Patient Experience: Does it all come down to wearing sensible shoes?

The plane’s preflight music was Celine Dion, and i felt my IQ beginning to drop. Her music has the same effect on me as a Vulcan nerve pinch, making me want to curl into a fetal position. Given the choice of having to listen to an entire Celine Dion CD or sticking finger in an electrical outlet, I would give the outlet serious consideration.

Men are to talking about golf the way their counterparts are to talking about sensible shoes, only worse. Personally, I would rather listen to the discussion about espadrilles. Case in point. The gentleman on the flight. His shoes looked like they were woven from the skins of chicken ears.

“I was playing the thirteenth hole at Augusta…”–or some place, the place didn’t matter to me any more than what followed.

“Do you play?” I nodded. “What’s your handicap?”

“My swing,” I said. He smiled at me indulgently, like Ward Cleaver might have looked at June if she had accidentally dropped a brownie on the new carpet.

“The hole cat-legged to the right, and I have a natural slice. And there were three bunkers about a hundred and eighty yards out, hidden by a berm at one-seventy. You can sense my problem, can’t you.” I wanted to tell him that I did, and that it wasn’t anything that counseling couldn’t correct.

“I had my three-wood and I was playing a Titlest Pro–and you know what that means. The temperature was eighty-one, a ten-knot headwind, and the humidity had to be thirty-four. And since there was a waning moon, gosh only knows what that was going to do to the rotation of the ball once it reached altitude. I can’t even begin to tell you how nervous I was about having to figure in the curvature of the earth on the flight of the ball.”

“What kind of shoes were you wearing?” I asked.

I’ve read novels about the training snipers undergo to learn how to calculate the flight of a bullet and it seemed a lot less complicated than what this guy had to consider with his golf ball. I deja-vued to the scene in the movie “Airplane” when the woman seated next to the film’s protagonist on the plane hanged herself rather than having to keep listening to the whinging of the man next to her.

Not wanting to hear about the other seventeen holes, I pulled out my laptop, plugged in my earbuds, looked out of the plane’s window and tried to determine what affect the curvature of the earth would have on my writing. Negligible.

When I ponder the complexities of healthcare I wonder why payers–the dark side, and providers eschew fixing the easy problems. Population health management, ACOs, and the Affordable Care Act–the oxymoron is theirs not mine are very complex issues affecting both parties. These issues mandate that a lot of their strategic initiatives should be planned on an Etch-A-Sketch using a wije-board. Goodness knows how you run a business effectively when weekly Washington is firing SAMs at your attempts to figure it all out.

Just what are the easy problems being overlooked? Patient/Customer/Consumer experience.

Payers are going from a B to B model to a B to C model. Raise your hand if you enjoy calling your insurance company. Can you imagine what it will be like trying to get someone to talk to you in a retail insurance market? “The average wait time to speak with an agent is expected to be three-and-a-half weeks.” Payers should Google the word “churn.” People are going to be jumping off of that bandwagon like fleas off a dog sporting a new flea-and-tick collar.

Providers are starting to wonder where there next dollar is coming from. Clinics stole away many of their most profitable offerings, so they’ve been trying to add primary care providers (PCPs) to lock in revenues. Retailers (think CVS and Walgreens) hijacked many of the most profitable and most frequented offerings of the PCPs, so we can say goodbye to those revenues.

With that being the case, it would seem sensible to focus on any strategy that might help retain patients, customers, and consumers. Gone are the days when a provider could say “we don’t have customers, we have patients.” Without paying attention to the experiences and expectations of whatever you call them you will have neither.

The value payers and providers place on customers is very different from the value customers place on payers and providers. And the value gap is getting wider each time either organization fails to answer its phones, and fails to provide a way for a customer to complete their business online.

People need two things from their provider–they need to get better, and they need to be able to do business with their provider. With payers they need their claim to be covered and they need to do business with their payer.

Currently, the only way to do business with either one is to call them. And the people who have to make those calls would rather sit and listen to someone talk about golf than having to call.

Since neither business will ever provide a service that enables people to conduct all of their business needs correctly, one hundred percent of the time without being placed on hold or transferred to someone else who will not be able to help them, why not design a customer portal that can meet correctly, efficiently, and effectively all of their needs every time?

