Can You Decrease Readmissions By 50%?

The June 10, 2014 issue of Hospitals & Health Networks (H&HN) contained the article Technology is the key to patient engagement at the individual level. It is worth reading. http://ow.ly/ylgxZ

It got me wondering about how we define engagement, wondering about engaging patients, and about engaged patients. I think engaged patients are the result of different efforts. Most efforts to engage patients stem from efforts made by the hospital.  They tend to be one-way, from the hospital to the patient. They reflect how the hospital feels its patients need to be engaged.  What they miss by not being two-way is a knowledge of how patients feel they need to be engaged with the hospital.

If the engagement were two-way both the patients and the hospitals would benefit.

I believe technology will be key to patient engagement. I think that designed correctly technology should play a major role in reducing readmissions. I also believe that someone should consider asking the patients how technology could help them.

I recently developed a patient access/experience strategy for the call center of a large teaching hospital. One finding was that 99% of all of the patients who asked to speak with a nurse received a voice mail stating that a nurse would get back to them within 48 hours. Because of my fear of large numbers I did not calculate the cost of those callers who went to ED, but it was orders of magnitude higher than the cost of having a nurse or two in the call center. Most of those who went to the ED did not have an emergency. Many simply wanted a refill.

Let’s look for a moment from thirty-thousand feet at how the discharge process works at most hospitals. When I am discharged I sign my discharge orders, and if I am lucky someone from the hospital calls me in a few days to ask how I am doing or feeling. If someone calls me on day three, and my wound opens on day four, or I am feeling sick, or there is a complication from my treatment or from my procedure or from my medication or from something new, what are my likely responses?

I could call the hospital—see above; I could ignore it; or I could go to ED.

If I was unsuccessful previously calling the hospital, I may not even consider that option. If I call, I might speak with someone who could help me, or I could get a busy signal, I could be put on hold, my call could be transferred, or I could be sent to voice mail—see above. Four of those responses are not good for me, and all five may not be good for the hospital.

Why? If I do not get to speak with someone, chances are that I will solve my problem by going to ED. If I do speak with someone they may tell me to go to ED or to the hospital. Chances are good that the hospital is going to incur a cost and record a visit that may
not have been necessary if the hospital had provided me with a technological
alternative.

What might that technology look like?

I see it working something like this.

Before I am discharged the hospital adds me to their discharged patient portal, an interactive portal that contains information about the specifics of my illness or procedure—my meds, their side-effects, complications that could occur and what I should do about them, symptoms that may arise and what I should do about them. The portal also allows me to input data. I can input that I took my medications and any side-effects I am having. I can input any complications, my diet, exercise, BP and pulse, weight, and any
questions I may have.

The system would be designed to alert someone at the hospital each time any of the data I input is outside of the acceptable norms. This way, instead of me playing doctor and determining what I should do, the hospital can act before I act. They can have someone call me, can send a nurse to my home, or can send a physician to my home.

Not every patient will use this technology, but each one who does will not only be doing themselves and the hospital a favor, they will be more engaged and will have a better overall experience.

 

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.

Patient Experience, Social-CRM & Russian Salad Dressing

I was settling in to my first bite of overstuffed pastrami and corned beef sandwich—apologies to the vegetablists.  One of the four octogenarians seated in the booth next to me was speaking loudly to the other three about the catheterization he underwent the prior day.

Thankfully, his friend, who was eating the egg salad special interrupted him and asked, “How long have you known Bernie Westoff?”

“I don’t know Bernie Westoff,” replied the cath patient.

“He is one of your LinkedIn contacts.”

“How do you know that?”

Egg Salad stated, “I looked at your contacts.”

“Who told you you could look at my contacts?”

“You set it up that way.  Everyone can look at them”

This conversation continued for the next several minutes.  I was tempted to pull out my iPad, open the LinkedIn app, and join the fray, but instead I kept my eyes straight ahead and worried about the Russian dressing dripping down my arm.  Crowdsourcing 101.

I think the one application of crowdsourcing most overlooked is one which hardly fits the definition. This type is not premeditated and it does not originate within a company. More often than not, the company is the target of this type of crowdsourcing—Social-CRM.

Most definitions of crowdsourcing involve a call going out to a group of individuals who are then gathered via the call to solve a complex problem—problem solving—much like the Law of Large Numbers.  The crowd is likely to have an upper limit in terms of the number of members. By default, traditional crowdsourcing is fashioned to work from the top down; it is outbound, a push model.

