Who Should Manage Your Social Media Strategy [Accepted for publication in The Physician Executive]

By Kent Bottles, M.D., and Tom Sherlock

Hospital and medical group leaders are facing the most challenging healthcare environment in recent memory. The need to decrease per-capita cost and increase quality to respond to federal healthcare reform and the global economy is a daunting task that requires two-way communication with a broad range of stakeholders. As reform unfolds, hospitals and medical groups of all sizes are embracing social media tools as soon as they realize that they're no longer optional.

At least since the first quarter of 2010, analysts have been reporting that websites and search engines no longer dominate online communication.[i] Deloitte's Social Networks in Health Care[ii] recently concluded that healthcare executives “who do not consider how to incorporate social networks into their future strategies risk being run over on the super-highway of health information sharing.”

Your social media strategy will work more smoothly when no one department has control, because it's likely that before long employees in many of your departments will be using social media to do their jobs. It's time for your Internet strategy to be managed by a qualified person — definitely one of your best-and-brightest — who reports directly to senior management and works with all department heads as an equal colleague.[iii]

You no longer have the opportunity to be an early adopter, but you can give yourself a big advantage by having people in every department who've been trained how to use social media intelligently, and who follow the lead of your social media manager. It's essential that you understand that each of these tools is designed to nurture personal relationships and thereby strengthen loyalty to your institution:

• We use Twitter as our principal example because it's a more important business tool for hospitals and medical groups than Facebook.
• If your organization isn't already on Facebook, you should wait until you have a specific strategic reason for using it.
• Blogs can be particularly effective business tools if they let readers get to know and understand the blogger. Paul Levy’s "Running a Hospital" blog[iv] has shown how a CEO blog can be a powerful communication and branding tool.
• Many of your people should be listed on LinkedIn. Each person's profile will be unique, but a certain amount of coordination is necessary to make sure your institution is identified accurately and consistently, for example.
• Your YouTube channel can present videos that let people get to know some of your key physicians and nurses, for example. Your social media manager can see to it that the content, style, and production values of your videos will send the right message about your organization.

You might conclude that you need to hire someone new to manage your website and your social media strategy. But don't rush into a decision to bring in someone new to be your social media manager just because they have experience with these tools. It would be far better to find someone who is already thoroughly familiar with and personally committed to your institution.[v]

Note right away that social media is not something you use for advertising or marketing, and that it doesn't duplicate or replace any of the functions of your website. When you reduce it to its fundamentals, social media strategy isn't complicated. It's social. It's about establishing and nurturing authentic relationships in ways that will build loyalty to your institution. Your social media manager will:

• Listen to what's being said about you anywhere on the Internet, with special attention to your own social media channels.
• Respond by engaging those who are talking to or about your organization.
• Establish relationships by showing people respect, honesty, and enthusiasm, and then nurture those relationships by authentic personal interaction. Your social media manager will gradually get a feel for how much time to put into each of the relationships that are established.
• Bring to your attention the insights and opinions he's hearing and the facts he's learning so that with his help, you can evaluate any implications for what you do and how you do it. Not all feedback is valuable, but some of it certainly will be. Senior management should balance a healthy skepticism with openness to input from people who use social media to tell you something.

There really are no social media experts, because we're all still trying to find the best ways to use these tools.[vi] One of us has been on Twitter since June 2008, and one of us is among the most influential physician twitters according to several metrics. We each spend at least two hours a day on Twitter, and yet we cannot claim to be an expert on how you should use Twitter or the other tools — because your social media strategy will have to take into account a unique combination of goals, strengths, target audiences, and local concerns.

Adopting an effective social media strategy involves a challenging but rewarding process of discovery that must be done in-house. A smart, creative consultant with significant experience in healthcare social media can fast-track the process by explaining the basics and best practices, and by helping your social media manager learn how to consistently create content that interests your target audiences.

Social Media Does Not Belong in the IT Department

It's surprising that anything that has to do with the Internet is sometimes still assigned to the IT department. Websites and social media aren't primarily technical matters, and social media may eventually take 50% or more of your social media manager's time (your social media manager should have responsibility for your website too). The rest of his or her time might be spent on content development for your website and keeping up with the literature.

While some IT people may enjoy doing web design, website maintenance, and now social media, one may presume that they were hired to do something quite different. The skills required for IT are a world away from those needed for social media.

Nearly a decade ago, a technical headhunting firm was trying to determine why the Web developers they sent to their clients were striking out so often. The problem turned out to be that they were requiring that a web developer have at least three years' experience with the C++ programming language. They were sending programmers to do a communicator's job. Programmers (and graphic designers) aren't usually the people who have the combination of writing, communication, and relationship skills that are needed to ensure that your Internet strategy supports your overall business strategy.

