Leo: “You search [Google] for psoriasis and you are telling the world…”

Jeff: “So what if you have psoriasis…. what’s the harm to [a patient who has type 2 diabetes] and google gives you ads…. we have to get down to [what is the real harm] and not have this discussion up here about creepyland”

That’s the start of the conversation at towards the end of episode 132 of This Week in Google. Jeff Jarvis goes on to suggest Google has a vested interest in protecting people’s data. He makes the point, if Google were to cross a line from what is perceived as creepy into actual malicious harm, their goose would be cooked. People would never use Google again. Jeff thinks the benefit we get from Google knowing more about us, coupled with their business interest, outweigh the risks.

Is he right? Do you think search engines know too much about us based on our search habits? What about this conversation in particular, around health related searches – a topic many hold as close to the vest as financial records?

I see both sides of the coin. I recognize the concern many have about not wishing to disclose sensitive health data for a various number of reasons - secrecy, perceived fear of insurance or employer reaction, data ownership, etc. I also see the value in a site like google knowing enough about me to return relevant results, based on a holistic picture of me. So what if they serve me related ads at the same time?

Curious what you think…

Here’s a direct link to the conversation, starting at 1:03:30

This Week In Google 132: The Google Father – YouTube.

Dr. David Agus is a professor of medicine and engineering at the University of Southern California. A portion of his forthcoming book, The End of Illness,” was adapted for an article in the Wall Street Journal recently. It captures the absolute essence of how consumer oriented innovation will define how healthcare is delivered in the future.

The word empathy keeps coming to mind for me, as I consider these big, bold visions of the future – one which George Jetson would approve. They are empathetic towards what people actually want. Often, that’s now how businesses, like provider organizations, approach solving problems such as revenue or growth. We have to get better at thinking with empathy about designing how we deliver care. What do healthcare consumers want? That’s how new markets are created in other industries and, if Agus’s vision comes to fruition, it’s how we’ll all control our own health destiny in the future.

Also, note what Argus says about the role of the physician: “…doctors won’t just examine them once a year; they will continually monitor the next generation of patients, offering advice along the way.” Doesn’t that sound a lot like what empowered patients and the social media savvy ask for?

I see them being able to monitor and adjust their health in real time with the help of smartphones, wearable gadgets—perhaps like small, invisible stickers—to track the inner workings of their cells, and virtual replicas of their bodies that they will play much like videogames, allowing them to know exactly what they can do to optimize every aspect of their health. What happens when I take drug x at dosage y? How can I change the expression of my genes to stop cancer? Would eating more salmon and dark chocolate boost my metabolism and burn fat? Can red wine really lower my risk of heart attack?

From a drop of their blood, they will be able to upload information onto a personal biochip that can help to create an individualized plan of action, including both preventive measures and therapies for identified ailments or signs of “unhealthiness.” (Other body fluids—like tears and saliva—might be routinely tested, too.) They would be on the lookout for problems like imbalances in blood-sugar control, a risk factor for diabetes, and uncontrolled cell growth, which could signal cancer. Their doctors won’t just examine them once a year; they will continually monitor the next generation of patients, offering advice along the way.

via The Future of Personalized Medicine – WSJ.com.

I’m not a huge fan of what I call blatant marketing. You know it when you see it, particularly with interactive campaigns online. You want me to do what? Like this page, give you my home address, and retweet your link for a chance to win an iPad? No thanks. I avoid frequent shopper cards at the grocery store for the same reason. When Vail Resorts launched Epic Mix last year, I was skeptical. Vail wants to track every move you make, literally, on their mountains.

Vail installed RF chip readers in every lift line and started putting RFID chips in their lift tickets. You go through a line, and they know it. They also know your age, gender, address, family members and travel dates. With the tracking and demographic data, they have a pretty good idea about your habits at their resorts. You can even tie your credit card to your ticket for on-mountain purchases. I imagine the database thinking something like this (you know, if databases could think):

The Jones family starts skiing at 10am most days. Not surprising since they are from the East coast and have the time change. The kids are both in ski school today … cha-ching! Oh look, mom and dad just stopped for lunch at the high end restaurant and the kids are eating pizza at the casual on-mountain restaurant. Mom skis black diamonds mostly and is logging 2x as much vertical as dad. They seem to come out every year around the same two weeks. Judging from their address, I bet they make about $110,000 a year and take two major vacations. We should email them a month before, I’ll make a note of it. I wonder if they’d want a time share….

