The Customer Web

Three hospitals will soon let 30,000 patients read the notes their doctors write about them and the state of their health during an exam. The idea makes some docs uncomfortable; they’re worried about how patients will react to seeing blunt observations like “morbidly obese” in black and white.

Another healthcare provider is testing avatars to prod patients who don’t follow doctors’ orders – combining Internet-connected, at-home diagnostics with an automated rules engine so that the avatar knows whether to nag about laying off the salt shaker, or ask if the patient took her pills.

Pushing the limits of Web-enabled customer relationships? That’s the whole point. IT teams over the past year have spent a lot of their time looking inward, focusing on cost cutting and infrastructure improvements, which tend to take a back seat in high-growth times.

But the best also keep improving their customer experience no matter the economy, and increasingly that means delivering a better Web experience, because the Web’s where people want to do business.

That’s why we looked at three industries that every one of us touches – healthcare, banking, and government – to find examples of organizations testing the power of the Web to connect with customers. The technologies themselves aren’t always cutting-edge, but their application is focused on specific problems or goals or new products – and, ultimately, on helping customers remain happy customers.

— By Marianne Kolbasuk McGee, Andrew Conry-Murray, and John Foley, with J. Nicholas Hoover

Next Page: Doctor’s Orders

Electronic health records generally give a patient online access to lab results, medication history, information on allergies, and some of the doctor’s diagnoses. They usually don’t provide the detailed notes the doctor writes about an office visit, notes that might include the doctor’s observations about a person’s symptoms, behavior, and appearance – for example, if the patient appeared agitated, frail, or confused.

Beginning in January, Beth Israel Deaconess Medical Center in Massachusetts, Geisinger Health in Pennsylvania, and HarborView Medical in Washington state will begin a trial of OpenNotes, a program in which about 30,000 patients will get access to most of the notes their doctors write about them during visits. A hundred primary care physicians have volunteered to participate.

“Legally, patients have the right to see the notes, but we don’t make it easy,” says Jan Walker, project leader at Beth Israel and an instructor of medicine at Harvard Medical School.

Under the OpenNotes pilot, funded by a $1.4 million grant from the Robert Wood Johnson Foundation, participating patients sign in to their healthcare provider’s patient Web portal, which provides secure access to their records and doctors’ notes. The pilot will run one year, and doctors and patients will be surveyed at the end about how it went and whether it should continue.

Doctors’ attitudes about patients seeing their notes tend toward the extremes. “Some say it’s the wave of the future,” Walker says, while others say, “No way José, not interested.” Doctors in the trial can exclude patients they think won’t be able to handle either the technology or information involved. And patients, of course, don’t have to access the notes.

Projects like OpenNotes engage patients in their own care and are likely to improve their health, says Dr. Jonathan Darer, Geisinger’s medical director. Better outcomes are known to occur when patients ask doctors more questions about their care, Darer believes.

The program could be particularly helpful for patients who get nervous during doctor visits and don’t remember everything that was said, Walker says. And for patients in denial about their health problems, she adds, putting the information in writing can be a helpful jolt.

Next Page: Right Message to Right Patient

Telemedicine is another area where the Web is being used to improve the well-being of patients, and Partners Healthcare, a Boston-area integrated health system, is a pioneer.

Its Center for Connected Health has been using digital cameras for several years to let patients or their caregivers take photos of surgical incisions and other wounds as patients recover at home. The photos are sent to wound specialists who monitor the healing process, cutting back on the number of times patients need to be seen in person and increasing the efficiency of Partners’ field nurses sixfold over the years, the center estimates.

Yet even with that efficiency gain, one problem with expanding remote monitoring is how to sort through all the data it creates. Partners is experimenting with automated responses, in the form of automated motivational patient coaching.

For instance, hypertension patients enrolled in the trial use an in-home blood pressure device to take readings three times a week and transmit data online. The data is uploaded to Partners’ Web portal, which has a rule-based software engine that’s tweaked for each patient.

“We write rules to send the right kind of message to the right patient,” says Doug McClure, corporate manager for operations and technology at the Center for Connected Health. Each individual is different – spikes in blood pressure for two patients could have different causes, and the patients could benefit from different coaching methods.

For one patient with a history of falling off a prescribed diet, the rules engine would be programmed to text or email him asking about his diet and reminding him to steer clear of salty foods. Another patient, known to forget to take her medication, would get a query about when she last took a pill. The system takes into account information from previous encounters, such as whether the patient reported traveling or being under stress. The rules engine helps narrow the possible causes of problems and then responds to the patient with advice.

The center also is examining how different styles of automated coaching motivate patients. “Some do better with coaches who are like drill sergeants,” McClure says, while others respond to a mentoring tone. For patients who want more of a human face on their coaches, the center is testing avatar technology developed by Northeastern University, seeing how patients respond to “Karen,” an avatar coach that sends texts and emails, including audio messages, to patients. Some patients like that richer user experience, McClure says, while others get more from “just seeing numbers on a graph. The question is how to personalize the message.”

Partners Healthcare’s avatar, Karen, gets after patients who don’t follow doctors’ orders.

