So, I’m about to take the test to get my Oregon driver’s license. Unlike the other forty-nine states, the Oregon test gives the applicants a chance to earn bonus points or to lose points. If you have a tattoo, add one point to your score.  Body piercings are worth one point.  Green, blue, or purple hair is also worth one point.

If you voted for Trump, subtract five points. I was at negative five points before I answered the first test question. Knowing I had nothing to lose, I stood in the middle of the room and yelled, “Make driving great again!” Minus two more points.

A man who works at a manufacturing plant that makes items for hardware stores is suspected of stealing from his employer.  Because he is under suspicion, each night he when leaves the plant, the guards search him and the wheelbarrow he is pushing.  In the wheelbarrow is always his lunchbox, thermos, hardhat, safety glasses, and overalls.  They never discovered any stolen property.

It never occurred to the guards that the man was stealing wheelbarrows—sometimes the answer is too obvious.

Customer experience is a bear.  Sometimes you eat the bear.  Sometimes the bear eats you.  If Comcast’s or Verizon’s customer service people went on strike, would anybody notice?  Sort of like the question, if a tree fell in the woods, and nobody was there, would it make a sound.

The front-page banner on a recent issue of Men’s Health Magazine read, “Tons of useful stuff.”

In healthcare, none of the provider or payer websites or apps can even brag, “Here’s a half-dozen things that may be useful.”  To be even more accurate, the only four semi-useful things I’ve found on healthcare websites are:

• Pay your bill
• Find a doctor
• Requestan appointment
• Contact us

A pretty lackluster set of functionalities.

Your website may look pretty, but so does Monet’s painting Sunflowers.  The thing is, you can’t schedule an appointment with either of them, so pretty isn’t worth much.  If you’re confused, that’s okay, I’m not.

Patients and customers can find a cloud in each of what your health system believes are its silver linings.

Many thanks to those of you who have been such steadfast followers over the years of my regurgitations of the gossamer voices which continue to disrupt my waking moments.

It’s statements like that which explain why so many clinical psychologists continue to read my musings. Apparently, several them are in an online chat group whose singular mission is to assess my mental acuity.  There’s a specious rumor being floated that the oddsmakers in Las Vegas are taking bets as to whether I am an idiot savant or just an idiot.

I started running again last week after four months of waiting for my meniscus to heal. Normal humans would probably start off slowly; run a minute, walk a minute. But it appears that Mr. and Mrs. Roemer raised a particularly hardy breed of idiot—I did 8 miles today. I was encouraged by the fact that I almost passed a ninety-year-old woman.  Even though she smoked me during an uphill part of the run, I was comforted by the fact that I looked good in my running uni and Ray Bans.  By the time I finished the eight miles, every part of my body hurt so much that I couldn’t even tell that I had a meniscus.

Segue.

The woman walking from the hospital should have been watching where she was walking rather than speaking on her phone.  She did not see the sinkhole until she fell into it, at which point she could see it in detail.  The doctor, upon seeing her in the hole asked if she was okay.  Learning that she was in pain, he wrote her a prescription and dropped it and a pen into the hole.

A few minutes later the hospital’s director of revenue assurance walked past the hole.  She too inquired about her health.  He opened his briefcase and dropped an insurance claim form into the hole.  You should complete the form, but I don’t think having fallen into a sinkhole is covered under your plan.

The chief patient experience officer happened upon the woman and wanted to know what had happened.  Speaking with her for a few minutes, he asked the woman: how was your experience with us prior to falling in the hole?  “Would you mind filling out this patient experience survey?” He asked.  He tossed the survey and a pen into the hole and left.

The woman considered her predicament.  She thought, at least I can occupy my time by filling out the forms until I am rescued.

A consultant looked in the hole.  He went by the moniker, the Voice of Reason.  (You can buy Voice of Reason t-shirts during the intermission.)  He assessed the situation and jumped into the hole.

“Now we’re both stuck,” she said.

“That’s okay,” I told her.  “I’ve been in this hole before and I know the way out.”

If you try to recast consumerism and access and engagement and experience on your own, you may find yourself in the same position as the woman.  A lot of meaningless assistance.

My experience tells me that most efforts to improve consumerism are done without any knowledge of what their efforts should look like when they are done.

Here’s a big hint. If you design it correctly, and you must design it, it should not look like anything.  Consumerism, access, engagement, and experience should be ninety-nine percent invisible to your patients and consumers.

That ninety-nine percent should all be behind the scene.  It should be built into your consumerism architecture and platform.  The one percent seen by the patients and consumers is the hands-on user experience.

It helps if you think of it this way. Consider your tablet or phone and the underlying operating system—iOS, Android, and Windows.  Your devices are easy to use.  Their use is intuitive. What you see is the one percent.  Far more than ninety-nine percent of what makes them easy to use is invisible.  The hardware, the architecture, the processes, and the applications were designed.

