Strategy

Patient Relationship Management–lessons from Thumper

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Today it feels like I got a little too befuddled, steered into the skid, and took a left into the dementia cul-de-sac.  I like to dig a little esoteric hole right up front to test myself—hopefully I won’t overshoot.

One billion, two hundred and twenty million. That’s the number of hits on Google for ‘hotel’. A fairly competitive business one could easily surmise. A business in which one would benefit by trying to attract and retain customers, especially loyal customers. Their tagline is, ‘It happens at the Hilton’. You know what they say, ‘It happens’–it certainly does, ‘It’ happened to me. I’m standing at the Hilton Honors desk, checking in to the hotel. I’m in Memphis. Tennessee is one of the friendliest places I’ve ever been. The people are genuine. We go through the niceties of how my flight was, and what I’m doing in Memphis. Yada, yada. I then provide the clerk with my Hilton Honors number.

“I’m afraid you don’t exist, Mr. Roemer.”

I have the right to remain silent; I just don’t have the ability. I can feel it coming. I’m about to have a Roemer-minute. You know the feeling, when the words are going to jump pass the lips before you have the chance to go into lock down mode. I’m a bit of a stickler for English, so I press him to do better with his statement. “Here I am”—I am Sam, Sam I am, I wanted to add, but I didn’t know how up to speed his was with his Green Eggs and Ham reading. “How can I not exist?”

“In the system. You’ve expired—I checked my pulse to make sure I hadn’t—you’ve been deleted.”

“My reservation?”

“No, you. You are no longer an Honors Club member.”

Now I had it. I hadn’t expired, they expired me. Somebody had to think up that little gem of an idea, and somebody else had to approve it. They could have just pretended I was still in their little club and not said anything and everything would have been fine. Bambi 101. Thumper’s mother; ‘If you can’t say something nice, don’t say anything at all.” A clear violation of the rule. As competitive as the hospitality industry seems to be, how smart does one need to be to know that it is not a good idea to expire customers?

I was in the middle of my run today, four miles away from the parking lot.  Next to the dirt trail was a bright orange Igloo water cooler with a hand-written note stating it was provided by a local running store.

What have you done for your patients recently?  What makes you stand out?

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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How to calculate Meaningful Use’s ROI

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Just to make sure we are all turned to the same page in our Cliff Notes on Meaningful Use, today’s conversation is, “There is no “R” in ROI.”

Are you familiar with the Abilene paradox?  It is a paradox in which a group of people collectively decide on a course of action that is counter to the preferences of any of the individuals in the group.  It involves a common breakdown of group communication in which each member mistakenly believes that their own preferences are counter to the group’s and, therefore, does not raise objections.

I think it occurs more often than we think.  Try to recall the last meeting you attended in which you really disagreed with something that was said.  Chances are you knew some of the others in the meeting well enough to know they also disagreed.  The reason you know they also disagreed is because you had discussed the topic.  However, none of you raised your disagreement during the meeting.  Why?  Because you did not want to rock the boat.

It is similar to a pseudoconsensus.  Pluralistic ignorance.  These create a bystander effect—people are more likely to speak out about an issue when they are alone with someone than when others are present.

After further consideration I think we must consider the very real possibility that there is no ROI for Meaningful Use.  I write this in all sincerity.  Healthcare executives march in lock-step or group think to achieve the myth of finding an ROI for Meaningful Use.  The ROI is healthcare’s quest for the Holy Grail, albeit without the Monty Python sound track.  They cannot proceed without one, so they set the target, figure out what data will demonstrate that they have hit it, and disregard the reams of data that does not support the ROI.

What if the government came out with a standard stating all hospitals ought to buy, install, and use a fifty million dollar transplant device that also flosses the patient’s teeth?  This initiative is “optional”, but the government will pay the hospital a two hundred thousand dollar rebate.  There are several types of transplant flossers—the ones that deliver that fresh mint taste cost extra.

If we were having a business discussion about the ROI for the transplant device, healthcare executives would be foaming at the mouth about how impossible it would be to calculate an ROI, and rightly so.  They would argue all hospitals are different, they have different cost structures, the devices are all different.

The standards for Meaningful Use are arbitrary.  The standards were developed by people who do not need to meet an ROI.  There was no mandate in the development of those standards to create standards which when met would yield an ROI.  Any attempt to force an ROI will naturally differ in a number of ways:

  • by provider—size, structure, offering, geography
  • by their interpretation of Meaningful Use
  • by which EHR they implemented
  • when they began the implementation
  • how well they implemented the EHR

Somebody somewhere may hit a positive ROI on Meaningful Use, just like somebody playing darts may hit a bull’s eye.  Any positive ROI will be accomplished more out of chance, and from having fit the data to a predetermined ROI rather than measuring the ROI against its true impact.