Moving from trials into larger populations of patients isn’t easy. For one thing, insurers aren’t always willing to pay for remote care and wellness services. If more insurers start reimbursing for their use, telemedicine technologies will become important tools in reining in healthcare costs, says Forrester Research Inc. analyst Liz Boehm.

The Web is also being deployed to address more mundane healthcare concerns, such as the inconvenience of long waits in doctors’ offices. Allviant, a spinoff of Medicity, which specializes in health information exchange technology, has developed a Web-based service that texts patients when a doctor is nearly ready to see them.

Arizona State University, with 69,000 students, will soon start using the CarePass service at its Campus Health Service, which sees more than 250 patients a day. Students check in for appointments by texting the health center or logging into its Website. They’re then told when the doctor will be ready to see them and can opt to wait in their dorm rooms or elsewhere until they get texted or emailed that it’s time to come in. This approach also could keep contagious patients away from the office longer.

Next Page: From Toasters to Browsers

Banking is another industry that touches nearly everyone’s lives, and more so than in healthcare, the Web already is an essential channel for customer ties. For example, nearly 20 million Chase credit card holders can go online to make major changes to the way they manage their revolving credit cards, including an option to pay zero interest on recurring household purchases such as gas and groceries. It’s part of Blueprint, a service JP.MorganChase started in September.

Wells Fargo & Co. customers can experiment with beta services such as SettleUp, an online tool that helps people split costs for group events and track and collect payments via the Web. And customers of USAA, a mostly online bank that caters to members of the armed forces, can use an iPhone app to deposit checks into their accounts without having to go to a branch or ATM, or even mail the physical check. Instead, customers photograph the check with the phone and send the electronic image to the bank.

Long gone are the days when banks lured new depositors to branches with the offer of a free toaster. Today, they rely on the browser to attract and retain customers, through online services including account management and bill payment. Banks recognize that new features, such as personal financial management tools, in which customers can track spending habits, create budgets, and manage their debt, will help keep customers from switching banks.

“A customer with online banking plus bill pay plus personal financial management is a customer for life,” says Jacob Jegher, a senior analyst at Celent , a research and consulting firm that specializes in financial services.

Bankers echo that sentiment. “If we create a better way for customers to manage card finances, we’ll gain their loyalty long term and get more of their business,” says Tom O’Donnell, general manager at Chase Card Services.

Next Page: Behind the Times

Still, some bank sites haven’t kept up with the times. “If you are a Twitter or Facebook user, or you shop at Amazon, these are rich, Web 2.0 sites,” says Celent's Jegher. “Then you log into your bank account, and it’s circa 1999.”

In Silicon Valley, those would be fighting words. But banks operate under different conditions. For one, many banks use IT systems that are decades old and operate in silos. Checking and savings account data may be in one system, home mortgages in another, credit cards in another. So even if a customer has accounts in all three systems, they likely run on different platforms with different data structures, requiring the bank to make significant investment before a user can access all three accounts from a single Web page.

Case in point is Blueprint, the new service from Chase, which required more than 300,000 IT staff hours to prepare for the service. “We fundamentally had to reconfigure our core operations and processes to support how Blueprint works,” says O’Donnell. The company also spent nearly 50,000 hours training customer service agents. “In time, effort, and energy, this is one of the most substantial efforts we’ve undertaken."

Banks also must navigate myriad laws and regulations before they can deliver a new product to customers, creating a drag on innovation. And any product that hits the Web must go through a rigorous development life cycle to ensure the service – and sensitive customer information such as account numbers and IDs – is secure.

Finally, there’s a culture issue at play. Banks tend to be conservative, even when it comes to the Web, where people are accustomed to lots of new features and functions. This conservative culture affects the speed at which new Web applications come online.

Wells Fargo Labs is a case in point. It launched a site two years ago on which customers can experiment with new products and applications that are still in beta. SettleUp is one such application that lets groups coordinate financial arrangements.

Say a group of friends rents a cabin for a weekend. The person who makes the reservation and pays for the cabin can use SettleUp to create a Website that all the friends access. The site shows how much each person owes for the cabin and lets them send payments electronically. The site tracks payments and sends email reminders to who’s tardy in paying.

“People love the product,” says Joe Harrison, senior VP of Wells Fargo Internet Services Group. “Without marketing it, we’ve gotten good, strong growth, all through word of mouth.” The company also has gotten extensive feedback on how to improve SettleUp.

Sounds like a winner, yes? But SettleUp has been in beta for a year, and Wells Fargo isn’t in a hurry to move to a full production version. “We don’t have a timeline for when SettleUp becomes a full-fledged product,” Harrison says.

Contrast that approach with Mint.com, a Web-based personal financial management site. In the same two years that Wells Fargo kicked off its Labs initiative, Mint.com was launched, racked up 1.5 million users, and this September was purchased for $170 million by Intuit, maker of the accounting software Quicken and TurboTax.

Where’s all the money going? Mint.com knows.

That kind of supercharged rollout and uptake of a Web service seems almost unpalatable to Wells Fargo, which doesn’t consider its customers early adopters. “We never want to rush customers into areas or environments they aren’t comfortable with,” says Harrison. “I wouldn’t say we move slowly. I’d say we move with our customers.”