Social-CRM (S-CRM) tends to work from the bottom up. There are no boundaries to the number of members; in fact, there can be thousands of members. Also atypical is the fact with S-CRM no single event or call to action drives the formation of the crowd. The crowd can have as many events as it has members.

The unifying force around S-CRM is each member’s perspective of a given firm or organization. Members are often knitted together by having felt wronged or put-off by an action, product, or service provided or not provided by an organization. Most organizations do not listen to, nor do they have a means by which they can communicate with the S-CRM crowdsource. This in turn causes the membership to grow, and to become even more steadfast in the individual missions of their members.

In traditional crowdsourcing, once the problem solving ends, the crowd no longer has a reason to exist, and it disbands. With S-CRM crowdsourcing, since the problem never seems to go away, neither does the crowd.

Every hospital and payer has one or more S-CRM groups biting at its ankles, hurting its image, hurting the brand, causing customers to flee, and disrupting the business model. Even so, most organizations ignore the S-CRM crowd just like someone ignores their crazy Uncle Pete who disrupts every family gathering.

The fact that your hospital may have a Facebook page and a Twitter account managed by two people who are officed in what used to be a supply closet will not do much to dampen the whinge factor created online by those individuals wondering digitally about why the hospital seems to have so much difficulty even answering its phone to schedule an appointment.

Social-CRM is not a fair fight. Perhaps the best approach is to find out why people are complaining, and then develop a plan to fix those issues that have them screaming the loudest.

 

The Fish Doctor’s Fallacy on Improving Population Health Management

Pretend for a moment that you are in ichthyologist, a fish doctor. And your job is to manage the health of tens of thousands of fish in a very large pond, the same job that your colleague had last year.  To accomplish your task, each week you come to the pond Monday through Friday—ichthyologists are in a union and they do not work weekends. And each day you capture and evaluate the health of one hundred fish at random, examining the same fish each day that week.  You find a variety of fish ailments among the fish you examine, and you treat each fish according to its needs.  Over the course of a year you may examine and treat some of the same fish more than once.

Over fifty weeks—you get a two week vacation—you have examined and treated five thousand fish.

Let us examine the question of whether or not your approach to managing the health of the fish in the pond worked.  How can one determine how well have you done your job? If there was a scale to manage the effectiveness of your approach, at one extreme would be that examine the health of all of the fish at the end of the year and record that on average the fish were healthier than they were a year ago. At the other extreme, you would come back at the end of the year and find that all of the fish were doing the backstroke.

Your approach relies on that belief that examining and treating a given fish over a single weeks’ time will give you the information you need to ensure that that fish will be healthy throughout the year.

Your approach also relies on the belief that examining and treating only five thousand of the tens of thousands of fish over the course of a year will give you the information you need to ensure that the average level of health of the fish in the pond will be better than it was last year.

If it sounds simple, that is because it is—too simple.  Too simple to be effective.

I used to be a mathematician; I know that is difficult to believe.  I have forgotten most of what I learned, but I retained just enough to be a boorish hit at parties.  There is something called the Law of Large Numbers. It is used in probability theory. In principle, it describes the result of performing the same experiment a large number of times. In theory, the average of the results should be close to the expected value.  The more trials you perform, the closer you should expect to be to the expected value. Using a large number of trials should result in stable long-term results for the average of these random events.

The Law of Large Numbers has value in the population involved in your experience is too large to run the experiment on the entire population.

As an example of an experiment, think about predicting whether the flip of a coin will result in a head or a tail.  The probability of tossing either a head or a tail is ½.  The probability of tossing five heads in a row is 1/32. There is something called the Gambler’s Fallacy which works as follows.  Most people, who saw the coin come up heads five times in a row would bet that the next toss of the coin would be tails.  Most people would be wrong since there is still a fifty-fifty chance that the next toss will be either a head or a tail.

The Law of Large Numbers also relies on the fact that the trials, the sample data, will asymptotically—I can’t believe I spelled that correctly—approach the expected result.

The converse to the Law of Large Numbers is the Law of Small Numbers, also known as a Hasty Generalization, and the Pigeonhole Principle. Hasty generalization’s fatal flaw is that it relies much more heavily on the belief of the expected outcome than it does on the sample size of the experiment of the population being investigated.  The false belief that was created before the process began that the trials will yield the expected outcome adds a bias that invalidates the approach.

Someone asked me why I think Patient Access/Customer Experience (PACE) plays a vital role in the success or failure of Population Health Management (PHM).

I have spoken with several hospital executives about their efforts to effectively implement a program of PHM.  Some of their names would be familiar to you.  This is what I learned from them about what they are doing.

They believe that the success of their efforts is tied to the amount and quality of the data they can collect on the people who visit the hospital, patients.  Some hospitals even collect data a few days before the person comes to the hospital and for a few days after the person leaves the hospital.

They believe the data do two things for them; manage the health of a given patient over time, and use that person’s data, in conjunction with similar data from other people with similar health problems to foretell the needs and manage the health of that group of people over time.  Lastly, the information from various patient groups could then used to glean the needs and improve the health of the population as a whole.

Ichthyology and Hasty generalization.

  1. Can my health be managed based only on data collected when I am in the hospital?
  2. Is there any data to manage my health if I do not come to the hospital?
  3. Can this approach be effective for managing the health of an entire population?

There is a solution to the problem of the Law of Small Numbers, and fortunately the solution does not require having the entire population at the hospital every day of the year.

What is the alternative to having the success of PHM rely solely on having the hospital capture data on everyone every day of the year?  Why not have the hospital manage data, and draw inference from data that the members of its population input? Why not create an interactive (2-way) vehicle that allows:

  • People to input data about their health:

o   Diet

o   Exercise

o   Adherence to medications

o   Weight

o   Pulse and blood pressure

o   Requests to speak with a nurse or doctor

o   Requests refills

  • Hospitals to monitor the health of an individual:

o   Correlate that data with similar individuals

o   Contact an individual when a person’s data is outside of expected boundaries

o   Send a physician or nurse to the person’s home

Under this type of a Patient Access/Customer Experience (PACE) tool hospitals are no longer limited to only collecting data for people only when they are in the hospital. Using this type of tool hospitals have more data about an individual, and have more data on more individuals.

This same tool can be used to decrease readmissions.  People want to be well, and allowing them to play an active part in communicating their health is a win for both parties.

Dying to Improve Patient Experience?

I stumbled across an article on the La Brea Tar Pits.  For those unfamiliar with them, over thousands of years the gas from oil deposits close to the ground evaporated leaving the byproduct tar oozing from the ground.  As it happens, this oozing is in LA, as in Los Angeles.  To date more than three million fossils have been excavated from the tar, including fossils of saber-toothed tigers and wooly mammoths.

It made me wonder what would happen if tar pits were discovered today in other US cities. My guess is that the EPA would immediately declare the site off limits and establish it as a Superfund cleanup site.  The Feds would look into whether British Petroleum was somehow behind the leak, thinking perhaps that BP simply dumped the oil it cleaned up from the Gulf of Mexico disaster.

Next we have Blockbuster, the video chain that required two trips to their store for every one use of their product.  If you are wondering why there are so many Rite Aids and CVSs in the US, I’m guessing most of them are housed in former Blockbuster buildings.  Redbox will be the next and final video chain to go bye-bye.  Maybe CVS can figure out how to squeeze a Minute Clinic into a box.

Several years ago I attended a convention on customer experience whose keynote speaker was the most recognized CEO in the cable television industry.  A reporter noted that cable television subscriptions had capped at around seventy percent, and remarked that it would not get any larger due to the number of older people who do not use technology and who did not subscribe to cable.  The reporter asked the CEO how the industry would deal with that situation.  The CEO stated “We are waiting for them to die.”

Healthcare does not have the luxury of waiting on anything.  There are those who want to skirt the issue by saying that we have patients who do not use technology, people who do not have access to the internet.  Indeed there are.  However, the converse is true and it is true in much larger numbers.  Applying technology to patient experience is not a binary trap, not an either or situation.

One of the great things about technology is that it is impartial, it does not takes sides, and it is relatively difficult to hurt its feelings.  Plus it has a great memory—it gives the same answer, the correct answer, every time to the same question.

Foresight versus hindsight.  How difficult would driving be if the only view available to the driver was the view from the rearview mirror?  Three years from now the best hospitals will look back at these discussions and wonder why not reinventing patient experience was ever an option.

Three years from now the other hospitals will look back at these discussions and wonder why reinventing patient experience was never an option.

Patient Experience: What Patients Hate The Most

The world record for the high jump remained unbroken for years.  Do you know what had to happen to break it?  Somebody decided to try jumping backwards…Today we are going to look at how healthcare can jump backwards, not it time, but doing something totally different and far from its comfort zone.

My wife and I had finished having dinner at a nice restaurant and we were waiting for our check.  The waitress brought it.  I looked at the amount and it was only twenty percent of what I had expected. A moment later the wine steward appeared and laid a slip of paper on our table—forty-five dollars.  In turn came the busboy, the sous-chef, the maître d, the dishwasher, the pastry chef, and the head chef.  All told we received eight separate bills for our meal, and no single bill showed the total amount.

