multitasking
  8. Parallel parking
  9. Anything to do with fire
  10. Opening jars
  11. Sharpening a pencil with a knife
  12. Tipping
  13. Driving
  14. Cooking on the grill

Maybe this comes from that hunter-gatherer thing.  Total your score silently in your head—you can do this because you also happen to think you excel in math.  My guess is that 98% of us scored somewhere between 56 and 70, the majority leaning towards the higher end of the range.  Granted, these are simply opinions, nothing any of us has to prove.

However, when pushed most of us will back down on one or two things if we had to prove our prowess.  Take juggling for example.  Even an egoist will be reticent to rate himself an excellent juggler.

Here we go.  Why then when we (ladies, this also includes you) are faced with something challenging at work we do our best to convince ourselves and others that the task can be no more difficult than opening a jar, asking directions, or asking for help?  We prefer to fly solo, believing we will somehow figure it out on the way.

I cannot recall the last time I heard someone facing a big ugly IT project state anything like:

  • You’ve got the wrong person
  • I have no idea how to do this
  • There is no way this is going to work

EHR, reform, Meaningful Use, interoperability.  These are big ugly projects.  Some are projects for which only a scarce few have real subject matter expertise—a handful of which truly ‘get it’, and others for which no one is credentialed.  Yet when we hear the proclamations about how standards are coming, how the N-HIN will work, and how reform will impact healthcare over the next five years, they seem to be stated with such assurance so as to infer that these industry-altering programs are no more difficult than parallel parking.

Remember the game Trivial Pursuit?  There was an inverse relationship between how certain I was of an answer and the certainty with which I asserted it.  If I said the answer quickly and with enough confidence I could occasionally convince the other players not to even check the answer on the back of the card.  For example, if the question is “name the bird who lays its eggs in the nest of another bird,’ and you belt out, ‘racket-tailed coquette,’ you just may pull it off.

It’s just an observation on my part, but why is it that when the nice people in charge tell us that they know what they are doing to me it sounds like they are yelling, racket-tailed coquette.’

“Are the best intentions of EHR Half-Full or Half Empty?”

Doublethink. Functioning simultaneously on two contradictory beliefs and accepting both as true. By definition, one must be false, unless of course you are living in a parallel universe, in which case you’re in need of more help than I can deliver. George Orwell defined it as, “A vast system of mental cheating”—on yourself, I might add.

What does doublethink accomplish and why does it exist with varying degrees within each of us? First, it allows us to overcome our own competence. I think that’s worth repeating, overcoming our own competence. We know better and yet we talk ourselves out of accepting what we know, creating an equal and offsetting false belief.

Second, it acts as a safety net. How? Let’s say we are one hundred percent confident in Belief A. Well, almost. There’s always that little nagging disbelief, that little devil on the shoulder trying to convince you otherwise. Sort of like ‘buyer’s remorse’—only we’ll call it believer’s remorse. Just in case Belief A is wrong, maybe I should have a backup belied, Belief B. Jeckyll and Hyde.

How does that impact one in the EHR problem?  Buckle up. Most people with whom I’ve worked are very passionate about what they do and are paladins of their methods.  Sort of EHR young Turks.  Belief A. They do everything they can for the program.

While sincerely believing in the importance of EHRs, here’s what else I’ve observed.  Much of that belief envelopes the limited notion of believing that nothing lays outside of their skill set. They often recognize it more as a desire than a belief.  They know fully that they will face challenges which are new to them.  They know fully that many implementations have failed and that they need to spend more effort on change management and work flow alignment than was budgeted.  The list of challenges for which they lack the expertise never empties.  They know the light at the end of the tunnel is just a train. They know fully that solving the current problem only seems to reveal the next one.  Belief B.

So, we’ve come full circle. We outwardly profess we can do what others have failed to do, yet in our heart of hearts we believe that you may never see an ROI. Doublethink.

Which gets us back to our original question, “Are the best intentions Half-Full or Half Empty?”

Is I is, or is I isn’t?

As I Was Going Up The Stairs, I Met A Man Who Wasn’t There.  He Wasn’t There Again Today. I Wish, I Wish, He’d Go Away.

Is I is, or is I isn’t?  Am I me, or are you me?  One of us is not who I appear to be.

I have been having some trouble, as if you couldn’t tell.  Blog trouble.  WordPress or someone is toying with me.  I am getting emails from me—or should it be myself.  I don’t know, but one of me is writing to me.