Next Page: 307 Million Customers

When it comes to moving with its customers, the federal government is making swift progress with Government 2.0, the concept of government serving as a platform for new applications and services. It may be the most ambitious and far-reaching Web-based customer-engagement initiative ever conceived. There are 307 million U.S. citizens, and federal CIO Vivek Kundra refers to them as “customers.” Projects are under way across the federal government to interact with the public online in new and novel ways.

As the name implies, Government 2.0 comes with a heavy injection of Web 2.0 technologies: blogs, wikis, social networking, mashups, Web apps, and widgets. It’s from this foundation that agencies are breaking from their 9-to-5 comfort zones and into the era of 24-by-7 interactivity. The government has launched new public-facing Web sites such as Data.gov, HealthReform.gov, and Recovery.gov, and put a fresh, social media look on others, including Whitehouse.gov, Defense.gov, and CIO.gov.

For example, in March the White House launched a new section on Whitehouse.gov called “Open for Questions,” where people can submit questions on the economy and rate their concerns. Within 48 hours, 93,000 people had submitted 104,000 questions. President Obama addressed some of them in an online town hall streamed live at Whitehouse.gov.

Transparency, a big part of the government’s customer-service push, is playing out in a number of ways, first and foremost in the release of data that previously had been locked in databases far from public view. The Data.gov site, launched on May 21, started out with 47 data feeds; by September, it exceeded 110,000 feeds, ranging from EPA toxic chemical information to National Weather Service storm predictions.

Transparency is one element of Obama’s “open government” initiative, which he spelled out in a memo to the heads of federal agencies and departments on Jan. 21, his first full day in office. The other guiding principles, even more integral to customer engagement in government, are public participation and collaboration. On Regulations.gov, for example, visitors are invited to “Make your voice count” by posting comments and ideas on thousands of new and draft regulations issued by the federal government each year.

This isn’t just an Obama administration phenomenon. The trend is playing out at state and local levels as well, where tech-savvy politicians are using the Web to connect with their constituencies. Congressman John Culberson, R-Texas, posted the entire text of the healthcare bill to the Internet and is using software from SharedBook to let people annotate the bill and comment on it.

“I’m crowdsourcing the healthcare bill in order to make it as transparent as possible.” — Rep. John Culberson

Users click and drag their cursor over the section of text they wish to comment on, then enter their comments, which appear in a tabbed area. Users also can reply to comments left by others. Comments appear in a window underneath the document. The idea is to let Culberson’s constituents “analyze the healthcare bill word-by-word, sentence-by-sentence, and have a real-time debate about what the healthcare bill means,” Culberson says. “I’m crowdsourcing the healthcare bill in order to make it as transparent as possible.”

Next Page: Government App Stores

The release of government data via Websites, feeds, and APIs and in machine-readable formats not only gives the public visibility into the workings of government, but it also makes it possible for developers and private-sector companies to get involved.

Earlier this year, Washington became the first city to open an application catalogue, the DC App Store, for third-party applications that incorporate city data. More than half of the apps there have been built by non-government developers. The DC App Store’s menu includes a tool to verify business licenses, an atlas of the city, a WiFi hotspot map, and an app that informs commuters of bus locations and schedules.

San Francisco recently followed D.C.’s lead, releasing a series of data sets to spur application development. “We are trying to turn government into an organizing platform for civic engagement by giving our residents the tools to build the kind of government that works for them,” San Francisco Mayor Gavin Newsom said in a blog post announcing the city’s DataSF App Showcase.

In some places, the most basic of government services – the 311 public information call center – is becoming a Web-based, interactive service. San Francisco and New York City have added Twitter feeds to their 311 services to update and alert the public with important information and to let citizens send messages about everything from abandoned cars to graffiti.

Several municipalities have released iPhone apps that let people submit pictures of potholes, dilapidated properties, and missing street signs. Pittsburgh’s iBurgh, developed with help from local iPhone developer YinzCam, automatically includes location information with problem reports; NYC 311 lets citizens fill out city forms from their phones.

Pittsburgh’s iBurgh iPhone app makes it easy to complain.

This summer, Washington became the first city to open its 311 system via an open-source API, which lets third parties develop apps that can submit 311 requests to the city’s call center. One of those apps, called SocialDC311, won a city contest for third-party developers; it lets users send 311 queries from Facebook or an iPhone.

There are limits to how far government agencies can push the concepts of openness, transparency, and participation. In the military, for instance, officials are grappling with the degree to which staffers should be allowed to use Facebook and other social networking tools. Lt. Gen. Jeffrey Sorenson, the Army’s CIO, says the Army needs to balance the push for openness with the need for security, and the Army is developing social media policies that do both.

But there seems no turning back on the expectation that public engagement on the Web will be a part of the Army’s strategy. Says Sorenson, “We’re trying to move from a culture of ‘need to know’ to ‘need to share.’ ”

— By Marianne Kolbasuk McGee, Andrew Conry-Murray, and John Foley, with J. Nicholas Hoover

Write to Marianne Kolbasuk McGee at mmcgee@techweb.com

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