Social Media Does Not Belong in the Marketing Department

One of your marketing people may be best qualified to be your social media manager:

• if she's a creative, energetic, and enthusiastic person who is not the least bit cynical or world-weary;
• if she's enthusiastic about social media, is already using it on her own, and talks about it every day to anyone who will listen; and
• if she understands that Twitter and Facebook are not marketing platforms. As recently as just a couple of years ago we spoke of “social media marketing” — but no more, because that phrase sends the wrong message.

Because developing and nurturing relationships is the whole point, social media can't be effective if it's automated in any way, and for the same reason outsourcing your social media strategy and execution to a marketing agency or other vendor is almost always a bad idea. Agencies may try to persuade you to entrust social media to them, but that's calculated to meet their needs, not yours.

Studies suggest that people like brands with an authentic personality, and your social media manager is going to be out there on the front lines every day, using his or her own name, showing people who you are — and doing and saying things that give people reasons to be loyal to your organization. That's got to be done in-house by someone who understands your organization and is personally committed to it.

You might find that someone in your marketing department is the person best qualified to be your social media manager. If that's the case, that person should begin reporting directly to senior management, and should be relieved of his or her duties in the department. As already mentioned, many people in your organization are going to be using social media as part of their jobs, and you can eliminate potential obstacles by keeping responsibility for your Internet strategy independent of any one department.

What to Look for When You're Selecting a Social Media Manager

Your social media manager should have easy, informal access to senior management, and should attend top-level meetings at least once a month. The position is that important, and you do need to be personally involved at least to this extent.[vii] If the person you're considering as your social media manager is not someone you would look forward to meeting with, then he or she isn't the right person.

Many hospitals and larger medical groups will already have a person with the qualifications to be social media manager somewhere on staff, but he or she may not immediately come to mind. Don't assume that social media is something that's best suited for women — or that it's just something the kids are doing these days.

You're looking for a remarkably intelligent person with the following qualifications and characteristics, a person who might be male or female, younger or older:

1. Someone You Can Trust. You want someone you can trust without hesitation, someone to whom you're willing to give everything — including confidential information about current challenges and future plans — that will enable him or her to do the job. Social media tools can be used to build trust in your institution, but the process must begin with your trusting your social media manager.

2. An Accomplished Writer. You want someone who welcomes the opportunity to write all day every day. This rules out many of your people, but it's essential. You might even initiate your search by asking everyone who works for you to identify themselves if they really enjoy writing.

3. Creative Imagination. A successful social media manager will have the ability to see possibilities and connections in everything he sees, hears, and reads. To build a list of followers, he has to give them a reason to follow — and interesting, informative tweets are what that's about.

4. Organizational Skills. Twitter's constant barrage of facts, opinions, and ideas must be tamed if it's going to benefit your organization. Managing social media for an organization involves coordinating social media strategy throughout the departments, and it means keeping databases or lists of followers, people being followed, and contacts made, for example. These can take Twitter's free-flowing stream and turn it into an organized system.

5. A Charming Personality. You want a genuinely nice person with an outgoing personality — a good listener who finds it easy to establish professional relationships with people, and who can respond to people who are annoying or idiotic without becoming hostile or sarcastic.

6. Generosity. You want someone who can tweet generously about other healthcare institutions and organizations in your community, including your competitors when they do something worth noting or congratulating. This is social media, and promoting your community in this way will enhance your reputation (and confound your competitors).

7. Empathetic Listening Skills. You want someone who can interact honestly and ask and answer questions with genuine empathy — because if people feel that their concerns have been validated, their respect for your organization will grow.

8. Honesty and Diplomacy. You want someone who will speak truthfully because she feels a deep sense of responsibility to the people who follow her on Twitter. You need someone who will be able — after consultation with senior management when that's called for — to deal unflinchingly with controversial matters, as part of crisis management, for example, or when a hot topic that might impact your organization — like the role of the physician vis-à-vis the role of the nurse — is being discussed.

9. Good Judgment. Look for a person who will not embarrass your institution, his colleagues, or himself — or reveal confidential information of any kind. Interesting tweets will sometimes be provocative, but you want someone who understands the critical distinction between being intelligently provocative and being irresponsible — someone who is aware of the line and doesn't cross it.

Hiring the right person to be your first social media manager will ensure that your hospital or medical group will use these essential tools to compete effectively. Hiring the wrong person, or not embracing social media at all, is a recipe for failure in a rapidly changing healthcare environment.

Kent Bottles, M.D., is a former medical school professor, president and ceo, chief medical officer, and chief knowledge officer who is now an independent health care consultant, keynote speaker, and writer.

kentbottles@gmail.com and http://twitter.com/KentBottles

Tom Sherlock is an Internet strategist, Website producer, and content developer who has worked with businesses and healthcare professionals since 1994. tom@aicolorado.com and http://twitter.com/ColoradoHealth
Sidebar: Some Major Social Media Tools

Facebook — a social networking community originally for college students, then expanded to include high school students, and since September 2006 available to everyone; founded by Harvard student Mark Zuckerberg and friends in February 2004; in October 2007 Microsoft bought a 1.6% share of Facebook for about $240 million.

Jumo — a new social network for “people who want to change the world”; launched in a beta version on November 30, 2010; founded by Facebook co-founder Chris Hughes, who designed and managed the social networking systems used by the Obama campaign.[viii]

Linkedin — a business-oriented social network of more than 75 million professionals from around the world; founded by Reid Hoffman and former employees of Paypal and Socialnet.com; launched in May 2003.

Twitter — a social networking and micro-blogging service where updates are displayed on the user's profile page and instantly delivered to other users ("followers") who have signed up to receive them; founded by Jack Dorsey and Biz Stone; launched in October 2006.

YouTube — a video-sharing service founded in February 2005 by former PayPal employees Chad Hurley, Steve Chen and Jawed Karim; bought in November 2006 by Google for $1.65 billion in Google stock.

---

[i] Jim Tobin notes in Mashable/Business that some major websites are starting to get more traffic from social networks than from Google http://mashable.com/2010/10/22/social-media-optimization/ Also see Justin Kistner: “Social is now dominating time spent online — and brands aren’t keeping up,” Useful Social Media Blog, Nov 2, 2010 http://bit.ly/cRG0HM

[ii] https://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/US_CHS_2010SocialNetworks_070710.pdf

[iii] Because of the focus of this article, we'll call this person your "social media manager," but you will actually want him or her to be your Internet strategy manager, with responsibility for coordinating all aspects of your institution's use of the Internet.

[iv] http://runningahospital.blogspot.com/

[v] During the 2008 political campaigns, many candidates simply hired to a college kid to "take care of" social media for the campaign. The results were often pathetic, and the campaigns were unable then or now to evaluate the lost opportunity. Many of these kids knew how to communicate with their friends, but actually interacting with voters and activists was not even on their radar. We strongly recommend that you reject suggestions that you hire an intern to "take care of" social media for your hospital or medical group.

[vi] Bill Sweetland at ragan.com is a teacher who knows how to use humor to make his points — by poking fun at social media "experts," for example. See “A short guide to the clichés of social-media speak” http://bit.ly/cfEeT5 and “The Don Draper guide to social media marketing” http://bit.ly/atBmQe

If you decide to hire a consultant to guide your organization, ask first to see a resume that includes information about his or her personal experience with blogs, Twitter accounts, Facebook pages, and other social media tools. Have one of your people follow applicants' Twitter timelines long enough to determine whether they're worth your time and money.

[vii] See Joe Stanganelli: “C-Suiters Out of Touch With Social Media,” Internet Evolution Oct 27, 2010 http://bit.ly/drrdIz and Leslie Gaines-Ross: “Why So Few Tweets from the C-Suite?” Harvard Business Review blog,” Oct 12, 2010 http://bit.ly/cF9NHu

[viii] “We’ll be matching people based on their skills and interests with organizations around the world that need their input,” Hughes said. “It’s a discovery process that first matches, then helps people build relationships, then lets people share their resources.” http://www.fastcompany.com/1587959/facebook-chris-hughes-jumocom See http://jumo.com and http://blog.jumo.com/

Twitter: An Essential Tool for the Physician Executive [Accepted for publication in The Physician Executive]

Every morning at 5:30 AM, I am at my computer scouring the Wall Street Journal, the New York Times, the Philadelphia Inquirer, and other news sources for articles about health care and wellness. These articles are then summarized in 140 characters with a link to the original article and tweeted. As of today there are 3070 followers of my informal aggregated health care news service, and I hear about it if I am late or slack off on the job. My twitter community depends on me, and I depend on them.

Twitter has transformed my professional life as an independent physician executive consultant-keynoter who advises health systems and medical groups. Twitter is the main tool I use to monitor the latest developments in the world of health care delivery, payment reform, and physician integration.

I follow about 1,000 health care professionals on twitter, and I often learn about developments in real-time long before they hit the newspapers and journal articles. A few months ago, I was preparing a keynote for a Governance Institute Conference on Social Media for Hospitals and Doctors. One of the people I follow on twitter mentioned a Deloitee Touche white paper on just this subject. I looked it up and included some of their findings and recommendations in my talk (http://ow.ly/29QZy). Without my twitter community, I would probably have never seen this valuable resource.

My Twitter Community

My twitter community has become an extremely powerful resource for my professional development. When I mentioned in a tweet that I was going to be in Boston speaking at a World Health Care Congress last year, three of my followers suggested we meet in person to discuss health care transformation. Instead of having room service alone in my hotel room, I had a delightful lunch with @janicemccalum and an informative dinner with @healthblawg. In between conference sessions I also networked with @susancarr. Janice McCallum is a digital publishing expert and product strategist who specializes in data analytics. Months after our lunch, Janice invited me to attend 2010 Data Content: The Infocommerce Conference in my hometown of Philadelphia where I learned how construction, chemical, and legal ratings companies are managing data in the digital age. Healthblawg in real life is David Harlow, a well known health care attorney who has become my go to guy with legal questions about reform. Susan Carr is the bio editor of Patient Safety and Quality Healthcare Magazine, and I now have a new resource in this area.

In December I hosted a holiday potluck in my home so that Philadelphia area members of my twitter community could meet in person. It was really an enjoyable event to finally put a face to a twitter buddy who I had been learning from for years. Attendees included a health care economist, a customer relationship marketing director from a pharma company, a CEO of a healthcare innovation company, a nurse entrepreneur, a children’s hospital executive, a University of Pennsylvania senior, a biotech start-up executive, and a mergers and acquisitions managing partner. Business cards were exchanged and who knows what will develop, but I now have met several of my twitter community and feel even closer to them.

Getting Speaking and Consulting Gigs

There is no doubt in my mind that my online presence has led to keynote and consulting opportunities. When Swedish Hospital in Seattle was planning its 100^th Birthday Celebration Conference, Melissa Tizon, communications director at the hospital, contacted me to speak on payment reform and social media; she told me she followed my tweets and knew I was the right person for these subjects. While at that conference I got to meet the CEOs of GE and Epic who also spoke during the program.

When Pamela Lewis Dolan of American Medical News wrote about the new Mayo Clinic Center for Social Media she quoted me because I was a well-known active physician tweeter. (http://www.ama-assn.org/amednews/2010/08/09/bil20809.htm) Several keynote clients of mine have stated they first learned of me from this news article.

My Research Department Works for Free and Is Scattered Across USA

I remember distinctly marveling at how Procter & Gamble taps into freelance inventors all over the world to come up with more than half of their new consumers products. Little did I know when I read about this example of mass collaboration in Wikinomics: How Mass Collaboration Changes Everything (http://ow.ly/3kvWP), I would soon be able to apply this same principle in outsourcing for free my research needs as a consultant to hospital systems and medical groups.

Last year I was preparing to facilitate a medical staff board retreat on Computer Physician Order Entry (CPOE) and Information Technology for a hospital in the West. As preparation for the weekend session I wanted to send a white paper to all the participants, but I had trouble locating the perfect document. I typed a cry for help to my 1000 twitter followers: “In need of white paper on getting doctors to accept CPOE.” Within a day, @ahier, a health care information technology expert in Oregon who I have never met face to face, emailed several overviews that worked perfectly.

This month I woke up early to check out twitter before heading off to help with a leadership training academy for a health care organization that is seeking to transition from a manufacturing company to a solutions shop. I noticed that one of the healthcare professionals I follow (@lizasisler) posted a tweet with a link to a blog post about the potential uses of Microsoft’s Kinect technology for health care. After reading the link, I used the information in my presentation to the leadership academy 5 hours later the same day. How is that for just in time research from an unpaid colleague who lives in Cleveland? (http://ow.ly/3kwOm)

Twitter & Conferences

As I write this on December 6, 2010 I noticed in my twitter feed that I can follow today’s 2010 Mayo Clinic Health Policy Center Symposium, Achieving the Vision: Advancing High-Value Health care by following the hash tag #mayohpc. Most of the conferences I attend now encourage participants to tweet during presentations so that a permanent record of the conference exists on twitter. Tweet streams allow me to keep up on conferences that are too far away or too expensive for me to attend, and I can read them when I have time (not necessarily in real-time).

Martin Ebner (http://www.slideshare.net/mebner/how-people-are-using-twitter-at-conferences) has studied the use of twitter at conferences before, during and after a conference. I certainly learned the utility of twitter before the 2010 ICSI Annual Colloquium. When I used twitter in the weeks and months before the meeting, I was able to attract participants from all over the country to sign up, identify speakers who were experts on innovation in health care, and discover hot topics that were being discussed on twitter.

During the conference, twitter can encourage networking between participants. Ebner found that attendees used twitter to share resources, communicate with others, participate in parallel discussions, jot down notes, establish an online presence, and pose organizational questions. Ebner quotes two participants, one with a positive view of twitter at conferences and one with a negative view:

“In the background we discussed things more deeply than the guys on the stage.”

“Twitter can be distracting – you pay less attention.”

After the conference, the tweet stream from a conference can also be used as a permanent record of the discussion, and it can extend the conversation for days and months after the actual event is over and everyone has gone home.

Twitter has become an extremely powerful professional tool for me as an independent physician consultant/keynoter.

Kent Bottles, MD lives in Philadelphia where he is an independent health care consultant, keynoter, and writer. He can be reached at kentbottles@gmail.com or 610 639 4956

Community Hub of Wellness & Health (CHWH) In Accountable Care Organizations (ACOs)

Hospitals are going to change. What worked in the past will not work in the future. The passage of the federal health care reform law and the inevitable transition from fee for service to global payments is changing the rules of the hospital game. Hospitals will have to make do with less financial support from both government and private payers and at the same time deliver higher quality health care with measurably better outcomes. Hospitals will take care of fewer and fewer patients as care continues to migrate to the outpatient setting, the home, and wherever citizens live carrying their smart phones. The development of Accountable Care Organizations (ACOs) to receive and distribute these global payments will affect hospitals whether they decide to take a leadership role or a wait and see attitude. There will be winners and losers among hospitals; there will be fewer hospitals in America in ten years than there are today in 2011.

Hospitals that survive this transformation of the health care delivery and payment system will become the community hub of wellness and health (CHWH) that citizens turn to in a time of rapid and chaotic change. Becoming a CHWH will require hospitals to expand their services and expertise well beyond the traditional role of an acute care facility. It will also require hospitals to embrace social media and disruptive digital tools that are now available to help care for a defined population living in the community. Hospitals will have to forge a new culture or their ACOs will fail, no matter how sophisticated and expensive their legal structures and physician integration plans become.

Hospital leadership seems ill prepared for this transformation in mission. Robert Naldi, the CFO of Maimonides Hospital in Borough Park, Brooklyn, is not alone when he says, “I don’t spend a lot of time thinking about global issues. When I hear Medicare is being cut six billion dollars over the next ten years, Medicaid cut four billion dollars the next, that ten billion dollars doesn’t change what I do on a Thursday morning…. I don’t spend any energy forecasting the next three or four years, because I don’t think anyone can do that. We’re lucky if we forecast the next six months, things change so rapidly. I just don’t waste time on it.” (http://ow.ly/3Dlxp)

At a time when the most sweeping federal health care legislation since the 1965 Medicare law has been passed, someone in hospital leadership or the hospital board should be spending “energy forecasting the next three or four years.”

In the present payment system, hospitals are profitable when they are filled to capacity doing surgery, generating laboratory results, and producing imaging studies. Hospital administration and specialists have the most prestige and power, and the culture of the system reflects this reality. In a global payment system, the ACO caring for a defined population will do well when patients are successfully treated at home and managed so that hospitalizations are avoided. Primary care physicians will be instrumental in this new approach to care that emphasizes prevention and only essential testing, imaging, and referrals to specialists; the old specialist centered culture will be challenged by this new reality.

Some hospital leaders are taking a wait and see attitude because of the federal court challenges to the individual insurance mandate and the November 2010 election results of a Republican dominated House of Representatives that wants to repeal the federal health care reform law. National Business Group on Health President Helen Darling, a former Republican Senate staffer, says about those who call for repeal: “If they really understood it, they wouldn’t. I don’t think we’ll get a better solution in the U.S. in our lifetime. If it gets repealed or gutted, we’ll have to start over and we’ll be worse off.” (http://ow.ly/3D7Ih)

The other approach is to be proactive and plan how the hospital will take care of a defined population in an ACO. According to Mary Ella Payne, vice president of System Legislative Leadership for Ascension Health, their physicians and nurse leaders met in June 2010 and agreed that the status quo, fee-for-service system is unsustainable. Even in the absence of a health reform bill pushing the idea, ACOs make sense to Ascension Health. "Regardless of what happens with the big picture, we feel like we need to move ahead with reforming our delivery system. We felt we needed to do this because it's the right way to manage care for our patients." (http://bit.ly/glgGzA)

