One of the biggest challenges to keeping data in motion is the legacy systems that have been implemented over the past forty years. One of the greatest inventions and the biggest hurdles is the database. The methods once employed to capture useful information were an amazing step forward from paper, but have outlived their usefulness now that we’ve reached a stage of maturity where it is no longer impressive to capture, store and retrieve data.

Not only do many systems ‘sit’ on data, they are often not very good at sharing with others. In two separate discussion yesterday, the first between physicians who focus on information technology (AMDIS), and then later a panel discussion with the CEO’s of Kaiser Permanente, Geisinger, The Mayo Clinic and Intramountain Healthcare, both spent considerable time on the challenges of silo’d data and poor interoperability. The bright spot of the second discussion was patient access to their own health records but only in these more advanced healthcare systems.

Sharing success

Intramountain’s CEO told a great story about a patient needing urgent care being helicoptered from a city 400 miles away, but being inside the Intramountain network throughout, with complete data transparency so that by the time the patient was in Salt Lake City, they had been under continuous care (with continuous data) for the entire event. A doctor was even monitoring throughout using a mobile device. By contrast, a patient being transferred from a hospital across town initiates an electronic medical record only when they arrive at the Intramountain facility. The data necessary to make decisions only starts to come into play well into the care cycle.

Intramountain benefits from having one of the oldest Electronic Medical Record systems in the country and the benefits are obvious. Others on the panel were in the same position but they are exceptions to the healthcare rule.

Effects

It is great to have these examples, but most can’t tell this story. What does silo’d data and lack of interoperability between systems mean for us? It means the important diagnostic decisions, financial options, and best practice patterns aren’t available in the timeframe needed for action. The result is uninformed care and duplicated and wasted effort.

The frank fact is that software for electronic medical records isn’t serving the audience of patient, physician and the extended care community. Millions of dollars spent entrusting the solution to big electronic health record vendors hasn’t achieved the goal of information accessibility across the healthcare value chain. I predict the next wave is interoperability based on data in motion.

I asked him how he knew.  He pointed to his smartphone and said, “It’s a new thing we are doing to show our appreciation.” Huh…my low-tech local grocery store has taken a big step up in having the right data, in the right hands, at the right moment, and with the right context. I wasted no time getting my latte and left the store with a big smile on my face.

Personalization

But I have a secret…we really like shopping at Trader Joe’s. We go to Safeway because it is closer to my house and carries some things TJ’s doesn’t. Recently, we’ve begun gradually spending less at Safeway and more at the other store, probably something he didn’t know. The ‘personal’ touch he showed, however, is more than we get elsewhere and provides something to think about before we take our business a few miles away. Now, I don’t think he really knows me personally, but his systems were smart enough to capture that a good customer just punched in their discount code at register 3 and provided him with the name. The elapsed time between identification of the client and the offer of a token of appreciation was probably less than ten seconds. To redeem my drink, I simply used my code again at the Starbucks register and watched the sale ring up as $0.00. Having that data just a minute later would have been too late as I would have left the store and the opportunity would have been lost.

But wait, there’s more

If that was where it ended, it would have been a nice story. The manager also offered a big discount on roses from the flower shop. I replied that I buy my flowers from somewhere else, and he said, “Yes, that’s why I’d like you to get them here.” He knew what I didn’t buy at his store. He was making an attempt to capture my business without selling against himself. I said that I couldn’t today but asked if it was good for next time, and he replied, “I’ll put the offer on your account through the 31^st of December.” I loved it.

I probably will buy the flowers another time.

This story is likely to become something we all see happening at an increasing pace as more enterprises move toward better tracking of customer trends, improved availability of key data, and strategic use of mobile devices. It isn’t just about loyalty, either, as the rose offer showed…it is about expanding revenue by having the tools to increase revenue in creative new ways. When the ’2 Second Advantage’ can happen at Safeway, it can happen anywhere we find ourselves.

BPM experts - