Your Dinner’s Sill Warm: It’s In The Dog

One day several years ago my friend and I decided to grab a beer after work.  One beer turned into two and yadda, yadda, yadda, all of a sudden it was 8 p.m.  “Didn’t you say that your neighbors were coming to your house for dinner tonight?” I asked him.

He looked frightened as he rushed out of the bar.

The next morning I asked him how much trouble he was in with his wife Debbie and whether he made it home in time for dinner.

He reached into his briefcase and pulled out one of his starched, white button-down dress shirts.  “I found this nailed to my front door when I got home.”  Written in lipstick across the front of his shirt were the words, “Your dinner’s still warm. It’s in the dog.”

It helps to know people’s expectations and how seriously those people view their expectations.  Debbie had clear expectations for that night’s dinner.  My friend had a different set of expectations for the same event.  The difference between her expectations and his expectations is known as the expectations gap.  It’s also known as your dinner’s warm, it’s in the dog.

What does a perfect user experience look like?

Today.  Downtown Philadelphia. Noon.

I am approached on the street by an older gentleman who was wearing a Vietnam War Veteran’s ballcap.  From the movie Apocalypse Now, I remembered the sound of Wagner’s Ride of the Valkyrie playing as a swarm of helicopters skimmed over the surface of the Mekong Delta—for those of you younger than fifty, the Mekong Delta is in Vietnam.  Robert Duvall, playing the role of Lieutenant Colonel Bill Kilgore, reflecting on the attack said, “I love the smell of napalm in the morning.”

I digressed.  My encounter with the man wearing the ballcap went like this.

“I like your shoes,” he told me.  I was wearing my chestnut-colored Ted Baker’s.  “Where did you get them?”

“eBay,” I replied.

“I wish I had me a pair like them.”

“When did you serve?” I asked.  He knew he had me right there and he started to reel me in.

He asked me if I was ex-military and then he mentioned that he needed to get to Trenton to go to the VA.

I told him I only had $4 in my wallet.  To which he replied, “That’s unprofessional and somewhat demeaning to just assume I wanted your money. You should have asked me how much the train ticket costs.”  Which then I did.


But I only have $4.

And here’s the kicker. He said, “There’s an ATM right there,” and he pointed to the ATM.

He had designed the perfect experience for him and for me.  He knew his expectations and he knew how he wanted me to meet them. It was apparent that he had choreographed our entire dance and it was not a simple two-step.

It was also apparent that this was not his first dance.

I wondered how many years he had been doing this.  Twenty years ago, instead of directing me to an ATM, would he have directed me to the closest bank?  “This bank will cash your check. Let me walk you over to save you from having to walk back here with the cash.”

I am looking forward to returning to this same corner next year. My guess is that by then he will be using the PayPal app to save me the trouble of having to walk to the ATM.

For user experience to be effective you must design it—not just from your perspective, but also from the perspective of the person’s behavior whom you want to shape.

Healthcare.  Healthcare and call centers.

My colleagues and I are developing consumerism scorecards for many of the largest health systems. Two of the scorecard’s broad categories are a system’s call centers and its digital capability—apps, website, social media.

“How can you give them a score of zero for their call center without even calling the system?” My colleague asked me.

“They get zero points simply because they have a call center,” I replied. People call because they have no other choice.  People go online because they want to. Nobody wants to call.  Ever.

Good user experience is not making something users don’t want better.  Good user experience is eliminating the thing they don’t want.


Consumerism Isn’t For Your JV Team

Last night as I’m sitting on a hard bleacher awaiting my fifteen-year old’s baseball game, I noticed that a  mom of one of the players, who was sitting next to me, looked a little forlorn. Being naturally inquisitive, I asked her if everything was okay.

“I lost his glove,” she replied.

Noticing a glove on her son’s hand, she saw my look of confusion. “Not his, she said. “My husband’s. I had it with me last Thursday at practice, and I left it here.”

“I don’t suppose this was a new glove. Judging by the look on your face I’d say this was your husband’s favorite glove; thirty years old, supple, broken-in, folds as flat as a sheet of paper.”

“Twenty-five years old,” she corrected me as she lowered her eyes.

“It rained almost every day last week,” I told her, which caused her to grimace even more. Having nothing better to do, I waxed eloquently. “That glove must have meant the world to your husband. He probably planned on giving it to your son in a few years. He probably didn’t plan on having his glove spend a week in the rain.  The glove probably reminds your husband of some of the memorable events of his life.  Every scar on his glove, each stain on the leather, probably points to something important in his formative years. If his glove lay outside last week, field mice probably chewed it to bits.”

She brushed away a tear, and she made a beeline to the lost and found.

“Any luck?” I asked when she returned.  She shook her head in despair.

Your husband’s hurt over this will heal over time,” I told her. “But he won’t forget it. Twenty years from now when the two of you are watching something on TV, something will remind him of the time you lost his glove.”