Implementing an EHR can be very good for a hospital.  However, it should be a business decision for the hospital based on the same set of business rules the hospital would use to justify any other large expenditure.  If the hospital achieves an ROI it will not be because of having followed an arbitrary set of standards.  Any ROI for an EHR will come from having done it correctly.  Hitting the figure any other way means two things; it was a coincidence, or you are in for trouble down the road.

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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If you come to a fork in the restaurant…

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In Greek mythology, there was a not so nice man, Procrustes.  He had an iron bed in which he invited wayfaring strangers to spend the night.  Some of the strangers were too long for the bed and others were too short.

Apparently Procrustes liked things orderly and could be a tad anal when learning his guests did not fit.  He would set on them with his smith’s hammer, to stretch the shorter ones to fit.  If the guest proved too tall, Procrustes would amputate the excess length.  Truth be told, nobody ever fit the bed exactly because Procrustes had two beds.

In contemporary terms, a Procrustean Bed is an arbitrary standard to which compliance is forced.  A Procrustean Solution involves fitting a business problem to a preconceived set of strictures.

Raise your hand if you have already figured out where this is headed.  Preconceived.  Arbitrary.  Compliance.  Strictures.

Do you spell Meaningful Use with an upper case Procrustean or one in lower case?  I prefer the upper case.  The business problem being fitted is the implementation of EHR.  The preconceived sets of strictures are the Meaningful Use standards.

This in turn leaves the healthcare provider in what is best described as a Morton’s Fork scenario.  Shall I explain?  A Morton’s Fork is a choice between two equally unattractive alternatives—a dilemma.  The concept originated in 1487 under the rule of Henry the VII as a result of tax policy to ensure everyone paid taxes.  The argument was because the rich had enough money to buy things they must have enough money to pay taxes, and the poor who had bought nothing had saved their money, and thus had money with which to pay taxes.  The two prongs of the fork—back then forks only had two prongs.  Q. E. D.

The healthcare provider must choose between—as one may not choose among—two alternatives.  Attempt to meet Meaningful Use—a Procrustean Solution—turn their business model inside out to meet the government’s Gossamer standards.

Attempting to meet the standards does not ensure they will in fact meet the standards.  Should they only meet ninety-nine percent of the standards, they lose.  The Pareto principle does not apply.  There is no 80:20 rule.  They will not receive any incentive money as Meaningful Use is an all or nothing game.

The second alternative is to not meet Meaningful Use.  This choice may be voluntary, or involuntary—trying to meet Meaningful Use and failing.  Alternative Two—it is said—will result in reimbursement penalties from Medicaid and Medicare.

I do not think those penalties will be implemented, or at least they will not be implemented in the documented timeframe.

I also do not think there is a Morton’s Fork, because I think Meaningful Use will disappear because it is so arbitrary and capricious—and because the number of large providers who will meet it could all drive to lunch at Morton’s in a Yugo, at which time they could dine with a fork from Morton’s.

We have now come full circle.  My work here is through.

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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My latest post to healthsystemCIO.com

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I think there is plenty of merit to quit chasing Meaningful Use and get on with your business.

http://healthsystemcio.com/2010/05/28/ten-catechisms-of-meaningful-use/

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 terrorists smarter than us?

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Sri Lanka has been in a twenty-six year civil war with the Tamil Tigers. NPR reported the leader of the Tigers was killed. Within a day, the Tamil Tigers’ web site posted a blurb stating that the leader was not killed—a la Monty Python—“I’m not dead yet.”

I’ll be brief. The bad guys. These bad guys live in the jungles, others live in the Afghan mountains. As far as I’ve been able to ascertain, they don’t use Cisco servers, they don’t have a call center. There’s no marketing department, no financial analysts, no freshly minted MBAs walking the hallways telling them what to do.  They have established virtual nations.

Yet as primitive as these groups are, they know the value of rapidly employing social networking to their advantage. What amazes me is not that they do it, but that most people reading this don’t have a proactive policy and the resources required to effectively manage their social media.

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 wildebeest postulate

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The Kalahari; vast, silent, deadly. The end of the rainy season, the mid-day heat surpasses a hundred and twenty. One of the varieties of waterfowl, most notably the flame red flamingo that nested in the great salt pans in Botswana, has begun its annual migration. In the muck of one of the fresh-water pools that had almost completely evaporated, writhes a squirming black mass of underdeveloped tadpoles. A lone Baobab tree pokes skyward from the middle of the barren savanna. In its shade, standing shoulder to shoulder and facing out, a herd of wildebeest surveys the landscape for predators.  Sir David Attenborough and PBS can’t be far away.