It all comes down to access.

A remarkable experience for every person every time on every device. It’s not a pipe dream, it’s a requirement.

Stay safe my friends, and may all of your shoes be sensible.

Is the term “Payor” healthcare’s oxymoron?

One of the great things about fall is that as I prune back the vestiges of my virtual garden I am able to collect basketful upon basketful of overly ripe metaphorical tomatoes, perfect for tossing at aberrant analogies and inappropriate idioms.

It’s a curious time.  We give away money to the middle class and rich so they can upgrade their BMWs on the backs of the poor.  The feds market that idea as though that pittance will either jump start the economy, or to hide the fact that that the administration has managed to budget for a nine trillion dollar deficit gap over ten years.

By now we know there are no quick fixes, no magic formulas for fixing the economy.  Finding a formula that works will be more difficult than learning how to neatly fold a fitted bed sheet.

“Is it the essential paradox of the age of Obama that we have to destroy the village in order to save it, bust the budget in hopes someday we’ll balance it?” Nancy Gibbs, Time, September 9, 2009.

“It takes an idiot to raze a village.” Paul Roemer, today.

Congress is trying to decide what the final bill will look like without ever having read the first draft.  How will we know when they have something that makes sense?  Do we watch the Congressional chimney to see if the smoke is white or black?  Does that mean we have a bill, or is it simply that the chef burnt the Peking Duck?

Then there are the payors.  Get me started, or don’t.  We all know that one of the driving factors for reform is the behavior of the payors.  A friend asks—for full disclosure I note that she is one of “them”—why do people view health insurers differently from auto, life, or home owners insurance.  She was serious.

Here’s my take on the answer.  If the health insurance firms provided life insurance they’d be exhuming the deceased and trying to prove they weren’t dead.  Car smashed, get a check.  House leaks, get a check.  Die, get a check.  Need surgery.  Not so fast.  Let’s see if you’re covered for that.  If not, whew.  If yes, let our doctors decide if you really need the surgery.  It won’t cost you a minute of your time as our doctors don’t even need to examine you.  You see how this plays out?

It happened to me after my heart attack, albeit with my disability payor, sort of the evil step sister of the health side.  My doctor put me on six months disability, naturally, the payor declined to pay.  There doctor, who never examined me decided I was fine, at least that’s what their letter stated.  How do we know these doctors even exist?  Have they ever been seen in the daylight?

Most Americans don’t believe that insurance companies are interested in helping people.  They like us fine when people are payors.  They are much less fond of us when people become patients.  It’s a simple matter of flow theory.  As long as the flow of cash is in-bound, all is well.  When people move to the dark side, from payors to patients, payors have no patience.

Is there anyone who believes that there is a single payor in the country whose mission statement says anything about doing all we can to help those who need us?  Of course not.  Payors have claims adjusters.  What is their role?  It’s certainly not to adjust the payment higher.

Do payors incent their employees to pay out as little as possible?  I believe they do.  Do payors penalize or retrain people who pay out too much?  I believe they do.  Do they design the claims and dispute process so as to make it so cumbersome on patients and doctors that parties give up prior to settling?  I believe they do.

I believe the payor business model is not much different from that of tobacco companies.  For years tobacco firms claimed there was no public evidence to support the fact that nicotine was addictive.  It turns out they buried the evidence.  Payors claim they are not bad actors.  Some claim the moon landing was faked.

I am a firm believer that pictures can sometimes convey more than mere words.  To me, this link explains a lot about what’s wrong with healthcare.

http://www.youtube.com/watch?v=Z7Forzj5-O0 Start playing at 6 minutes and 40 seconds.

EHR: Got a few minutes?

Before we get started…I am on the plane yesterday, sitting in a middle seat.  An attractive woman fights her way down the aisle and sits next to me.  Five minutes later it happens again.  I felt like I had just won the USAir lottery.  The man who sits directly in front of me looks like the Taliban’s Mullah Omar, including the black turban.  Across the aisle is a screaming four-year-old.  For a second, I thought about executing a Jet-Blue exit strategy and deploying the emergency exit slide.

At a business dinner last night, we got into a conversation about driving habits.  The young woman across from me was explaining an incident for which she was pulled over for driving 94 miles an hour in her convertible Mercedes.  When the police officer asked her why she was driving so fast she told the officer she was trying to dry her hair.