Moving the clock backward twenty minutes, my son and I were getting out of the car.

“Is your glove in the trunk?” I asked. This is after I had previously asked him if he had everything he needed for his game.

“I hope so,” he said shamelessly. I popped open the car’s trunk. “You hope so?” I repeated.

“It’s not here, Dad.”

I left him with his friends and I drove home to look for his glove. Ten minutes of searching; no glove. I checked his closet. There it was. Death by 1,000 cuts.

“I hope so.” What kind of a response is that?

As a member of your system’s executive team, you can’t rely on “I hope so.” Will what we are doing work with work?  I hope so.

Will your system’s efforts work?  I hope so.

Can you confirm for me that what you are doing will drive consumerism?  I hope so.

Do you have someone leading the effort who has done this before? I hope so.

Do you think your system can design consumerism in a way to change patient acquisition, access, and engagement?  I hope so.

Will you still be working here next year?  I hope so.

Changing how your health system’s business model functions demands more than trusting that change to your JV team.  You would not build a new hospital without hiring an architect.  Why would you recast consumerism without hiring someone who has done it before?

Consumerism is not HCAHPS. It’s not wayfinding or valet parking. It’s not as simple as changing the aesthetics of your system’s website. Changing your system’s homepage from sapphire blue to cerulean blue does not help the person who is trying to schedule an appointment.

Consumerism requires taking your entire business model from bricks to clicks.  Your consumers—patients and prospective patients—are demanding that they are able to do what they want, whenever they want, every time they want, and on whatever device they want to use.

Your system’s consumerism strategy should be able to be summarized in one phrase. If your consumers can’t carry your health system around in their pockets on a smart device, its consumerism strategy will have failed.

Patient Experience: Fool Me Twice, Shame On Me

Consumerism Axiom: Experiences that don’t create value from the perspective of your patients will never create value for your health system.

Here’s why.

There are two types of people; those who will try something until it works, and those like me. I may try something once, but if it’s too much work, or if it doesn’t work, I won’t even consider trying it a second time.

Last weekend my wife and I did the grocery shopping. Not my favorite activity, but there I was pushing the cart.  We shop differently from one another.  I approach grocery shopping in much the same way a NASCAR pit crew approaches changing refueling and tires.

Speed counts. Efficiency counts.  Up one aisle and down the next.  Bypass the aisles I don’t need to visit.  No grazing. Not stopping to view the items highlighted by flashing red lights.  I don’t pause to taste the toothpick-skewered mini pigs-in-a-blanket offered by a maternal-looking employee.  Squeezing tomatoes to test for ripeness is forbidden.

And if someone unaware or indifferent to my need for speed, parks their grocery cart in the middle of an aisle, blocking my path, a cold sweat appears on my forehead, and my eyes are sweeping the aisle to hunt down the offender.

Anyway, back to my wife and me.  My wife does not shop the same way I do.  She’s not into NASCAR. She’s a grazer.  She approaches shopping with the notion that if the store thought an item was important enough to sell that it is probably important enough for her to view.  Grocery stores have lots of items.  I do not have lots of patience.  No sooner had we made it past the fruit and vegetable supplies the blood pressure app on my watch was sending me alarms.  While she was searching for something skewered on a toothpick to taste, I was looking around for a rest area for husbands, thinking perhaps I could watch an entire baseball game and take a nap while she grazed.

We had finished our shopping and went to pay for our groceries.  She immediately directed me to push our cart to the self-checkout aisle.  I tried to warn her off.  “Those things are a waste of time,” I told her.  (Did I mention patience was not my strong suit?)  I began to turn the cart towards a checkout line that had someone with a pulse to scan out items.  In a flash, she blocked my path and gave me the look.  You know the look—nice try, but we are doing this my way.  I demurred.  Big mistake.

There we were.  Us against the self-checkout scanner.  And then she reached into her purse and withdrew the envelope—the envelope with the coupons.  Coupons take time, and they require the patience of a saint. I was so far back in the line for canonization that it would require another two or three papal conclaves before I might hope to see the front of the line.  (Did I mention patience was not my strong suit?)

The self-checkout process failed at the scanning of the very first coupon.  She pushed the button to ask for help.  A red light flashed above our register.  The store’s hallway monitor made her way to our register, inserted her fail-safe key, and the red light stopped flashing.  The monitor began to return to her station.

I did not want to see her leave us alone and helpless.  I begged her to stay.  “We both know this is not going to go down well.  She has more coupons.  We have fruits and vegetables that do not have barcodes that can be scanned.  We are going to be here for hours,” I whined.

“If you think you are going to need that much help, you should go to one of the lines where there are checkers.”