Some things never change. I make my way across the freshly laid macadam to meet the school bus. Fifty feet in front of me is a young silver maple tree, the tips of its green leaves yielding only the slightest hint of the fall colors that are hidden deep within. The late afternoon sun casts a slender shadow across the sodded common area. One by one they come—soccer moms; big moms, little moms, moms who climb on rocks, fat moms, skinny moms, even moms with chicken pox—sorry, I couldn’t stop myself—as they will every day at this same time, seeking protection in its shade. My neighbors.  It’s only seventy-five today, yet they seek protection from the nonexistent heat, a habit born no doubt from bygone sweltering summer days. A ritual. An inability to change. In a few weeks the leaves will fall, yet they will remain in the shadow of what once was, standing shoulder to shoulder facing out, looking for the bus. A herd. Just like wildebeest.

The kids debus–I just made that word, hand me their backpacks, lunch boxes, and hundreds of forms for me to complete.  I look like a Sherpa making my way home from K-2.

I shared this perspective with the moms, and have halted most of my bleeding. I can state with some degree of certainty that they were not impressed with being compared to wildebeest. So here we go, buckle up. By now you’re thinking, “There must be a pony in here somewhere.”

Some things never change; it’s not for lack of interest, but for lack of a changer. For real change to occur someone needs to be the changer, otherwise it’s just a bunch of people standing shoulder to shoulder looking busy. How are you addressing the change that must occur for EHR to be of any value?  EHR is not about the EHR, it’s about moving from a 0.2 business model to 2.0.  Are you chasing ARRA incentive dollars simply because someone is writing a check?

Someone who sees the vision of what is is—sorry, too Clintonian—must lead.  Be change.

One of the great traits of wildebeest is that they are great followers.

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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Is this a fair representation of the hospital business model?

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I have been looking for a way to represent pictorially the hospital business model and the forces which act upon it.  The picture below came to me last night while playing this board game with my daughter.  It is from the children’s game, Boobytrap.  The way the game is played is that the players try to remove the red, blue, and green pieces without causing the trap to spring and displace all of the pieces.

If we represent patients as the individual playing pieces and make the assumption that each side of the game exerts pressure on the model, I think it represents fairly the external forces with which the large provider model has to battle.  As the forces increase from some combination of costs, regulation, procedure price ceilings, and payor reimbursements, the number of patients in the model will decrease and may do so in a catastrophic manner.  Without a concurrent decrease in those four forces it is unlikely that the model will support additional patients.  Clearly, without changing the size of the board it is impossible to grow the number of patients beyond the board’s capacity.

A couple rules come into play.

  • The forces are all external.  They cannot be controlled or abated by the hospital.
  • The strengths of the various forces change over time
  • The forces result in some maximum number of patients which can be serviced under the hospital’s existing business model.
  • As each patient is lost, the stability of the model weakens.

Does this way of depicting the large provider business model ring true?  Does this help illustrate why the model must change?

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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Wayne Newton’s 4th law of relative immobility

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Last night I was speaking with a woman at a gathering of graduates from my high school.  She got into the subject of reading glasses and then commented that she first learned she needed regular glasses since the age of four.

As she was not wearing glasses, I asked her if she’d had Lasik.  No, she said, “I always hated how I looked in them, so I quit wearing them in high school.”

“Don’t you miss being able to see things?” I asked.

“Not really.  This is how I’ve seen the world for the past thirty years.  I’ve grown comfortable with how I see the world.”

I think a lot of business leaders have the same perspective—sorry for the pun.  They get comfortable with how they see their world—comfortable with the issues and how to address them.  Given the choice, people will stay in their comfort zone.

Do you remember your physics?  Relative motion is the branch of physics that studies the motion of the body relative to the motion of another moving body (Newton).  For example, if you are in a train and another traveling at the same speed pulls alongside you, it appears to both set of passengers that neither train is moving.  If your train decelerates it will appear to you the other train has accelerated.

Now, take the perspective of someone standing on the platform viewing the two trains.  To that person, there is no illusion.  The bystander can see exactly what is happening; who is moving forward and who isn’t.

Business leaders get caught up in what I call Wayne Newton’s 4th law of relative immobility.  When they look out their windows at the executive in the hospital across the street, it appears they are both moving at the same speed and at the same direction.  That is how they have seen the world each day for the last several years.  They look at each other, wave, and then go about their business, knowing their competitor hasn’t passed them or changed course.