Let’s roll back a few hours.  Got the time?

I am sitting at the airport holding my two two-dollar bottles of water scanning my options from among the array of shops.  Fast food.  The guy sitting across from me looked like he was eating Jell-O made from kelp.

Sundries.   Clothing, MSNBC—when did they get into retail?  Shoes, laptop devices, every possible cell phone accessory.  A nifty collection of watches at some kiosk.

A few years back I bought a Polar watch to help me track my running.  It measures heart rate, altitude, temperature, distance, rate, laps, and tracks and calculates my average pace.  What do I use it for when I run—the time—never took the time to learn how to use the other functions?

I also have a few antique watches—the kind you have to wind.  The only thing they do is keep time.  Then there is my Tag Heuer—a name I am not able to pronounce.  It is waterproof down to 300 meters.  I quit diving four years before I even found the watch—but it seems to work well in the shower.  It appears to have more Jewels in the back than the crown of a dictator from a third-world country.

The next time you are in a meeting, or sitting across from someone, look at their watch and see if you can read the time.  You may be able to estimate how much they paid for it by how much exposure it has on their wrist.  Some watches look like they have enough gadgetry to have been a prop in a Bond movie.  Altimeter, lunar phases, time zones in countries to which they have never traveled.  The face of the watch is so decked-out with features and functions that have nothing to do with keeping time that you may as well settle for knowing the moon is waxing.

My Polar watch is an allegory for EHRs that are failing and underperforming.  Lots of features, very little utility.  EHR implementations that do well seem to be those designed to go shallow on functionality and cut a wide swath utility.  Those that go deep into the functionality and narrow on utility are gathering dust.

Is there any good news?  Sure—when you turn on the computer monitor, you’ll notice a little digital clock in the lower right corner.  You may have wasted $200 million on the EHR, but you’ll always know the right time.

Kind Regards,

Paul

Paul M. Roemer
Managing Partner, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Why is the large provider business model obsolescing?

Margaret Thatcher said, “Anyone who finds themselves on public transport after the age of 26 must consider themselves a failure.” There’s probably some sort of corollary for anyone twice that age that spends part of every day writing to imaginary people on the web.

When I write I like to pick a side and stand by it instead of standing in the middle of the road where you can get run over by the traffic from both sides. Likewise, I don’t look for consensus around an idea. Consensus is the process of everyone abandoning their beliefs and principles and meeting in the middle. When was it decided that meeting in the middle is beneficial? So, achieving consensus about a problem is nothing more than that state of lukewarm affection one feels when one neither believes in nor objects to a proposition.

Having this approach to solving business problems tends to yield a high number of critics. I don’t mind critics; those are the same people who after seeing me walk across a swimming pool would say that my walking only proves that I can’t swim. I rather enjoy it when someone offers a decidedly personal attack on something I wrote if only because it means they can’t find a legitimate business principle on which to base their argument. I love the debate, and I don’t expect anyone to agree with me just because I say it is so.

In trying to promote a different way of looking at the large provider business model, I’ve learned that it’s not possible to lead from within the crowd. The “as-is” was created by history, by followers. The future will be created by someone who believes it can be done better. I believe firmly in the notion that improving the business model by building off the current one is like trying to cure a cold with leeches.

The approach that has been used to grow the business for the last fifty years is that the hospital is responsible for everything. And yet, who is responsible for the hospital? Who is accountable for the fact that the business model is obsolescing itself?  We have loads of new stuff—expensive stuff.  No other industry can tout new and improved better than healthcare.  However, in those industries new and improved means faster, smaller, cheaper–it means adding services to reach significantly more customers, not fewer.

Each new and improved procedure with its more costly overhead has application to a smaller percentage of the health population, thereby allocating that overhead across fewer patients.  In turn, that makes the low-margin services unprofitable.  Those services will be cut lose, picked up by new entrants with lower overhead.  Those entrants will make a good business out of services discarded by hospitals.  The cycle will repeat, as it has for decades.  The profitable new entrants will move up-market.