I looked at my wife. The expression on my face was one of pleading.  The expression on her face was one I knew well—get over yourself.  At this point, I would have been calmer had I been giving myself a root canal.  Feeling like my head was about to explode, I again started to look for the rest area for husbands.  Other husbands were doing the same thing.

Two kinds of people.  People who believe processes are supposed to work and people who know processes won’t work.

Those kinds of people bring those same aspirations and prejudices to healthcare.  Some believe that if they go to their health system’s website enough times that sooner or later they will be able to do what they need to do.  That if they call the call center enough times that someone will be able to help them.

And then there is me.  You get one chance to meet my expectations, to give me the experience I want.  I am not going to beat my head against a wall hoping that things improve.  Fool me once, shame on you.  Fool me twice. Shame on me.


Why Is A Patient Portal So Ineffective?

Not all my meetings with health system leaders go as well as I might have hoped.  I was in the mode of part mad professor, part merry prankster. However, I tried to appear polite. I sat upright and placed my hands on my knees like I was sitting in a pew.

“You know what year it is, right? It’s the future.” I told the health system’s call center manager.

“As much as I might like to hear about the future you come from, I’ve got a hundred people on hold who want to talk to us.”

“Doesn’t that suggest that you have a problem?”

“No one knows if that’s something or nothing.”

“You should put those words on a patch for your employees to wear.  Like a motto on a scroll below two crossed question marks. Since you don’t have a CRM system, if you need to call someone back, how do you find their number?” I asked her.

“We look them up in this phone book.”

“Why is the phone book on a chain?” I could tell she was getting tired of me interrogating her.

“People steal them. Don’t you remember the 70’s?”

I looked around at her call center.  “You appear to be very bright.  This is customer experience, it’s not like splitting the atom.  Judging from what I see here, this place is still waiting for the 70’s to arrive.”  Knowing that I was never going to get her to jump ahead even to the decade of faxes and pagers, and judging that my time had expired, I turned and ran for the door, lest I got swallowed up in healthcare’s version of Back to the Future, Part Deux.

So that was my day.

Many health systems believe their patient portal is a big step towards meeting the needs of consumers.  This chart should put that belief to rest.  Patient portals exclude most consumerism needs and experiences.  They exclude (RED) non-clinical needs, most of the people who have needs (non-patients), and when most of those needs occur.  And for those health systems who continue to believe that their call center is consumer friendly, the fourth pie-chart shows that the typical health system’s call center is closed three out of every four hours each week.

Patient Portal Failures

My Healthcare Consumerism Strategy Podcast

Healthcare Compliance Solutions invited me, as a subject matter healthcare consumerism expert, to be interviewed.  In the podcast, I cover the issues around how to improve consumerism, access, and engagement for all health stakeholders as a way to drive accountable care, population health, and wellness.  Here’s the link:

Healthcare Consumerism Podcast

Healthcare Consumerism: Why Is Google Smarter Than We Think?

I went to Google’s homepage and something finally occurred to me, something I’ve been looking at and using for over a decade.

Type in ‘Google’ and you will see what had me so vexed.  I often wondered, why would a company which controls most of the World Wide Web’s users have given so little thought to its home page?

There is only one thing to do—enter something in Google’s search bar.  And that one thing lets you do everything Google does and everything that every other company or individual does or has done. I bet it took Google months of design to decide that the simplest solution was the best solution.  Googe probably started the design of its landing page with dozens of links simply because they wanted to show how much they had to offer.

Then the many became one.

It controls the world by giving control of everything anyone may want to do to you.  And, here’s the nifty bit.  Everything for everyone, every time, at any time, and on any device.

That is exactly like my mantra for healthcare: a remarkable experience for everyone, every time, at any time, and on any device.

Now let’s compare how Google presents user experience to its users to how another internet leviathan presents user experience—Amazon.

Amazon’s page has too many things to do.  Google’s page only lets you do one thing.  And what do 99% of Amazon’s users do?  They bypass all the extraneous stuff and type what they want into Amazon’s search bar.  They opt for the experience they learned by using Google because they know that doing so gives them what they want, every time they want it, at any time they want it, and on any device, they want to use.

Amazon’s homepage is a kluge.  There are a million links to click on Amazon’s landing page.  In fact, Amazon’s landing page looks like most health systems’ landing pages—a million choices.  But here’s the difference between the landing page of a health system and Amazon’s landing page.  A health system’s landing page has a hundred or more clickable links, but only think that happens when you click one of those links is that you are transferred to another page with dozens of clickable links.  And so forth and so on until you hit a dead end.  You never get to a page that lets you do what you wanted to do.

Health system web pages are all hat and no cowboy.   Instead of employing a=the design concept of the many became one, health system’s website adopted the axiom that the many became many more.

Google’s entire business model, its entire company, its entire suite of offerings are available in a simple search bar. Google is all clicks and no bricks.