And users were involved in every step of the design. It is called human-centered-design. Users knew the design would meet their needs and be simple to use before a single line of code was written.

The good news for healthcare consumerism is that a lot of the challenging work has been done for you.  The devices and the operating systems already exist.  The only remaining task is for healthcare to define what it wants to do with those tools.

Healthcare can design an experience for patients and consumers on those devices that can do everything they want, and it can be designed in a way to give them the experience they want.

Healthcare has almost everything it needs to recast consumerism.  The only thing missing is defining what it should look like when it’s done and someone with the will to do it.

Jump into the hole with me and we’ll figure this out.

I mentioned that I moved to Portland, Oregon. When I landed at PDX, I told my friend that the number of Republicans in Oregon had just doubled. If you’ve ever added a drop of oil to a solution of vinegar and water you may recall that the vinegar and water seemed to run away from the oil. I was Portland’s drop of oil, and no amount of shaking was going to result in a vinegarette.

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.

I just moved to Portland, Oregon. Nobody here has a tan. I’ve discovered twelve new species of moss. It’s the only place I’ve run where I’ve seen moss growing in the streets. I’ve been thinking of getting a dog but I’m concerned that when I let him outside that if I leave him out too long, he’ll come back green.

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.

I have developed a certain affection for the television shows Survivor, Naked and Afraid, and Life Below Zero.  If you are not familiar with the shows, their premise is to determine who among the contestants has the inventiveness and mental toughness to exist on a diet of insects or to live when the average temperature is forty below zero.

Having slept on the glacial face of a volcano at seventeen thousand feet, I fancy the notion of competing on those shows.  Give me a piece of twine and a pull-tab from a can of soda and I will build the iPhone 12.

So, last summer our power was out for four days because of a thunderstorm.  Instead of having to hunt narwhals while wearing nothing other than my skivvies—don’t try to picture that in your mind, I was ensconced in my home; no air conditioning, no television, and having to fight my way around obstacles at night with nothing to guide me other than my wits and the light from me cell phone.  The showers were cold, my soft drinks were warm.  I survived the first two days with nary a scratch.

By day three the lettuce was wilting and so was I.  I reflected on my not too distant halcyon days, days when I could sit in my air conditioned home and watch television shows about people trying to survive in a Brazilian rainforest eating grubs.  It was then I decided that were I able to survive my own odyssey I would put aside my dreams of living a wilderness adventure and make due with mowing my lawn.

I have no segue for this post, so here we go.

Chances are your health system’s website is a clunky old thing designed by the elderly (people over the age of thirty.)  The time to rethink what you want out of your website has come and gone; that train already left the station.  The only way to play catch-up is to dump the sclerotic vision that defines your online presence, and figure out what your stakeholders expect from it.

People who visit your website have an experience, they just have a good one.

The best way to not have to measure patient experience is to design such a good, interactive online experience that measuring it would be redundant. Design these things into your website and you will have the most progressive health system on the planet.

• If half of your callers would rather have their needs met online, figure out how to let them do that. If you don’t know what they want to do online, ask them.
• If half of your patients will seek a second opinion, give them a link telling them why they should stick with you
• If half of your competitors’ patients are seeking a second opinion, give them a link telling them why they should pick you
• If twenty percent of your callers have questions about their bills, use co-browsing and online videos to explain your bills
• You know your patients are going to dispute their reimbursement, show them how to do that on your website; make videos explaining payer by payer how to do it
• If a percentage of your patients want to speak with a clinician, make sure they can. Heck, make sure they can do it at a time convenient to them, which probably will not fit the hours of your call center.
• If every single person who visits your website is either a patient or a potential patient, tailor all of its functionality to them—get rid of the other eighty links; links about the gift shop and posting baby photos online
• If you have a scheduling center instead of a real call center—80% of your calls are not about scheduling—create a real call center.
• Put a chat function on your website—how may I help you—and delete that silly contact us box that promises a response before the next full solar eclipse
• Let callers on hold enter their phone numbers instead of having to wait, and have the next available agent call them back
• Let call center agents email callers
• If someone contacts you through your website, respond to them within an hour
• Let people schedule appointments online
• Since a lot of people who are considering buying healthcare from your system visit your website, give them something to do when they get their—how about a customer portal where nonpatients can store and track their health data like they do with apps on their smartphone, a portal whose data you can monitor.
• Since only a fraction of your callers and website visitors are in your EMR, make sure you can meet the needs of everyone who isn’t—those people are called customers.

Prevent people from leaking at the start of their experience.  Design an experience focused on keepage, not leakage.  None of these features are difficult to accomplish using current technology.