For those taking the proactive approach, developing the hospital as the center of a trusted CHWH will be imperative. Hospitals have not been immune to the pattern of decline of trust that has affected many modern American institutions such as the Catholic Church, Wall Street, Congress, and large corporations. Forty two percent of the public report experiencing a medical error involving themselves, a relative, or a friend; 68 percent believe medical quality is a serious problem. There is also a relationship between trust and getting patients to adhere to medical advice such as stopping smoking or losing weight that will become more important under an ACO arrangement. Twenty four percent of patients in the bottom 5 percent of the trust scale successfully changed such behaviors, while 33% in the top 5 percent of the trust scale were able to do so. (http://ow.ly/3Dm6n)

Trust will be needed in order to establish a successful CHWH, and a successful hub will also increase trust in the hospital. David A. Shore lists why trust is so important for a hospital: it allows the organization to be an employer of choice; it allows easier access to capital; it affects regulators; it allows people to work together effectively; it reduces transaction costs; it allows rapid cycle improvement work to be successful at elevating quality; and it allows the hospital to take on challenging projects that are new to the hospital’s mission. (http://ow.ly/3DqgA)

The CHWH would support the Healthy People 2020 program, which provides science based 10-year national objectives for improving the health of Americans. (http://www.healthypeople.gov/2020/about/default.aspx) Hospitals that expand their mission to include the new objectives in Healthy People 2020 such as social determinants of health and health related quality of life and well being will become more trusted in their community and more successful in functioning as an ACO. I have not identified hospitals that are mature in developing a CHWH, but there are examples of programs that fit nicely into this concept.

The Kaiser program that brings farmer’s markets into 30 hospital facilities in four states is an example of a CHWH program. (http://ow.ly/3Dodm) Dr. Preston Maring introduced the Friday Fresh Farmer’s Market at Kaiser Permanente Oakland Medical Center in May 2003; since then it has grown to include a system that supplies locally grown fruits and vegetables for 23 Kaiser hospital kitchens as well as the weekly farmer’s markets. Maring also helped establish a seasonal market at GM-Toyota's New United Motor Manufacturing Inc. plant in Fremont, where 5,000 people work. In Los Angeles, Kaiser worked with Sustainable Economic Enterprises of Los Angeles, to open the Watts Healthy Farmers' Market. That market also provides health screenings, nutrition education and other activities. Dr. Maring says, “Markets change the community. They provide good food, fun, a meeting place.” (http://ow.ly/3D) Such programs also create new trusting relationships between the hospital, farmers, food distributors, and other employers that can only increase the standing of the hospital in the community.

In the United Kingdom, the new Mansfield Community Hospital in Nottinghamshire is being designed so that there is easy access for both pedestrians and vehicles. The architects envision a hospital that is seamlessly integrated into the community and where citizens will congregate in the café located in the main entrance. (http://ow.ly/3CH7l)

The CHWH could also become the trusted repository for advice about how to utilize smart phone digital technology. Susannah Fox of the Pew believes digital devices and mobile wireless service will transform healthcare by making it portable, personalized, and participatory. She describes a Stanford Project Health Design study that helped chronically ill teens transition to adulthood by monitoring the teens’ moods by their iPod songs and the words they used in text messages. Because these patients were digital natives they agreed to a level of surveillance that would probably disturb most traditional and older patients.

The Community Hub might have advisors who could explain the smart phone applications that harness the device’s computing power, cameras, audio, video, motion sensors, and GPS. These functions are being used in new ways to manage health and wellness. For example, there are fitness and weight control apps such as Tap & Track, iTreadmill, and Calorie Counter by Fatsecret that can keep track of exercise program progress and even replace personal trainers and pedometers. Diabetics are finding apps such as Glucose Buddy and Handylogs Sugar useful, and hypertensives are buying apps such as HeartWise and My Blood Pressure and Heart Rate. There are even applications for sleep hygiene and stress reduction. Many in the community will find these technologies difficult to understand and use without a trusted community resource to guide them.

These are only examples of services that a CHWH might offer, and obviously different communities will require different services to support the health and well being of the citizens who live there. Julie Salamon’s book Hospital: Man, Woman, Birth, Death, Infinity, Plus Red Tape, Bad Behavior, Money, God, and Diversity on Steroids provides a fascinating case history of how Maimonides Hospital in Borough Park, Brooklyn tries to engage a community that is changing from exclusively Jewish to include Chinese and Pakistanis. The story of how Douglas Jablon, vice president, patient relations/special assistant to the president, connects with these diverse communities underscores the difficulty and necessity of using personal contacts and street smarts to deliver social services in a way acceptable to Muslims, Jews, and Chinese. His thirty patient representatives came from Haiti, Ukraine, Greece, Germany, Pakistan, Nigeria, and Borough Park. “Some were Ph.D.’s; others had only high-school diplomas. They were notary publics, so they could act as official witnesses to Do Not Resuscitate orders and do favors for doctors who needed something notarized.” The Maimonides ER dealings with the Hatzolah (emergency medical service run by Orthodox Jews) and Miriam Lubling (founder of Rivkah Laufer Guardians of the Sick, a major source of patient referrals) illustrate just how complicated and difficult engaging a community can be. As the COO at Maimonides observed, “You have to deal with things here you don’t have to deal with in Manhattan.” (http://ow.ly/3Dlxp)