Health systems are the opposite. Not a single aspect or function of a health system is available online.  A health system’s human-centered digital design strategy is all clicks and more clicks.  There is nothing there, there.

Health system websites do provide a user experience.  They just don’t provide a good one.  The user experience is not helpful to users, consumers, or patients.

Two types of users go to a health system’s website.  Patients, and people who at some point may become patients.  Health systems should try to create two experiences–on for patients and one for people who at some point may become patients.  Designed correctly, those two links will include everything its users want and nothing they don’t.

Instead of asking, ‘what else can we add to our website,’ health systems should be asking, ‘what can we get rid of?’

And that is why people may go to several times a day and why they may go to your health system’s website only once a decade.

The other brilliant feature of Google is that the user functionality of Google is exactly the same whether it is displayed on a three-inch mobile screen or a fifty-inch plasma screen.

Do you wonder why that is the case?  Once again the answer is very simple.  On average, people are within three feet of their mobile device twenty-three out of every twenty-four hours.  All of Google is never more than an arm’s length away from its users.

Your health system, even the best health system is a phone call away, Monday through Friday, from 8 a.m. until 6 p.m.

And that is why patient and customer experience and access and engagement are so poor and out of date.

What Is Your Digital Healthcare Consumerism Score?

I was standing at a busy intersection clicking my heels and repeating the phrase “there’s no place like home.”

A young woman approached me and tapped me on my shoulder.  She had a Kim Jong Un wannabe haircut.  Her heavily tattooed legs were wrapped from her thighs to her ankles in cellophane, and she had more metal in and on her body than the Tin Man.  The cellophane confused me.  I thought she might be using it as a degaussing cloak to ward off alien magnetic rays.  She asked me if I was okay. I should have asked the same question of her. I learned later that cellophane is applied to people with new tattoos to prevent the tattoos from bleeding.)

“Are we in Oz?” I asked.

“No, we are in Los Angeles.” “Is there a difference?” I asked—I can be quick when I need to be.

Most of the major streets in L.A. have what appear to be three-foot natural grass putting greens embedded in the sidewalks.  But I never saw anyone practicing their putting.  I did, however, see several dogs use the greens.  I wondered how city dogs—dogs who have never seen real grass—knew that the putting greens were for them.

“I’m sensing you’re a man of few words,” she said.  “I only use the ones that are needed,” I told her.

“So, what do you do?” she enquired.  Thinking this conversation could take more time than I had, I replied “whatever it takes” and I left the scene.

Rule number 1: If you Google something and get no hits, whatever you Googled does not exist. I Googled “Healthcare Consumerism Score.”  Zero hits.

Rule number 2: Just because you get a hit when you Google something does not mean that what your search yielded has any value. I Googled “Healthcare Consumerism Index.” 1,030 hits.  950 of them from a single firm.  And those 950 hits offer 950 uninteresting ways of trying to make their survey data sound interesting. If you are interested in reading about cost and value spending—how they define consumerism—you should get a copy of their report.  Me? I’m waiting until they make it into a movie and stream it on Netflix.

And here is my issue.  Who is interested in cost and value spending?  Health systems and the feds; not consumers.  Consumerism without consumers is no better than a tuna sandwich without the tuna.

I’ve asked dozens of healthcare executives how they define consumerism.  They don’t.  I’ve asked those same executives how they measure the consumerism capabilities of their systems.  They can’t.

And so, I’ve created the Digital Healthcare Consumerism Index—DHCI.  The index measures one attribute.  What are the digital consumer capabilities of your health system, and if they exist, how good is the user-experience?

The DHCI measures eight specific digital consumer functions, plus a mobile-first rating and rating for user experience.  Your health system either provides the function, or it doesn’t—that keeps the math pretty simple.  In theory, the scores will range from zero t0 ten.  (But who am I kidding?  I have only come across one health system that scores above a five.)

In the artifice of healthcare consumerism, a fifty percent score puts you on the top of the food chain looking down on every other health system.  “We’re better than everyone else.”  Maybe it’s good enough to be the best of the worst.

In real world consumerism, the world in which your consumers and patients live, a fifty percent consumerism score has your health system looking up at such notable consumerism failures as RadioShack, Borders, and Sears.  Healthcare consumerism needs to improve significantly just to be good enough to meet the failure threshold achieved by Fortune 500 firms.

The digital consumerism mantra—bricks to clicks—is simple, but it is simple for a reason. It works.  The consulting firm McKinsey concluded that the greatest healthcare myth is that customers do not bring the same expectations about customer experience to healthcare that they do to other industries.

The phrase “I’ll know it when I see it” was used in 1964 by United States Supreme Court Justice Harold Potter in describing his threshold test for obscenity in Jacobellis v. Ohio.

Patients and consumers use the same metric when it comes to healthcare consumerism.  They’ll know it when they see it.  So far they haven’t seen it.