Pretty spooky huh?

So what did Vail do to change the value proposition of their data capturing? They launched EpicMix, a customer facing portal into the data. You sign up and register the ID number from your lift ticket. From there, things get social very fast. There is a FourSquare like game component where you earn pins – just like the real pins you see on people’s hats or jackets – for accomplishments. Ski 26,400 feet and you get the 5 Miler pin. Head into the Northwoods area and you get the Gone Wild pin. The service also tracks your runs and vertical feet per day and season and lets you compete against friends and family. There’s even iPhone and Android apps to track your stats in real time. And, of course, it all connects to Facebook and Twitter.

This year, Vail gave professional third party photographers the boot. Now, Vail’s own photogs hang out near huge EpicMix Photo placards around the mountain. Ski up, and they scan the RFID tag on your ticket and snap a few pics. That evening, the pictures are uploaded to your EpicMix account and can be shared on Facebook or Twitter for free.

Vail took customer tracking and turned it into a value added service. It’s a draw, something Vail’s resorts have which other ski areas don’t have.

It will come as no surprise I see a healthcare analogue in all of this. Rather than capture data about customers and keep it to themselves, Vail turned it into a customer-facing service. Does your doctor treat your medical records the same way? Can you go online and look at them? Do you get rewarded, even virtually, for losing those 10 pounds or controlling your asthma? Can you chose to share parts of your record with family or friends?  Can you chart your A1C scores over time?

Even with the rise of patient access into electronic medical records,  we’ve still got a ways to go before we reach the same level of understanding about personal data. I continue to see consumer devices and services leading the trend, which tells me two things: 1) people do want to own, collect, monitor and selectively share aspects of their health and 2) the consumer oriented companies can do it for cheaper. The later is likely owed to less red tape, regulations, research, etc. To be fair, there are iPhone apps which will graph your weight. And there are iPhone apps which will track your skied vertical feet. But the value of that data changes when it’s shared with your provider (not that it has to originate with them, mind you).

Any thoughts? Are you aware of any provider organizations who are going beyond MyChart (an example of a patient EMR portal) and offering value added analysis and services on top of YOUR health data? What kinds of things would you want to see, beyond direct, unfettered access to the record?

By the way, according to my EpicMix dashboard, in the last 12 months, I’ve skied 121,453 vertical feet at Vail resorts… not too shabby for busted knees!

Since I’ve basically given Vail a free ad, I might as well embed their EpicMix video, it explains the service pretty well:

It’s not surprising,  it happens to a lot of industries. Consumer devices and technology are making inroads where industry driven solutions are still struggling. People want access to health and fitness related data and so they are building their own solutions, outside of the provider-controlled walled garden. I suspect we’ll see a time when all of this merges together – consumer solutions, medical device makers, provider EMRs, etc. However, for now, it’s pretty clear that if you want to generate and control your own health related data, look towards the consumer space.

This announcement with Withings, maker of the popular Wi-Fi Body Scale (I love mine), highlights what is happening in the consumer world. Providers have been using sales sales with modem connected to your phone line to monitor weight gain in patients with congestive heart failure for years. They cost big bucks and the data goes into a seeming blackhole. The Withings scale is less than $150 and the data is available via API with existing interconnects to services like RunKeeper, FitBit, and now MedHelp (which is new to me).

We have recently discussed the Withings Health Cloud that allows users to import data from RunKeeper and Zeo into their Withings dashboard. The development of the Health Cloud however does not mean that we have given up our policy of making it possible for Withings users to export their data to other websites, quite the contrary. In the past weeks, we have added several new names to the list of our partners, both for the body scale and for the blood pressure monitor. Today, we’d like to shed some light on one of those partners: MedHelp.

via Withings and MedHelp have formed a new partnership | Withings blog.

This week, Apple released their latest disruptive innovation, iBooks 2 and iBooks Author. iBooks 2 is a free update to the iBooks app for iPads. iBooks Author is a free mac desktop application which enables anyone with some basic typing and drag-and-drop skills to create pretty amazing eBooks. eBooks can contain pictures, links, audio, video, rotating graphics, self study questions and more. This is the future of patient education, shared decision aids and pre and post visit care.