Hospitals are going to have to decrease per-capita cost of the care they deliver and increase the quality. The shift from fee for service to global payments directed to an ACO will require a major shift in hospital culture and mission. Those hospitals that develop CHWH to provide new services in new ways will better engage their community and become so valuable that they will survive. Those hospitals that fail to change will disappear.

What Would A Truly Patient-Centered Accountable Care Organization (ACO) Look Like?

Health care leaders are busy talking to attorneys and consultants about how to set up Accountable Care Organizations (ACOs). A recent Advisory Board survey found that 73 per cent of hospital finance executives said that creating such an organization was a top priority for their health system.

Last year my most popular keynote topic was patient-centered medical home creation; this year everyone wants a presentation on ACOs.

However not everyone has jumped on the ACO bandwagon. Bruce Bagley, MD of the American Academy of Family Practice was recently quoted as saying, “There are probably no experts about ACOs. It’s a developing concept.” And Jeff Goldsmith, PhD, of the University of Virginia stated at the same conference: “I think this is a stupid idea. Managed care without the risk – that’s like gin and tonic without the gin. How do you end up making choices if you’re not forced to make them?” (http://bit.ly/glgGzA)

I started thinking about what an ACO would look like if it was truly patient-centered. What if we designed an ACO that gave patients what they say they really want?

Don Berwick wrote an article in Health Affairs in 2009 that examined what patient-centered should mean, and since he became the head of Medicare in 2010 it might make sense to start there. After all, Medicare is pushing the ACO concept by creating pilot projects and encouraging the shift from fee for service payments to global payments for medical care reimbursement.

In the Health Affairs article, Berwick defined patient centered care as “They give me exactly the help I need and want exactly when and how I need and want it.” Berwick said he was ready to move beyond words like partnership and have providers become guests in the lives of their patients.

Berwick went on to imagine that really embracing patient centered care would mean having no restrictions on hospital visiting hours, inpatients choosing what food and clothes they wanted, patients participating in rounds and the design of medical services, patients really owning their medical records, and patients and doctors universally using shared decision making aids so that patients could make wise choices knowing the inevitable trade-offs involved in picking a treatment.

Such an ACO would invest heavily in patient education and self-management programs. And these presentations would go well beyond the currently offered traditional wellness curriculum.

For example, a truly patient-centered ACO would offer technology support so their patients could harness their smart phones’ computing power, audio, video, motion sensors, and GPS modules to explore new ways to self-manage their health and wellness. There are smart phone applications for fitness and weight control, diabetes management, sleep hygiene, stress reduction, and hearing and vision assistance. An ACO that partnered with their patients to fully utilize such technology could keep their clients healthier and out of the hospital. Such a strategy makes a lot of sense if your organization is accepting global payments where hospitalizations are not incentivized.

I could even imagine a truly 21^st century ACO expanding their primary care team to include physicians, advanced nurse practitioners, physician assistants, and even robots and avatars. Dr. Joseph Kvedar of Harvard’s Center for Connected Health believes that we will need to embrace emotional automation and use robots and avatars to meet the manpower needs of taking care of all the retiring Baby Boomers. In a YouTube video he states that one Boston hospital has already found that hospital patients prefer a robot for discharge planning to a real life person. The robot has all the time in the world and does not make the patient feel stupid when they ask the same question over and over again.

At first, I had a hard time getting my head around this emotional automation concept, but reading MIT’s Sherry Turkle’s book Evocative Objects: Things We Think With has convinced me that humans have already formed trusting relationships with technology. “We think with the objects we love, and we love the objects we think with.” How many of us talk about love when we discuss our iPhones or iPads that have really become extensions of our brains? Admit it, do you sleep with your smart phone?

The Health System that designs an ACO that is truly patient-centered will be highly successful. In addition to consulting attorneys and payment reform consultants, I would suggest that health systems think about how the new disruptive technologies (smart phones, tablet computers, avatars and robots, video games, haptics, and artificial intelligence) could be used to better manage a geographically defined population of patients.