If you do all of these things you will never have to worry about measuring patient experience.  You will already know it is great.  And maybe then we can ask why everyone in Washington is so concerned about building a wall to keep out the Canadians.

Last week I received an email from my dentist letting me know that I was due for a checkup and that I could schedule it on their website by clicking the inserted link.

Yesterday I received a postcard from my eye doctor asking me to schedule my annual eye exam, and letting me know that if I scheduled it in the next two weeks I would receive a twenty percent discount on either contacts or a pair of glasses.

Today I received an email from Chem-Lawn reminding me to schedule my fall fertilizer treatment, and an offer to receive a thirty discount on next year’s service if I prepaid for it this year. I received a similar email regarding the health of my car.

Everyone wants my business.

Well, almost everyone.

And they are not only making it easy for me to buy from them, they are unabashedly flaunting me with rewards for buying their services. Why are they doing this? They want to prevent me from having bad teeth and bad eyesight, a lawn full of weeds, and an unhealthy car.

Healthcare isn’t able to communicate on a personal enough level that it is interested in my weeds or teeth. While healthcare has many proactive initiatives, healthcare has not figured out how to connect those initiatives to you and me at a level that causes us to act. We act when we are ill.

Healthcare’s strategy is straight out of the 1970s; mailers, billboards, Stepford Wives-like commercials, and outbound telemarketing calls. If you do not understand history you are destined to repeat it. How well is that working?

And that about sums up everything you need to know about why, under its present course, healthcare is at least a decade away from being able to do anything more than just talking about population health, accountable care, and wellness.

Just saying you are a digital healthcare company or a population health company does not make it true.

Healthcare marketing needs a do-over.

There are probably tens of millions of people who would pay a healthcare provider or payer or national retail pharmacy to manage their wellness. But there is not a single firm selling wellness.

Until then, healthy people will keep getting sick. The only good news out of all of this is that when we get sick we will have good teeth, great vision, weed-free lawns, and cars that work well enough to allow us to drive to the doctor.

Since nobody wants to sit through having to read twenty-three of anything, I’m going to try to make this easy for each of us.

These are a few of Roemer’s Healthcare Axioms:

• Axiom 1: Nobody knows what it costs to acquire a patient
• Axiom 2: Nobody knows what it costs to retain a patient
• Axiom 3: Nobody knows what it costs to prevent leakage—heck, nobody even knows if someone leaked; before treatment, after treatment. Leakage is one of life’s great mysteries
• Axiom 4: Patients and members, both new and existing, will tell you that healthcare marketing has zero impact on who they choose as their provider and payer
• Axiom 5: Providers and payers will continue to play a zero-sum game, spending money on marketing campaigns that do not resonate with anyone outside of marketing

So, here’s how I got to the number ’23.’ (You can come up with your own number using this same approach.)

I started thumbing through this month’s issue of Philadelphia Magazine, and I was gobsmacked by the number of full-page healthcare ads, so much so that I felt the need to count them. By the time I reached page sixty-six I had counted twenty-three ads.

Four providers and two payers paid for those twenty-three ads. Doing the math—four plus two, divided into twenty-three—indicates that each organization marketed to the magazine’s readers about four times in the first sixty-six pages.

I took some time to reach each ad, and to ask myself if there was anything in any of those ads that would compel me to take action. There wasn’t.

It is worth noting that all of the ads had the same look and feel. It was almost as though all of the marketing departments, independent of their firm, operated from the same marketing omnibus—it means compilation—of acceptable healthcare marketing strategies.

The only difference among the ads was the name of the institution doing the advertising. The ads each pictured one or two animated and healthy people having the time of their lives. The people were frolicking, picnicking, biking and jogging. They were carefree.

I suppose the ideas behind the ads were that even if you had cancer, that if you brought your cancer to one of these organizations, you could be frolicking by the time you finished reading the magazine. The ads do not show someone with any hair connected to an IV dispensing cisplatin. Perhaps the thinking is that ads about frolicking are preferable to ads about cisplatin.

The same kinds of ads are on billboards and on television. They are in your mailboxes and mine. If every healthcare organization is pitching the same message, is the effect on consumers the same as if they had pitched no message? I think it is. I think consumers think the same thing.

I am willing to bet my neighbor’s BMW that not a single reader of the October issue of Philadelphia Magazine will be influenced one iota about who to choose as their provider or payer based on a magazine ad, a billboard, or a television commercial.

If you want to get my attention, tell me that you designed a tool that will help me manage my care and wellness. Don’t give me frolicking. Give me care and then I will care.

I am amazed at the speed at which most of the world changes.

When I was young, drinking-water was free, and our rotary phone was attached to the kitchen wall.

We used to get two newspapers a day; the Baltimore Morning Sun and the Baltimore Evening Sun. As a result, we knew everything that had happened in the world before ABC, CBS, and NBC televised the evening news at 7 p.m.