WordPress sends me an email every time someone comments on my blog.  The email enables me to decide if I want to approve the comment.  As of yesterday, I have approved them all—I appreciate you reading and making the time to share your thoughts.

Yesterday I opened an email from WordPress and started to read the comment.  It occupied nearly a full page.  Clearly someone had taken the time to craft this little missive.  It was very well written.  What first piqued my curiosity is that the tone and cadence sounded like my writing.  The author interjected snippets from a few of my posts.

When WordPress sends these emails it informs me of the author’s email, their URL, and their IP address.  The author’s email was listed as being mine.  Their website was listed as mine.  As I was going up the stairs, I met a man who wasn’t there—me.  I didn’t write the comment.  Someone had figured out how to send a comment to my post and pretend I had written it.

When I clicked the IP address Chrome opened a new window and informed me the IP address was fraudulent.

Am I becoming Sybil or merely simple?  Any thoughts?


HealthsystemCIO.com–a few thoughts

These are my comments to the post by Steve Huffman, VP & CIO, Memorial Health System.

Well written Steve. I think part of what is being missed by Washington is that in their effort to mandate providers move to facilitate a nationalized healthcare model; they have overlooked a few things. For starters, I think the EHR discussion has shrouded the fact that EHR is voluntary. Unfortunately, very few providers look at EHR as a decision they should evaluate—do I or do I not do EHR. Instead, they eschew that question, and view the need to do EHR as a decision that was made for them.

• Two business models are in play, a national model and the one used by providers. In the end game, even though it is only mentioned in the privacy of their own policy rooms—and not streamed on CSPAN—the national model is ultimately being designed to connect every doctor to every patient—one big hospital under thousands of roofs. The other model is the provider’s singular business model. It’s a patient-centric model (the healthcare business) and a business model (the business of healthcare). The two models have different goals and different requirements.

• If the model Washington is pushing were attractive, providers would be knocking one another down tying to be first in line to implement it. Clearly, that is not happening. Instead, Washington is offering billions in rebates, and there are still few takers.

• There is no viable plan on how to get from here to there—none, nada, zip. Instead of a coherent plan coming from them, they have put the monkey on the back of the providers, guiding them with carrots and sticks. Washington launched this idea without a much of a plan, and after the fact saddled the providers with three innocuous stages of rules—two of which remain undefined. They have yet to convince providers that they have a way to make sense out of having 400 different EHR vendors, no set of standards, hundreds of unique HIEs—I know you can’t have hundreds of anything and label it as unique—which bespeaks–the problem–and realistically expect it to work.

Why change your business rules and work flows to try to meet a plan that has stability of having been drafted on an Etch-A-Sketch? There are plenty of valid business reasons to evaluate changing the way providers work. There are huge potential gains in safety, care, efficiency, and effectiveness. These gains vary by organization. They vary based on the unique requirements of each organization. Properly planned and implemented, and EHR program with change management on workflow improvement can facilitate taking the business of healthcare from an 0.2 model to a 2.0 model.
Done poorly, and EHR will prove to be nothing more than a multi-million dollar scanner.

That being the case, you may want to use Steve’s methodology and ask him where you can go to buy a supply of the Composition books he uses.

Let’s meet up at HIMSS

With all the great events planned for HIMSS, I am writing to make sure you’ve heard about the free networking bash that FierceHealthIT is hosting at HiMMS on Tuesday night, March 2. It takes place at the World of Coca-Cola, a tourist attraction in its own right. If you’ve never been to Coke’s headquarters, it’s definitely worth seeing.

If you aren’t real familiar with FierceHealthIT, I encourage you to take a look at their sites, and mark this on your calendar.

I’ve gotten to know Wendy and some of the FierceHealthIT team as a contributing blogger for Fierce’s blog Hospital Impact,   From my perspective, these people really focus on a lot of the thought leadership issues, and it should be a great way to meet a lot of you.  I hope to see you there!

I am Stupified

Got the T-shirt.

Did you know AIG got $79 billion?  There’s also our friends at Goldman.  This got me thinking—some would argue that it in itself is noteworthy.  There’s a reason nobody shed tears for these guys, and that is the average person has no connection to them other than what they hear on the evening news.  We never got a car loan or a mortgage from them, so when they were dangling over the precipice we wouldn’t have lost any sleep had they been allowed to fail.  Unfortunately, the reports of their death were greatly exaggerated.