Twenty Books I Read in 2010 That Really Influenced My Thinking

1. Sarah Bakewell, How to Live Or A Life of Montaigne. This book is the best introduction in English to Michel Eyquem de Montaigne, the man who retired in 1570 to his Bordeaux estate to make wine and invent the modern essay. I had read the essays in college, but Bakewell inspired me to re-read them, which I am doing. Montaigne who lived during a time of almost constant civil war between the Protestants and Catholics is wise and has advice like question everything that works today.

2. Kathryn Schulz, Being Wrong: Adventures in the Margin of Error. Schulz really made me re-think how I view being wrong and failure. This book is hilarious, well written, but ultimately quite serious. To read a blog inspired by this book go to

http://ow.ly/3w5VC

3. Siddhartha Mukherjee, The Emperor of All Maladies: A Biography of Cancer. Both the biography of cancer and the training of an oncologist, this book is graceful, elegant, and well written. I am in awe.

4. David Blumenthal and James A. Morone, The Heart of Power: Health and Politics in the Oval Office. From FDR to George W. Bush, health care’s role in the office of the president and in American politics is dissected and analyzed. Reading this great book helps one keep the day-to-day ups and downs of health care reform in perspective. Partisan fighting and unfair attacks are nothing new when it comes to this divisive issue. Yes David Blumenthal is that guy who runs ONC under HHS.

5. John E. Wennberg, Tracking Medicine: A Researcher’s Quest to Understand Health Care. The founder of the Dartmouth Atlas and approach makes a sensible and compelling argument for shared decision-making as the only way to decrease per-capita cost and increase quality. Using University of California data, he also refutes the UCLA argument. (http://ow.ly/3w6aL)

6. Jeffrey J. Kripal, Esalen: America and the Religion of No Religion. The J. Newton Rayzor Professor and chair of the Department of Religious Studies at Rice University not only tells the Esalen tale complete with characters like Hunter Thompson, Joan Baez, Fritz Perls and all the rest, but he more importantly cogently analyzes the influence of Eastern religions on America.

7. Robert Kegan and Lisa Laskow Lahey, Immunity to Change: How to Overcome It and Unlock the Potential in Yourself and Your Organization. The best book on change management that actually works. Must read in my humble opinion.

8. Sherry Turkle, Simulation and Its Discontents. Sherry Turkle is the university professor I wish I were. She is the one pundit on technology I really trust.

9. Dennis McCullough, MD, My Mother, Your Mother: Embracing Slow Medicine, the Compassionate Approach to Caring For Your Aging Loved Ones. McCullough is that wise primary care provider you wish you had as your doctor and as the doctor to your parents who live on the other side of the country. (http://ow.ly/3w6aL)

10. Carol S. Dweck, PhD. Mindset: The New Psychology of Success. Stanford professor whose research has changed my mind about how important mindsets are to the individual, the organization, and the nation. (http://ow.ly/3w6tp)

11. Charles Seife, Proofiness: The Dark Arts of Mathematical Deception. The title says it all.

12. Eric Abrahamson and David H. Freedman, A Perfect Mess: The Hidden Benefits of Disorder – How Crammed Closets, Cluttered Offices, and On-the-Fly Planning Make the World a Better Place. Anyone who has seen my office or desk or talked to Elizabeth Melby knows why I love this book. And let’s face it, it is true.

13. Ian F. McNeely with Lisa Wolverton, Reinventing Knowledge: From Alexandria to the Internet. One of those brilliant big picture books that traces the institutions (library, monastery, university, republic of letters, disciplines, and the laboratory) that have nurtured, shaped, and changed human knowledge.

14. Faye Flam, The Score: How the Quest for Sex Has Shaped the Modern Man. Title says it all about this hilarious and true science book.

15. Daniel S. Greenberg, Tech Transfer: Science, Money, Love, and the Ivory Tower. It’s a novel, but after having been a medical school professor, I can tell you it rings true. A professor creates a rat that never sleeps, has a bowel movement, or urinates, and the US Army is very interested.

16. Tom Chatfield, Fun Inc.: Why Gaming Will Dominate the Twenty-First Century. The serious look at the future of gaming that inspired the blog post (http://ow.ly/3w6Ke)

17. Melvin L. Rogers, The Undiscovered Dewey: Religion, Morality, and the Ethos of Democracy. An important interpretation of America’s most important and influential philosopher, the main man for pragmatism.

18. H. Gilbert Welch, MD, MPH, Should I Be Tested for Cancer? May Not and Here’s Why. The title tells you why this is an important book.

19. David H. Freedman, Wrong: Why Experts Keep Failing Us. (http://ow.ly/3w6S6)

20. Steve Hagen, How the World Can Be the Way It Is: An Inquiry for the Millennium into Science, Philosophy, and Perception. A science writer turned Buddhist monk really knows how to write about science and religion.