The issue of how to regulate self-funded insurance plans is affecting medical practices and patients across the country, and one that will likely become more prominent in the coming years as more employers choose this approach, says St. Louis Post-Dispatch columnist Mary Jo Feldstein. Between 1999 and 2007, the percentage of workers covered under a self-funded plan rose to 55% from 44%, she says. She adds that for years, courts have debated how the Employee Retirement Income Security Act intersects with state laws regulating other health plans. The debate will have a big impact on the regulations of self-funded plans in the future, Feldstein says.

Only a small percentage of physician practices have implemented electronic medical records. The percentage varies from about 11% to about 20%, depending on the survey. I would wager that if you only looked at solo practices or smaller physician groups the percentage might be even lower. Cost, disruption of workflow, skepticism of the technology, and security issues are just a few of the obstacles impeding the widespread adoption of EMRs. Yet there are some community hospitals and physicians who are looking for ways to bring this technology to their communities and share patient information. Here is an example of how one community hospital is sharing its hospital's lab results, radiology reports, patient histories and discharge summaries, among other items, with area physicians—regardless of which EMR vendor the doctor uses, if any at all.

Charles Vargo, executive director of the Washington Physician Hospital Organization, which is comprised of about 100 practices—33 of which already have some sort of EMR—says that physicians were coming to The Washington (PA) Hospital and requesting an interface between their EMR and the hospital's lab system. But creating—and maintaining—individual interfaces to roughly 33 practices using about 15 different EMR vendors was too difficult for the 256-bed standalone hospital to manage. And standardizing to a single vendor wasn't an option. "We couldn't tell people to turn their back on their investment and start over," Vargo says.

So the hospital, which is located about 30 miles south of Pittsburgh, collaborated with the physician organization to develop the Washington Health Information Network. The network uses MobileMD's health information exchange and enterprise access application, which enables physicians to electronically access all of the hospital's health information systems from a clearinghouse. Physicians now have access to both inpatient and outpatient information in real-time. They can choose what lab results, x-rays, or reports they would like to be "mapped" or automatically recorded in their EMR. And if they don't have an EMR, they can still access the information through a secure Web portal. "We are the largest facility in our county and are the leader of care services here, so we needed to take a lead to move this along," says Rodney Louk, Washington Hospital's vice president of information systems.

Several vendors were considered for the project, but MobileMD was ultimately chosen because of its ability to interface with a multitude of medical records systems, along with its Web portal application. In addition, the vendor also offered ongoing support for all of the interfaces. "MobileMD was the only company that took responsibility for maintaining the interface between the clearinghouse and the physician vendor," Louk says. Neither the PHO nor the hospital had the resources in-house to manage all the physician interfaces.

From what I have heard about hospital partnerships, success often hinges on whether both parties have some skin in the game. Louk agrees with that sentiment. One of the reasons that the network, which began implementation in September 2007, has been successful is because both organizations are helping to fund the project, he says. The hospital is paying for all of the technical pieces and the ongoing licensing fees for the clearinghouse. In addition, the hospital will pay for 85% of the cost of the health information exchange component for the physician practices. The PHO helped fund the initial setup of the clearinghouse, and is paying the ongoing subscriptions for the physician portal, which is offered to doctors free of charge. The hope is that the free offering will aid in the adoption of the technology, says Vargo. "When they see the value, it may help push the issue of return on investment. A lot of people are in the paralysis by analysis phase where they are looking to see if it's worth their while to make the investment," he says.

The project is also viewed as a physician initiative rather than a hospital initiative because the PHO is spearheading the effort, which has helped the network garner a lot of acceptance. "The only way the hospital is going to see a benefit to this is if the masses go there," says Louk. "So that is the thought behind how we are organizing it and rolling it out."

When Angela Simpkin arrived at the urgent care, she couldn't tell where she was supposed to check in. Paper signs were taped all over the glass reception window. The scowling receptionist seemed unaware of her arrival. When Simpkin (not her real name) asked for assistance, the scowler pointed to a stack of forms and a sign that demanded, "Please complete form before registering."

"I was so irritated I was ready to turn and walk out," she says. "But then I remembered that as the mystery patient, this is exactly what I was here for—to observe and stay tuned into my reactions to the encounter. In less than two minutes, I had a pretty good idea about the real patients' experience."

Simpkin is a trained mystery shopper who specializes in healthcare. Sitting down in the waiting room, Simpkin covertly retrieved a notepad from her purse and, under the guise of doing a crossword puzzle, began to jot notes for her report—including a reference to the rude receptionist. She overheard conversations between other patients; two were complaining about the wait time, and a third said she had to go to the bathroom but was afraid to leave for fear of missing her turn.

Kevin Stranberg, another mystery patient, feels that his power of observation helps shed light on problem areas. "I'm not a clinical person, but when I do mystery shopping, I focus mainly on how the experience made me feel," he says.

Stranberg describes a negative experience: "The receptionist shoved papers at me and asked for my insurance card. When I said I had no insurance, she sighed and sounded irritated when she asked, 'Did they tell you about our payment policy? You'll have to pay something today.' Then the intake information asked for the same information on three different forms. So when the doctor walked into the exam room without making eye contact and mumbling some indecipherable greeting, I was mentally filling out my forms indicating that I would be highly unlikely to recommend this practice."