But you and I know why it looks that way to them.  The reason they have not been passed is because neither hospital is moving forward.  The reason they do not perceive a change of direction is that they are both moving in the same direction.  In actuality, there is no motion.  Only an outsider can see neither hospital is moving.

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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Herman Melville’s take on healthcare’s business strategy

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Someone once summed up one of Fred Astaire’s screen tests with the following; “Can’t sing.  Can’t act.  Balding.  Can dance a little.”  Probably the same guy who evaluated my Mensa application.  I’ve been accused of having a similar outlook.  I once accosted a guy who was walking on water, accusing him of not being able to swim—but that was a looonnngggg time ago.

The internet is full of opinions, but hopefully not full enough. One of the reasons I chose math over English as my major was the affection I held for getting the right answer, or barring that being able to know precisely where my errant efforts led me away from the answer.

In my narrow-minded view of the universe the downside of English, literature—the soft studies—was the notion held by those who taught that there was more to be divined by the story than just the story.  Those who can do; those who can’t teach.  They displayed a Stepford mentality in their obdurate ability to outthink both the author and their students, to bring forth nascent ideas of the author’s hidden meaning.

Herman Melville wrote Moby Dick.  I am willing to bet he wrote it just the way he intended to.  Nobody has uncovered a frayed notebook of Melville having penned his thoughts about the real meaning of life from a cannibal’s perspective, or suggesting Queequeg was a misunderstood cross-dressing sycophant who was never close to his mother.  We don’t come away from our reading of Moby Dick  with a more in-depth ability to understand anything except for perhaps what it felt like to live aboard a whaling ship.

These interpretations are poppycock.  Art critics do the same thing as they bloviate about the hidden meaning behind what the artist really intended to convey, meaning only they can see.  Ever notice how none of these popinjays, these opiners present their opinions as fact?  Pretentious fops.

I write and paint.  Those who’ve read my missives know there is no buried meaning.  If I had wanted to convey something else I would have written something else.  If I use dark colors and bold brush strokes when I paint it is because I feel they add to what I want to show; it is not a reflection of having missed two days of Zoloft.

Nobody will ever know what Shakespeare intended to convey with his addition of the three witches in Macbeth, or whether Joyce Kilmer had ever seen a tree.  That said, I do have a few strong opinions about where this whole business model of healthcare is headed.  I think these types of opinions; along with the opposite opinions differ from the type offered up as truths in an English Lit class.  They differ in that at some point they will be proven right or wrong—time will tell.

As I have written, I think the large provider model—the business model—is seriously flawed.  Moreover, I think it may prove fatal.  Providers will run out of costs to cut, will run out of processes to re-engineer, and will have no more Italian marble with which to line the foyer.  The good news is that they will still have the machine that goes “Ping” just in case somebody needs it.

I do wonder how Melville would have expressed his ideas about healthcare.

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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Hospital marketing strategies–my non sequiter

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I had piloted the Piper Cub for seven hours across endless miles of ocean.  The crash of my small plane left me alone on the uninhabited treeless atoll somewhere in the south Pacific.  I would have been sunburned badly if not for the shade cast by the thirty-foot tall New Jersey hospital’s billboard heralding its urology practice.  The billboard reminded me of the one I saw while solo kayaking the lower regions of Antarctica.  That billboard was from a hospital in Minot, North Dakota advertising its OB/GYN services.  Did you know there has never been a birth in Antarctica?

Hospital marketing has doubled in the last decade.  To whom are they marketing?  Appendectomies; twenty-percent off.  Maybe I’ll get two.  Perhaps I’ll buy some Plavix while I’m at it.

Ninety percent of hospital revenues result from a physician’s signature.  From where does the other ten percent originate, marketing?  Doubtful.  Do the billboards yield more physician signatures?

Hospital television advertising seems to focus its shotgun message in one of two areas; unsubstantiated claims of being the best or having the most, or having the latest and greatest machine that goes “Ping.”  You’ve seen the commercials broadcast to a television coverage area of a few million, advertising newly acquired technology for a non-elective procedure—that cost more than a few million—that less than a fraction of a single percentage of the population will need.  By the way, it is the same piece of technology that three other areas hospitals offer.

I am not sure I understand the logic behind hospital marketing.  Does it merely stem from the fact that other businesses do it?  I have personal knowledge of one hospital’s chief marketing officer whose annual salary exceeds more than four hundred thousand dollars.  She had no prior experience in healthcare.

Would revenues drop precipitously if hospitals did not market themselves?

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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