American poet John Godfrey Saxe based the poem The Blind Men and the Elephant on a fable told in India many years ago.  The poem is about blind men trying to describe the elephant solely on what they are able to feel.  As they are all feeling a different part, they each think the elephant is something different from what it is and from what the other believes.

It feels like the reform effort involves an equally obtuse process—dozens of people in separate rooms, each with their own pad of paper and box of Crayolas. When they finished creating their vision of reform, the person with the biggest office stapled all the pages together with the big red stapler like the one they used in the movie Office Space.

Here’s how this all ties together—don’t blink or you may miss it.  People weren’t vocal about AIG and Goldman because we weren’t connected, because it wasn’t personal.  The opposite is true about healthcare reform.  We are connected.  It is personal.  This is what Washington doesn’t get.  If they don’t demonstrate that they get it, it will fail.

Nancy Pelosi has been the poster child for the reform effort.  Her unfavorable ratings are at two to one.  Sixty percent of Americans, also known as voters, are against the reform.  I’d wager that nearly one hundred percent of those people have insurance, and rightly or wrongly, they believe that reform will take that from them.  There is a small but important distinction here.  They are not against reform per se; they are against the reform as is being discussed.  Moreover, the snowball rolling down hill that Washington–and most of the east coast–can’t stop is that nobody can accurately describe what it is they’re against.

How can the average person know if reform will work?  If reform can’t be explained clearly on a single page, Washington will lose the voter–they have.  The opponents of reform had their message down to a page; the one bullet point is “change the bill.”

Something to consider…

Did you know that having an EHR is not required?

Since it’s not, wouldn’t it make sense to approach EHR like you would any other business problem?

PRM Roadkill

(AP) New York. CNN reported that PRM died. Services will be held next Monday at Dunkin Donuts. Patients are asked not to attend, but instead to forward their complaints to Rosie O’Donnell.

A fellow, David Phillips, wrote, “Relationships should be considered part of the intrinsic value of the corporation”—he is an auditor. I read a paper co-authored by a slew of PhDs who concluded that the six components for measuring relationships include; mutuality, trust, commitment, satisfaction, exchange relationship, and communal relationship. I feel better just knowing that.

Patient Relationship Management—PRM. I hate being the one to break the news but, PRM is dead. I didn’t kill it. It’s dead because it never existed.  Relationship Management.  Who is actually measuring a relationship? What unit of measure do you use? Inches, foot-pounds, torque? PRM Carcasses are strewn about. You can’t manage what you can’t or don’t measure.

“What are you talking about?” She hollered. “We measure. We measure everything. If it’s got an acronym, we’ve got a measure for it. KPIs. CSFs. ACD. IVR. ATT. AHT. Hold time. Abandonments. Churn.”

Just because something is being measured, it doesn’t mean that the measure has anything to do with the desired outcome. I’d wager my son’s allowance that nobody uses a single quantifiable metric that precisely points to the health of an individual patient relationship. Seems silly? No sillier than really believing you have an ability to manage something as ephemeral and esoteric as relationships.

Just how good are those relationships everyone thinks they’ve been managing? Five percent higher than last month?  Down three percent over plan?  Permit me a brief awkward segue. Joseph Stalin said, “One death is a tragedy, one million deaths are a statistic.” The point is that scale matters—a great deal.  One death versus a million.  One patient interaction versus millions.  It makes a difference. The things we do that impact patients impact them individually, one at a time.

Technology metrics apply to patients—plural. Technology metrics are averages—patients aren’t.  You are measuring against the masses.  The mass does not churn, does not leave your hospital, does not ask to speak to a supervisor.  If I am the patient, not a single metric, not a single measure in your hospital accurately depicts the success or failure of our interaction.

So, what’s a mother to do? Stop pretending you are managing your business by managing relationships—since it’s not possible to do the latter, it follows logically that you can’t possibly be doing the former.

Here’s what you can do, manage your hospital using things you can measure. You can start by defining metrics for the following;

Patient Referral Management—how many patients came via referral?

Patient Resolution Management—how many patient problems were fixed?

Patient Recovery Management—how many patients did you win back?

Patient Retention Management—how many patients did you prevent from going elsewhere?

Show these to the VP of Operations and all of a sudden you have something to talk about. Show the VP how much you reduced some global metric—so what?