On the outset, the idea of combining text and video and pictures isn’t really that new. It’s been around since…well… the start of the web. But in the context of a book, there is something really strangely compelling about seeing a moving video in the middle of static text. I can’t quite describe it. After about an hour of tinkering with the app and pasting some images and text in from a keynote presentation, I had a nice little proof of concept. You can download it and see for yourself here.

There is something which draws you in when you see live action video playing within a frame of text. Adult education experts call this blended learning. We absorb more when we engage more of our senses.

So imagine this, your doctor tells you that you are going to need surgery. What’s that process going to be like? What do I do before hand to prep? What should I do when I get home, you ask?

“Well, you can just download my free eBook,” he says.

The book walks you through the pros and cons of surgery. It plays a video of the doctor outlining the procedure. A moving picture gallery shows you where to arrive, and what to expect the day of surgery. Another video shows you how to use the pre-surgical antimicrobial wash the doctor sent you home with. There are links to online communities from other patients who have been through the same process. There is even an embedded twitter search showing a real time discussion about your condition. Wow!

A few days after the procedure, you fire up chapter two. It shows a diagram of some basic stretching. The next page talks about nutrition. To make sure you understand the concepts, there is a short self test, don’t worry, it’s open book.

These tools are simple to create. They are easy to publish (for free). And, they are a tremendous value-add to patients. Apple has done it again. By disintermediating author from the publisher, they’ve given us all the ability to make robust patient aids. For that matter, patients could make them for other patients, and publish them on their blogs, or via the iTunes book store.

What are you waiting for, go publish your first eBook!

You can download my demo/work-in-progress book, Innovation in Healthcare: A Requirement For Success here. I’ll continue to update it after this post is live, however the point is not to provide a serious book about health reform and innovation tactics. Rather, the point is to demonstrate how the technology can be used in a healthcare setting (this book is more geared to the administrative types than patients).

The gallery below includes images and descriptions of features in eBooks. 

It was a classic childhood scene, a mom pulled her young daughter in a cherry-red wagon. Both had smiles as broad as a their faces would allow. When they made the a turn to the left, a young lady stooped down to the daughter’s eye level and said something that put them both in a fit of laughter. There was something really special about how much fun they were having. It’s a simple thing really, but aren’t wagon rides kind of a childhood rite of passage? That wagon can be anything – a pony, a space ship, a semi truck or just a plane red wagon.

The young lady stood up, adjusted her scrubs and went back to the nursing station. Mom and daughter turned the corner for another lap down the hospital floor hallway.

Have you ever stayed in a hip, boutique hotel? You know that cool thing they do with glass walls and bright lights? Well, that’s pretty much exactly what I was not expecting when I stepped off the elevator at the University of Minnesota’s Amplatz Children’s hospital. My friend, J, was giving us a tour. He explained each floor has a story teller character, some animal who’s image is repeated as a design theme throughout the floor. The wall was bright orange and yellow glass. If there had been club music I would have assumed we were, in fact, in a W hotel.

“The whole place was designed with onstage and offstage spaces,” J explained. An onstage space is patient facing, it is their space where staff are expected to play the role of compassionate caregivers. Fred Lee, author of If Disney Ran Your Hospital, would be proud. Offstage spaces are where staff congregate, or push noisy carts – the kinds of things which wake patients up at night or remind you that you are in a hospital. The idea of onstage and offstage goes deeper than having a separate hallway for food service delivery. Being onstage reminds staff they are, in many ways, a guest in the space. Families, particularly in a children’s hospital, settle into their rooms and the surrounding environs. Being onstage means always playing the part of someone who loves children, and serves families, and provides care, and doesn’t mind getting a cup of shaved ice for the third time that hour. Need to huff and puff about it? Take it offstage.

“You know, it’s funny, everyone thinks I’ve gotten into IT… I haven’t, I’ve gotten into connecting people and making the experience for these kids a little less scary.” J played a considerable role in the design of the hospital. One of his many contributions is the design and implementation of a state of the art video conferencing system. The system, available in about half of the rooms, consists of a wall of video monitors, including a 42″ screen, and a motion tracking video camera. From a bedside touch panel, kids can dial up family members who may be hours or many miles away. Some kids have even been able to attend school using the video linkups. “It’s a way to maintain some sense of normalcy and connection, ” J told us. Amplatz is a regional draw, servicing a wide swath of the midwest. Video conferencing can enable the dad who can’t take off work to talk to his child several times a day. Doctors can plug in a computer on wheels and do a split screen between the patient, the parent and the medical record, effectively hosting a virtual care conference. How cool is that?