A face on the data
Mystery shopping, a reliable assessment tactic used for years by banks, restaurants, and hotels, has exploded on the healthcare scene in recent years.

Although many healthcare organizations are measuring patient satisfaction, their data don't always pinpoint the experiences behind the scores. Mystery shoppers fill in the fine details and help organizations understand how patients feel about their experiences, apart from how they feel about their medical treatment.

Mystery shoppers are keen observers. The average patient in the physician's waiting room probably isn't timing how long it actually takes before he's escorted to an exam room. But mystery shoppers will know exactly how many minutes they waited—and will tell you if they felt it was too long. They'll also observe whether patients are informed of wait times, what can be overheard from the reception desk, and how close the nearest restroom and drinking fountain are.

"We don't just uncover the problem areas," Stranberg says. "We also identify things that contribute to a great experience. In one emergency department, we observed a nurse who came out to the waiting room and made rounds with patients about every 20 minutes or so. In that situation, I documented that it made me feel reassured and confident in the experience."

Mystery shoppers follow a feedback form with criteria developed in part by the organization being "shopped." In situations in which the organization has specific standards, the mystery shopping experience will ferret out how well the staff lived up to those standards.

When organizations make culture changes, real-life experiences and stories have the greatest impact.

It's one thing to have data about how likely people are to recommend your services, says Stranberg. But if you can stand in front of a group and say, "When the nurse got down to eye level with the elderly woman in the waiting room, and put his hand on hers, I felt that he, and probably every person in this ER, really cares about us," it has much more meaning.

Feedback from mystery shoppers validates data from patient satisfaction surveys. Interpreting data is a cerebral activity. The concrete, detailed descriptions and stories shared by mystery shoppers helps move that information from the head to the heart.

Steve Sparks, director of PR and marketing for St. Mary's Hospital in Madison, WI, recently engaged mystery shoppers. "We were completing a major expansion of our emergency department," Sparks says. "We wanted to know how easy it was to get in, if the signage was clear, how well our staff put you at ease, if staff made eye contact and treated you like a person and not just another clinical case."

The mystery shopping data were similar to the data from the quantitative surveys the organization had already completed. "For example, our survey asks if you were treated with respect, and the patient will grade you on a Likert scale. But the mystery shopper could speak more to the experience," Sparks says, adding that mystery shoppers also pointed out staff members who stood out as stars. "That was just as important in this process as finding the weak areas in need of improvement."

Sparks tells of a mystery patient who felt "discounted" when one provider poked his head into the exam room to speak with the other physician during an appointment—information that may never have been revealed by a survey. It's not intended to take the place of surveys, he says, "it's simply another form of research to drill deeper into the patient experience . . . Mystery shoppers put a face on the data."

A closer look at first contact
Barry Ensminger, vice president of external affairs for Maimonides Medical Center in Brooklyn, NY, recently engaged mystery shoppers to assess the customer experience with direct phone contacts to his organization. "We wanted to learn more about how all those phones were being answered," says Ensminger. "Does the caller get what he wanted? If a staff member in one of those departments doesn't have the information requested, how will he handle the call?"

During the assessment, a reputable outside firm made hundreds of telephone contacts. As a result, "virtually no one here has questioned the accuracy," says Ensminger. "That has been very important in building the buy-in needed to make the necessary changes. Equally important is that the mystery shopper report helped us to identify internal best practices. That way, when we go to make the recommended changes, we can utilize those strengths and replicate their practices throughout. Those two things alone offered lots of value."

Ensminger's mystery shoppers found that callers were disconnected during a number of transfers. In many departments, the employee answering the phone didn't have even some of the most basic information about hospital services. And in several encounters, the staff members seemed rushed and eager to get the caller off the phone.

"By using mystery shopping," he says, "I was able to point out our shortcomings in a way that eliminated the denial and built engagement. The approach gave hard evidence that no one can question. Not one person said, 'It's not a problem' . . . The data speaks."

A path to improvement
As a mystery shopper myself, I have been able to help physicians understand how their comments, gestures, body language, and facial expressions made me feel during an encounter. In many cases, the physicians were surprised to learn the kind of impression they made on me. And many of these providers, if receptive to coaching, were eager to learn some specific actions they could take to improve the patient experience.

In one case, I presented as a self-pay patient for a physical. During the exam, the physician mentioned that at my age, I should have a colonoscopy—and quickly added, "but that can be expensive." With a stroke of her pen, she marked it off her list. Three times during the encounter, the physician mentioned the cost of tests. At first I thought she was being helpful by keeping me informed about the cost for services. But by the time I left, I felt that she had determined what I could and could not afford and did not give me the option of making these decisions for myself.

During the follow-up coaching session, I had the opportunity to tell this physician how her comments made me feel and to talk with her about how she can engage the patient in making decisions about whether to pursue elective tests.

Done right, mystery shopping can help you evaluate how well your staff is living the organization's mission, vision, and brand promise in daily operations. Mystery patients will use real-life situations tailored to each particular area of your organization, from a physician's office to the emergency department to inpatient and outpatient settings. They may even have another mystery shopper accompany them as a family member in order to supply additional details from another important point of view.

And though telephone mystery shoppers will have different criteria than the in-person shoppers, they can glean several important details about your organization's services in this area.

Mystery shoppers can shed a revealing light, taking the mystery out of the customer experience.