To say the least it made for a confusing experience.

When we bought our house, our bill—the settlement statement—showed what we owed down to the penny.  We did not get separate invoices for the plumbing, the windows, the fireplace and the roof.  We also did not get an invoice so detailed that it itemized every nail and every tube of caulk.  Somehow those costs were folded in to other costs.  Do you know how they avoided the problem of multiple bills, paid to multiple contractors with multiple terms?  The builder acted as the general contractor.

It made for a much better experience than if we had been invoiced separately.

Since we all know where this is heading, I’ll head there quickly.

Healthcare:

  • There is no organization acting as the general contractor
  • Multiple invoices from multiple vendors
  • Different payment terms by vendor
  • Different coverage by payer
  • Excruciating line item detail—itemizing Tylenol
  • Nothing showing what is covered and what is owed and why
  • More complexity than a detailed IRS tax return
  • Patients do not know what they owe and to whom they owe it
  • Patients do not know what is covered and why other things are not covered
  • Patients do not know what anything cost ahead of time
  • Hospitals do not know their costs—they only know what they charge
  • Two people having the same procedure at the same hospital will not be invoiced the same amount

The entire hospital billing process makes for an awful patient experience.  Healthcare is the only service someone can purchase without having any idea what they owe and why.  If the amount is large enough it remains an awful experience for months and years until the amount is paid.

I’m guessing, but I would be willing to bet that not one person in fifty in a hospital could accurately explain a patient’s total charges.

The entire billing process could be reimagined, it could be reinvented.  And the reinvention could include a single bill.  For those screaming at their PCs that it cannot be done, the only reason it cannot be done is that it has not been done, and that is not a reason.

Patient experience has to do with dozens of things that are very important to patients, things that hospitals have not changed in decades.

To be the hospital of choice you have to be the hospital people choose, and people will choose the hospital that is the easiest to do business with.

Patient Experience Surveys: Too Little Too Late?

I am not a fan of surveys, not even a little bit.  For example, if I included a survey at the end of these comments to see how you feel about surveys, nobody would believe the results would impact my opinion about the value of surveys.  At best it might suggest that at least I appeared to be interested in what others thought.

These are my issues with trying to shape or modify a business strategy based on the information reported in surveys:

  • Most of those being surveyed are no longer your patients or customers.  Once a patient is discharged their ID badge changes—it changes from patient to prospective patient.
  • Prospective patients do not know what changes you have made based on the survey results you obtained because they are not patients any longer.
  • The best results hospitals can hope for by using survey results to drive change, other than trying to avoid CMS penalties, is a campaign that says “although you may not have liked us last time, now that we’ve read your survey responses we think you should give us another shot.”
  • Hospitals are not static.  Healthcare is not static.  Surveys results and Press Ganey data are not current.  The value of trying to implement change based on data that is seven months old would be like NASA trying to get to Mars—it takes about seven months—by aiming the rocket at where Mars is today.  It will not be in the same position in seven months and neither will the hospital.
  • If every hospital is trying to change by doing the same things over and over again using old data, it would seem that the only possible outcome is that their position relative to one another will change.  If you are ranked in the 51st percentile and I am ranked in the 49th and we both try to change our scores based on survey data, aren’t we equally likely to have scores that are pretty similar to each other.

Imagine that at HIMSS 2014 CMS holds a reception and one representative from every hospital attends.  Along with your drink coupon you are given a dart.  At the end of the room is a large cork board, and above the board is a banner titled “The Patient Experience Challenge.”

The CMS representative throws the first dart.  The position of your dart as compared to the position of the CMS dart determines whether or not you will be penalized.  The fifty percent of the hospitals furthest away lose.  Now here is where it gets interesting.  Everybody retrieves their dart and we run the contest again.  If we did that I am guessing two things would happen:

  • On almost everybody’s second throw the dart will end up in a different spot from where it was on their first throw
  • Most of the people whose throws were close to the CMS dart will still be those closest to the CMS dart, those whose darts were furthest away will still be furthest away, and many of those who were borderline will exchange places.

It seems there is little merit to scoring better than the 49th percentile.  I write that because the goal of what is being contested is to avoid the CMS penalty.  If we are being candid we know that raising patient experience scores is not the same thing as raising patient experience.  The two tasks require different strategies, focus, and different resources.

The hospital that wins the patient experience battle is the hospital that chooses to do what their competitors and peers are not doing.