I’m with J, the people aspect is by far cooler than the enabling technology. And the technology is impressive to be sure. The design aesthetic is also – and I say this with no hyperbole – the best design I’ve ever seen in a care space of any kind. But what really stands out at Amplatz is the atmosphere, the total package. It’s not the iPod docks, rainbow walls, x-box enabled video conferencing onstage touch screen dohickies…. it’s the utter selflessness that working around sick kids demands. You simply cannot bring your own baggage onto a floor where a family is fighting for what could be their last hours or months together. Kids level the playing field. Check your ego at the door.

Why does it work so well at Amplatz? I’m not entirely sure. There is undoubtedly some combination of culture, training, design and technology which enables the care environment. There is attention to design, particularly around experience. Hospital committees met and drew the initial brush strokes. A parent’s council then came in and refined the ideas. The ultimate decisions, however, were made by a council of children patients. It’s pretty hard to get the typical non-patient-centric committee compromises when patients get the final review. Clearly, you also have to give staff room too. I don’t mean physical room, but rather latitude to be empathetic, personable and compassionate. I didn’t get to observe the culture long enough to understand how Amplatz enables culture, although it is clear they do something right for their staff.

Every healthcare provider has a responsibility to be as good as Ampltaz. Here are some of my key takeaways from our short visit:

• Patient centered design with patient input and review
• Onstage and offstage spaces
• Give staff permission to be empathetic (here’s an example, at Ampltaz, any patient care conference supersedes staff conferences. If staff are in the conference room for a meeting and a provider wants to discuss care with a family, the staff all leave and reschedule their meeting…wow!)
• Enable connections, relationships and remove fear – that will drive your IT choices rather than letting them drive you
• Don’t be afraid to have fun – the space was fun. There were games everywhere. Each room had an Xbox! Why do we paint hospitals in muted tones and use dim lighting? No one wants to convalesce in a depressing cave.

The University of Minnesota Amplatz Children’s Hospital is a joint venture between UMN and Fairview Health System.

You can follow Amplatz on twitter here.

The 4AM Wake Up Call.

My friend was in the hospital a few weeks ago, nothing serious, a precautionary measure more than anything. I went to visit her and we sat and chatted. I always ask people about their experience. “What’s going well, what would you change?” At first, you hear a lot of kudos. “Everyone has been really nice.” I don’t doubt it. But, you can’t improve on compliments. I’ve found you have to ask people at least three times to get the juicy stuff.

“Well, I don’t understand why they keep waking me up at 4 AM to take blood. Is my blood only good at 4 AM,” she joked.

I know why they do it.

In The Accidental Mind, David Linden talks about the evolution of the human brain in Gladwell-like simplicity. He says evolution didn’t just pop out this perfectly coordinated mass of nerves and synapses. The brain, in fact, is the result of years of renovations, additions and remodels. One part developed to respond to the needs or deficiencies of another. The process of healthcare, unsurprisingly, isn’t much different.

Doctors usually want to round on patients first thing in the morning, around 7am. It frees them up for surgical cases or office visits early. When they round, they want to see the latest lab results. Lab tests take a few hours to coordinate and run. Thus the 4 AM blood draw.

It would be easy to point the finger at the doctor and say the patient is being inconvenienced to fit the doctor’s schedule. But, much like the human brain, it’s not that simple. Could the lab speed things up? How do we even get specimens to the lab, is that an efficient process? Well, that depends on who’s eyes you are viewing the process through.

Designing for experience

Designing for experience is about true customer focus. It is deeper than what we traditionally think of as customer service, which describes the way people interact with each other. Designing for experience requires an almost painfully high degree of empathy for the person using your product of service. You have to not only be willing to see it through their eyes, but also feel it the way they might. Getting to that level requires a holistic attention to detail. After all, how much of what we feel is defined solely by our verbal interactions with someone? How much comes from environment, ambiance, touch, visual details, perceptions, waiting times?

In 2001 Susan and I were living in Paris. No, there are no buts, it was that cool. One weekend in July started like so many others. We descended into the local metro station, Odeon, out of the sun and into the belly of Paris. After an hour of riding, including a transfer to a regional train, we began the ascent back towards the surface. The first thing we saw was a giant, antiqued sign proclaiming our location to be Main Street U.S.A. It was utterly surreal. On one corner was a 1950s themed ice-cream parlor. Across the street was a video arcade. There was even a mini Statue of Liberty. Somewhere in the distance Its a Small World After All was floating through the air.