Our television set was a piece of furniture the size of a dishwasher. To watch the television we had to adjust the rabbit ears to try to get the picture to stabilize. During storms, sometimes we had to attach a piece of aluminum foil to the antenna to stop the picture from fading. If we wanted to watch one of the other two channels, someone had to walk to the television and turn the selector knob. To be fair, rumor had it that there was also a UHF channel. That channel came with its own non-functioning antenna, but I never met anyone who was able to get the picture clear enough to watch.

Even so, we also watched the news, and when Walter Cronkite went from black and white to color, I knew technology had just about peaked. And then came portable television—television on wheels. Instead of something the size and weight of a chifforobe, televisions were so miniaturized that they could fit on a wheeled cart and could be moved from room to room. Naturally, we did not have to worry about connecting it to the cable outlet because there was no cable.

Next to the portable television, on the end table, was a spiral-bound, paper AAA map with the directions to get me from Baltimore to Vanderbilt in Nashville—stone age GPS.

As an aside, it occurred to me that the practice of healthcare and the practice of law have a lot of similarities—however, people don’t call having a thousand doctors on the bottom of the ocean a good step. The greatest commonality is that nobody wants to engage either a doctor or a lawyer until it’s already too late. I guess though that telling a lawyer that you were thinking of robbing a bank would garner about the same reaction as telling a doctor that you were thinking of taking up smoking.

So, back to the fact that many years ago what we thought of innovation as consisting of tap water, a morning and evening newspaper, color television, and a TV on wheels.

Almost everything has changed since then because of the rate of change of technology.

Almost everything.

I went to the hospital to get an MRI on my knee.  The clerk inserted a three-part carbon firm into her IBM Selectric typewriter and typed my admissions data.  I was instructed to go to the waiting room. A woman dressed like June Cleaver rolled a black and white television into the room and turned on the Get Smart. She told me there was bottled water in the avocado-colored refrigerator and that if I wanted to make a call, the phone was on the wall next to it.

The song from the Archies, “My Heart Went Bang-Shang-A-Lang” was playing on my transistor radio. I reached down and retied my Converse Jack Purcell sneakers. And folded neatly next to me, on the end table, was a copy of this morning’s newspaper and a spiral-bound map from AAA.

The business model of healthcare never left the 70’s.

McKinsey wrote in—Enabling Healthcare Consumerism—that consumers now control more than $330 billion of annual out-of-pocket healthcare spending and “the choices they make have the potential to affect 61% of all healthcare spending”.

That single statement is all one needs to understand to know why

This is a direct result of the large increases in the average deductible.

What does this mean for providers?  It means I decide what services I purchase and from whom I purchase them.

In the same paper, McKinsey found that over eighty percent of the people they surveyed believed digital solutions are the most effective way to perform healthcare activities.

Kaufman Hall’s “2017 State of Consumerism in Healthcare” reported that ninety percent of providers replied that improving the consumer/patient experience is a high priority, yet only eight percent of health systems stated that they have implemented some digital consumerism solutions with some demonstrated success.

The report went on to say, “Building digital capabilities should be integral to organizations’ efforts to improve the end-to-end consumer experience, yet many are taking a more siloed approach that is disconnected from a broader consumer engagement strategy”.

So, what do we know?

• Consumers control 61% of healthcare spending
• Over 80% of consumers want to manage all aspects of their healthcare digitally
• 90% of providers call consumerism a high priority
• Only 8% of providers are actively trying to implement digital consumerism solutions

Why is digital consumerism a business imperative? An article listed many internal provider business drivers of consumerism.  And there is the underlying failure point.  Consumerism is being driven by only one thing—consumers.  By the +80% of the people who want to access and engage digitally.

The underlying unmet business driver is the need for providers and payers to understand and meet consumer expectations.

There is a great disconnect between the discussion of patient experience and the discussion of consumerism.  Patient experience initiatives do one thing.  They measure, “How did we do when the patient was receiving care?”

Patient experience initiatives do not include any of the experiences patients have pre- and post-treatment.  They do not include any of the experiences of consumers—prospective patients.  And they do not account for anyone’s expectations.

There are more than 165,000 health-related apps on iTunes that do 165,000 different things.  iTunes is where people go to manage their health.  Get an app.  Get several.  And they go to the web.  The one place they do not go to meet their health needs is to your health system’s consumer portal and the reason they don’t go there is that your system doesn’t have a consumer portal.

Consumers, patients, and prospective patients are the new payers.  They are your customers and prospective customers.  Consumerism is the same thing as customer experience.  People who understand this know that consumers are not happy with what they are experiencing.

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

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

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

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

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

Did I mention that I am the Senior Hallway Monitor?

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