Is it a question of scale versus scope, or scale and scope?  What happens if instead of continuing to repeat the cycle, large healthcare providers were to invert it?  What makes them more relevant, adding the capability to perform a procedure used once a month or one used once an hour?  Which is more important to the future model, inpatient care or outpatient care?  I suggest that “in” or “out” will become irrelevant.

Those phone booths in the photo used to be the way to make public calls, now you can’t even find a booth.  Maybe some day someone will take a photo of a group of hospitals stacked next to each other in a vacant lot.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Who should be able to answer these business questions?

I wrote this piece for Hospital Impact, published April 22, 2010.  (Not the title I would have chosen.)

http://www.hospitalimpact.org/index.php/2010/04/22/planting_the_seed_why_assembly_line_medi?blog=1&c=1&page=1&more=1&title=planting_the_seed_why_assembly_line_medi&tb=1&pb=1&disp=posts

Now that spring is in full bloom, I’ve been doing a little gardening. My dogs are the anti-gardeners. No sooner do I turn my back after planting something, there they are, happily digging away and ceremoniously digging it up. I don’t know if that’s because they don’t like the particular plant, or just happen to disagree with where I planted it.

Today I discovered the youngest dog uprooted a plant and replaced it with a Reece’s Peanut Butter Cup. Perhaps she wanted to grow a candy tree.

One thing that always confuses me about gardening is this: When I plant a one-gallon shrub, I dig a two-gallon hole. I place the gallon shrub in the two-gallon hole and proceed to fill the remaining one gallon hole with the two gallons of dirt lying next to it. Without fail, there is never enough dirt to fill the hole. Perhaps you can tell me what I am doing wrong.

Here is another area of confusion for me: When you walk or are wheeled into a hospital, neither you nor anyone else knows the answer to anything.

That is astonishing. Nobody can tell you:

* With whom you will interact.
* How long you will stay.
* What will happen to you.
* How it will happen to you.
* When it will happen to you.
* Who will be doing the happening.
* Exactly when it will happen.
* Whether it will need to happen again.
* What it will cost.
* What you will be charged.
* What will be covered.
* How much you will owe.

I am stupefied. How can anyone run a business like this? My daughter knows what her lemonade stand costs per cup. Wendy’s knows the cost of a bag of fries and a large Frosty. Porsche knows the cost of a Cabriolet, the cost of the shift knob, when the wheels will arrive at the factory, when they will be placed on the car, who will build it, who will inspect it, and who will sell it. They can tell you exactly who will touch the car, when they will touch it, and what those people will do to it.

The only thing anyone at a hospital may be able to tell you is whether HBO is billed separately. If I wanted to fly into space with the Russians, I would know the answer to each of those questions. The cost, for example: $50 million.

Why can’t a hospital do this? Because it doesn’t know the answers. It is not because anyone is keeping this information a secret–it’s because they really don’t know. The truly strange thing is that they seem to be okay with not knowing.

Recently, I reconnected with a good friend whom I haven’t seen in years. He is the vice president of finance for a large hospital. He used to be an accountant–a very detailed and precise profession, unless you’re one of the guys who used to do Enron’s books. (The only thing I remember about accounting is that debits are by the window and credits are by the door–if I’m in the wrong room, I’m at a total loss.) This business must drive him nuts!

And so I’ve been wondering; would hospitals be more profitable if:

* They had a P&L by patient?
* They had a P&L per procedure?
* The steps for the same procedure, say a hip replacement, were identical each time?
* They had answers to any of the questions you read above?

Of course they would!

Some areas of healthcare already discovered this tautology–Lasik, endoscopy, the Minute Clinic. Assembly-line medicine. Some people say those words with an expression on their face as though they’d just found a hair in their pasta. The office of my Lasik surgeon looked more impressive than the lobby of my Hyde Park hotel. It may leave a bad taste in the mouth of some, but for others, they are laughing all the way to the bank.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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The Spandex Insecurity—the Ego has Landed

Now before you get all upset about the sexist picture, at least read a little bit of this to see why I selected it. Yesterday morning, five miles into my run, I was feeling pretty good about myself. I had passed seven runners, had a nice comfortable rhythm, no insurmountable aches, and Crosby Stills & Nash banging away on my MP3. I don’t like being passed—never have. Some people say I’m competitive. They say other things too, but this is a family show.