At that moment, we weren’t in a field outside of Paris, we weren’t even in France. We were in Disney’s world. We were 12 years old, wide eyed and ready to run through the park at 100 miles per hour. They had gotten every detail right. The writing on the street signs, the food vendors, even the rides. It was a classic Disney experience.

Disney is a master of designing for experience at its resorts. That’s not a young French girl playing Snow White. It is Snow White. That’s not a facade in front of a concrete building, it is an honest old-time ice-cream pallor. It has to be, because if we saw behind the curtain, if the magic were revealed, then our brains would instantly unplug from the illusion and we’d feel like we were, in fact, in a field outside Paris, or marsh outside Orlando.

The challenge with designing for experience in healthcare, and probably most businesses, is the historical precedent of designing by censuses and compromise. Politics have become part of our corporate culture. If we do X, does it upset the person in charge of Y? If so, what is the compromise? And there’s the rub. When we compromise to satisfy internal politics or business pressures, more often than not, we are making an even bigger compromise for the patient. It’s how we get the 4 AM blood draw.

The PocketPC and importance of the foot fetish

In 2002, I had a PocketPC device. Its marketeers clearly took liberties with the size of the average pocket, but nonetheless it was a fairly compact thing for the time. It had a stylus-based touch screen, miserable handwriting recognition and very limited Windows PocketPC software. But, I like to live on the cutting edge with gadgets, so I picked one up.

What I really wanted was to watch movies and TV shows while at the gym. The problem was that it used some obscure file encoding. Not only that, the videos had to be perfectly formatted for the screen size. I found that if I ran a video through two different programs on my desktop PC, I could manipulate the file enough that it would usually play on the PocketPC.

I was the only one at the gym watching their own personal video screen.

I’ll never forget the reaction of a friend who saw me on the elliptical one day: “you really are a huge nerd aren’t you?” It was a friendly jab. At least I think it was. Fast forward to today, almost every runner on a treadmill has an iPod, iPhone or small personal device. This morning I saw one musclebound guy in a weight belt and tank top entering reps onto his iPad which he carried with as much pride as his protein shake. I dare you to call him a nerd.

What once was once a niche use case, is now the norm.

This summer, at Stanford’s Medicine 2.0 conference, the precursor to the recently announced Medicine X series, Dennis Boyle from IDEO spoke about design thinking. He flashed up a slide of a stocking clad leg disappearing into a bright red high heel shoe. “If you want to make the best shoes, ask someone with a foot fetish to review them, they know more about shoes than you do,” Boyle told the audience. What a line!

The past few years have given rise to a new term, e-Patients. These paradigm changers are empowered, engaged, informed, and most of all, desiring to participate in their care and planning as an equal peer. An e-Patient can be someone who googled symptoms before going to the doctor, or someone who studies their lab results with the veracity of a Rhodes Scholar.

The Pew Internet and American Life Project reports, “one in five Americans have gone online to find people with similar health concerns.”

Still, not everyone one is convinced. One doctor privately quipped to me, “thats just what we need, more people using Dr. Google.”

I understand his reaction. The perception is e-Patients come with inaccurate information, too many questions, or have unrealistic expectations of a doctor’s availability. That misses the mark. The value of e-Patients, in addition to arugably reducing the burden on providers, is as the extreme use case. What if they are high-contact and high-need? Embrace it. They are the early PocketPC users who can tell you why using two programs to put videos on a device is seriously flawed. They are the ones with a foot fetish who can tell you why that color red isn’t ideal.

They are the ones who can tell you why a 4 AM blood draw is not a good idea.

Facing the future

Designing for experience in healthcare requires a wholesale change to the way we plan for and implement services. Rather than design by committee, teams need to focus on putting themselves in the patient’s perspective. If you want the ideal inpatient blood draw, sleep in a hospital room, and have someone wake you up at 4 AM two days in a row. By the third day, you’ll have some creative ideas for solving the problem.

Boyle suggested being pushed around your hospital in a wheelchair, not once, but hundreds of times. See if from the eye level of someone sitting down. You’ll notice how most nursing stations have counter tops higher than the eye level of someone in a chair. A hospital CEO once remarked to me, “you know it doesn’t really matter what art we put on the walls, all of our patients are laying down and only see our drop tile celling, and man is it ugly.”

Designing for experience also requires a high degree of empathy for the customer. It means you have to open yourself to feeling what they feel. Imagine being scared or confused or sedated. Empathy means thinking about what you would want in the same position. Have you sat waiting for 45 minutes in a doctor’s waiting room? Do you like it? Then why do we think our patients will. There are solutions to these problems, but they require us to design for the patient experience, not the personal or political needs of the organization.

If you think designing for end user experience comes at a high cost or the sacrifice of revenues, just look at Apple’s current market valuation. It can be done.

Designing for experience also means embracing the fringe use cases. Look towards our most frequent users, our e-Patients or our squeakiest wheels. What can they tell us about what works and what doesn’t? What feels like fringe today will probably be the mainstream of tomorrow. Do we want to be ahead of it, or behind it?

Experience is a differentiator. In describing my experience at Thomas Keller’s restaurants in this post, I said I expected the food to be amazing; it’s was a given. What makes the meals memorable are the experiences. It is the same thing which sets Disney’s parks apart from Six Flags. The Disney visit is a complete experience. It is the same thing which has made the Ritz-Carlton a world famous brand. We make choices based on emotion first, and reason second. Emotional connections are made with experiences. We expect excellent clinical care whenever we walk into a hospital. (If it’s not excellent, we have bigger problems.) Experience makes the competitive difference.

If we want a healthcare system which works, is high quality and patient focused, we have to start designing for experience.

“What keeps you up at night?

“A bad service.” – Thomas Keller

I’ve become very interested in ‘design thinking’ and experiences lately. Certainly, it was a common theme in Steve Jobs’s life. As I’ve devoured Icason’s biography on Jobs, some of the parts I’ve been most drawn to focus on his attention to detail over experience. Setting his flaws aside, and he had many, he insisted on perfection, not just with the physical aspects of his products, but how people interact with them. The Apple stores are a great example. He obsessed over the glass details, the color of the stone on the floors and even the font on the bathroom signs. He believed that attention to how people interact with Apple and its products was a differentiator. I think he was right.

I’m about as passionately devoted to all things Thomas Keller as I am all things Apple. Keller is known throughout the food world as the only chef with two Michellin stared restaurants. Keller, like Jobs, is obsessed with details; not only the details of his food, but of the diners experience.

In this recent CBS profile and interview, you get a taste of Keller’s appreciation for experience. I’m convinced he is one of the few other leaders who truly understands the importance of designing for experience.

Last month, I was in Las Vegas. I’m not much of a gambler, but I do love to eat. Keller has a less formal set of restaurants called Bouchon. Bouchon locations are based on classic french brasseries. It did not disappoint. I had the opportunity to chat with one of the bartenders – it’s my custom to sit at the bar when I’m traveling and eating alone. I asked what, if any, special training they had regarding service. “Well, it’s interesting,” he started,  ”so we make our own bitters and infused spirits, and we use this green masking tape to label them. Keller insists we cut the tape with a razor blade rather than rip it. Diners will never see these things, but he still wants it to be perfect.”

It took me a while to understand how his answer related to service. In talks I give, I often use a picture from the Per Se kitchen I took when we ate there and toured it in 2008. In each kitchen, Keller mounts a plaque which reads: Sense of Urgency. Our waiter and Per Se tour guide explained it. “In everything you do, wether it’s putting sauce on a plate or folding a diner’s napkin, do it like its the most important, the only, task in your life.” Trimming the masking tape with a razor is the same thing. If you take the time to do it precisely, you’ll also take the time to make the drink precisely.

Dining at a Keller restaurant is a complete experience. It’s not about the food alone. In fact, given the prices of a meal at his flagships, the expectation is of a stellar meal. If you had anything less, you’d leave questioning it. The differentiator, the thing that takes it from amazing food to memorial experience is the combination of the service, details, ambiance and food. Each dish is put on the exact right plate, for example. The size and shape is not only a compliment to the food, but how you are supposed to perceive it. Something whimsical and playful, like crispy fried pigs tail (hey, this vegetarian thing is a recent change), comes on a curved, wavy dish. Something fancy and formal like “oysters and pearls” gets a more elegant treatment. And that’s all by design.