I’m a mile away from my car when I see a slight blurring movement out of the corner of my left eye. A second later I am passed by a young woman wearing a blue and yellow, midriff revealing spandex contraption. Her abs are tight enough that I could have bounced a quarter off of them. She is pushing twins in an ergonomic stroller that looked like it was designed by the same people who designed the Big Wheel. I stared at her long enough to notice that not only was she not sweating, she didn’t even appear winded. She returned my glance with a smile that seemed to suggest that someone my age should consider doing something less strenuous—like chess. Game, set, match.

Having recovered nicely from yesterday’s ego deflation, today at the gym I decide to work out on the Stairmaster, the one built like a step escalator. I place my book on the reading stand, slip on my readers—so much for the Lasik surgery, and start to climb.

Five minutes into my climb, a spandex clad woman chipper enough to be the Stepford twin of the girl I encountered on my run mounts the adjoining Stairmaster. We exchange pleasantries, she asks what I’m reading, and we return to our respective workouts. The first thing I do is to toss my readers into my running bag. I steal a glance at the settings on her machine and am encouraged that my METS reading is higher than hers, even though I have no idea whether that is good or bad.

Fifteen minutes, twenty minutes. I am thirsty, and water is dripping off me like I had just showered with one of Kohler’s full body shower fixtures. I want to take a drink and I want to towel off, but I will not be the first to show weakness. Sooner or later she will need a drink. I can hold out, I tell myself. Twenty-five minutes—she breaks. I wait another two minutes before drinking, just to show her I really didn’t need it.
She eyeballs me. Game on. She cranks up her steps per minute to equal mine. Our steps are in synch. I remove my hands from the support bars as a sign that I don’t need the support. Without turning my head, I can see that she’s noticed. She makes a call from her cell to demonstrate that she has the stamina to exercise and talk.

When she hangs up I ask her how long she usually does this machine—we are approaching forty minutes and I am losing feeling in my legs. She casually replies that she does it until she’s tires, indicating she’s got a lot left in her. I tell her I lifted for an hour before I started; she gives me a look to suggest she’s not buying that. I add another ten steps a minute to my pace. She matches me step for step.

Fifty minutes. I’m done toying with her. I tell Spandex I’m not stopping until she does. She simply smiles. Her phone rings and she pauses her machine—be still my heart—and talks for a few minutes. I secretly scale down my pace, placing my towel over the readout hoping she won’t notice. She steps down from the machine. My muscles are screaming for me to quit, but I don’t until I see that she’s left the gym.

Victory at any cost. What’s the point? For what was lost, for what was gained (McKendree Spring). Men and women. Customers and companies. Most parties will deny they are competing, yet neither will yield. The customer is always right. Turns out it makes a better bumper sticker than it does a business philosophy. Nobody’s business policies reflect that attitude. If anything, were you to listen to what CSRs are instructed to do for the callers and compare that with what they are instructed not to do for the callers, it’s clear that their mandate is to minimize the negative impact to the firm, without regard to the negative impact to the customer. Remember the last time you tried to dispute an insurance claim?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Are you “The Hospital of Perpetual Implementations?”

“There is no use trying,” said Alice;
“one can’t believe impossible things.”
“I dare say you haven’t had much practice,” said the Queen.
“When I was your age, I always did it for half an hour a day.
Why, sometimes I’ve believed as many as
six impossible things before breakfast.”

There are a number of people who would have you believe impossible things.  I dare say some already have.  Such as?

“My EHR is certifiable.”

“They told me it will pass meaningful use.”

“We’re not responsible for Interoperability; that happens at the Rhio.”

“It doesn’t matter what comes out of the reform effort, this EHR will handle it.”

“We don’t have to worry about our workflow, this system has its own.”

Sometimes it’s best not to follow the crowd—scores of like-thinking individuals following the EHR direction they’ve been given by vendors and Washington.  Why did you select that package—because somebody at The Hospital of Perpetual Implementations did?

There is merit in asking, is your organization guilty of drinking the Kool Aid?  Please don’t mistake my purpose in writing.  There are many benefits available to those who implement an EHR.  My point is is that there will be many more benefits to those who select the right system, to those who know what business problems they expect to address, to those who eliminate redundant business functions, and those who implement proper change management controls.