How often do we design for experience in healthcare? There is a lot of emphasis on process design, particularly with lean and six sigma tactics. But do we really design things around how patients and visitors interact with our spaces and services? It’s virtually guaranteed that a phrase like ‘excellent clinical care’ is in almost every hospital’s mission statement, and even more certainly its marketing. But isn’t excellent clinical care the baseline expectation of everyone who walks in? I know I never expect to be treated incompetently. I’m not suggesting we stop focusing on safety and clinical quality. I just think we need to give some serious thought to everything else – the spaces, the service, the process, the ebb and flow, the details, the look and feel, the ambiance. We need to design our products and services with the end user in mind.

The following is a guest post from my father, hero and best friend George Dawson. 

“Illness is the night-side of life, a more onerous citizenship.  Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.”  ( American author and activist, Susan Sontag Illness As Metaphor (1978)).

My citizenship in that other place began on August 4, 2011.  It came without much time to get ready. The week started with a routine visit to my primary care physician and ended with a diagnosis of cholangiocarcinoma (cancer of the common bile duct) at Johns Hopkins.

For the past 30 years I have been a hospital CEO.  Cancer caught up with me two months before my scheduled retirement as President and CEO of Centra, a 6000 employee health system serving central and Southside Virginia. Aside from several outpatient procedures,  I had never experienced a significant illness or injury.  In some ways my professional career prepared me to be a patient.  I am still learning about the gaps in that readiness.

Throughout my career I have been very interested in what we have come to call ” the patient experience.” Centra, like many health care systems, has focused intently on patient satisfaction and the various related topics and measures of how our patients feel about their care.  We have been students of Quint Studer and his ideas about how to better serve.  We have listened to Fred Lee tell us how Disney would do it.  And we have benchmarked our performance against other healthcare systems using metrics from Press Ganey and the CMS HCAPHS reports.

As a patient,  I am learning new perspectives.  One of these has to do with the loss of personal identify I felt as I entered Sontag’s Kingdom of the Sick.  In the Land of the Well, people know who I am.  Certainly this fact relates, in part, to my role as the chief executive of a large organization in our community.  But it’s more than that.  People also know me as a husband, a father, a skier and a guy who grows heirloom tomatoes.  My friendships and associations go back 30 years. Just as each of us has a distinct fingerprint, every one of us has an identity that is unique and personalized.

When I became a patient, I felt this identity slipping away.  Immediately the focus was on my illness and treatment.  There seemed to be little time to understand or consider the person who was hosting this particular cancer.  I found myself trying to engage my nurses and doctors in conversation to establish some identity as an individual.

In one sense, my feeling of personal anonymity is the product of a good thing.  I chose my doctor and Hopkins as the place for my surgery because of their expertise and the large number of surgeries they perform on cases like mine.  Some 300 patients a year receive Whipple procedures at Hopkins.  It is a long and complex procedure and involves significant post-op care. I was an inpatient for nearly two weeks.  At Hopkins the clinical pathway for this procedure is well established.  Everybody on the treatment team knows each step of  the process and his or her role.  This is one reason why Hopkins has excellent outcomes for Whipple surgery patients.

At Centra we don’t perform Whipple procedures,  but we do plenty of high volume procedures with excellent outcomes. Examples include cardiac cathertizations, total joint replacements and breast surgeries.   Each has a well established clinical pathway and a clearly defined process.  My time as a patient makes me wonder how well we understand  and accommodate the uniqueness of each of our patients. How often do our patients feel the same loss of individual identity that I have felt?

Some specific ideas:

• It is about taking time to ask and listen to patients.  In our daily rush to complete the social history screen in the Electronic Medical Record,  do we really ask our patients who they are and listen to their  response?
• It is about the symbols and customs we adopt.  I have developed a adverse reaction to hospital gowns –  the kind that are split up the back.  For me the gown has become the symbol that I am in the Kingdom of the Sick.  When I put one on,  it’s a little like surrendering my passport.  I wonder what other unnecessary symbols and props we have adopted in healthcare.  And I wonder how often they serve to protect our status and control  rather than serve our patients interests.
• It is about the fragmentation in healthcare.  Specialized intensive care units, hospitalists and multiple consultants  have lead to greater clinical quality and efficiency.  At the same time they are barriers to really knowing our patients.
• It is about information.  The better we understand  the clinical pathway,  the greater our opportunity and responsibility to explain it to our patients.  If we listen as we do so,  we have the opportunity to understand what alterations or modifications are needed to meet each patient’s unique needs. In doing so, we have a chance to increase patient ownership and responsibility for recovery.  If we leave the patient out of the information loop the best we can hope for is a passive partner in the process.

I understand the difficulties those of us in healthcare face.  Short length of stays, pressures on productivity,  the complexities of our professions are real challenges. My lifelong  experience in healthcare management tells me pressures like these make it hard.

So I will leave  you with just one  question,  how well do you really know your patients?

Have I told you how much I love Amazon? Its the awesome! Let’s say I need something – an external hard drive (because I do…for back ups, but thats another post). So I goto Amazon and I type in “external hard drives”. Boom. I get a list of, not surprisingly, external hard drives. Which one do I chose? Fortunately, Amazon has some great data and filtering options. I want a desktop drive, not portable, so I filter those out. Next, I sort by popularity, which ones have sold the most. Among the top three sellers, I can then see which have the most user comments. From there I can drill into the comments to see what people have to say. Pretty soon, I know exactly which drive fits my price, features and quality expectations.

Why does Amazon’s shopping experience work so well and where is the analogue in healthcare? 

Amazon works because it plays into how consumers make choices. We are fickle things, us humans. Our behavior around choice is often described as fuzzy; we are both logical and emotional at the same time. Which hard drive’s case looks cooler? Amazon’s visual layout tackles that problem. Which one fits my practical needs of price and size? The filter settings help me narrow the list down. Finally, which is better? Which drive do other people like the best, and why? Which one sold more? Those are qualitative data points. We intrinsically value something which has sold more; usually for good reason. If two products are similar (price, features, etc), we go with the wisdom of the crowds.

How do people pick a surgeon? 

If someone is going to cut you open, how do you pick who does it? There is no Amazon for surgeons. There is no national site where you can type in “ACL repair” and see a list of smiling faces in white lab coats. You cannot then filter by cost, or star rating or – as I’ll suggest is most important - number of cases. This is a potentially life altering decision and yet according to the American College of Surgeons,  most people spend less time making it than they do researching a vacation.

There are a few ways to look at  statistic. Perhaps people aren’t as invested in the decision as they are where to sip mahitahis. But I don’t think that’s the case. I think people do care who cuts on them. We just don’t have any way to do the research. There is no Amazon for healthcare.

Right now, there is no way for consumers to comparatively shop for a doctor. So what do we do? We let another doctor tell us which surgeon to see. Hopefully its a good fit, and we like that surgeon. That’s a little like buying a car based off what a mechanic suggests; not entirely a bad thing. But, where is that mechanic’s vested interest? How do you know, based on recommendation alone, how reliable that car is?

A few weeks ago, Ed Lovern published a post on his great blog asking, “will consumers really use data about hospitals to make choices?”  Ed questions if people really use CMS’ HospitalCompare site to view quality measures across different hospitals. I share his skepticism. I think the data is largely abstracted and of little value to consumers. When I shop on Amazon, I don’t want to see which brand is most popular, I want to see which exact hard drive more people buy. We need to get to the procedure and doctor level.

In a 2003 speech, then IHI Director, Dr. Don Berwick called for a request for proposal (RFP) form hospitals who wished to preform his knee replacement. Dr. Berwick’s first requirement was “Don’t kill Don.” He went on to add:”report your current frequency of injuries…Demonstrate your awareness and use of the ‘Dartmouth Atlas and eliminate excessive care…show your measurement of functional outcomes and your total knee replacements…”

Its is that simple.

There needs to be a national database listing the number of cases, costs and complications. Adjust it by risk so very skilled surgeons who take on more complicated cases are no penalized. Publish it. Make it searchable, sortable and filterable. Let physicians upload videos about their philosophy of care so we can also factor in the important emotional aspect in decision making. Let patients leave comments about their experiences. Give us the tools to make the educated choices about our own care.

A start would be simple raw data on volumes. Each doctor should, on their website, publish the annual number of cases they do for each procedure the preform. Start there, so – knock on wood – should I ever need a total knee replacement (who are we kidding…not should, when), I can find the doctors who have done the most. Do you want someone who does 10 a year or someone who does 400 a year? Who gets more practice? From there we can begin to add data points like length of stay, total cost, complications, etc. We deserve this kind of data.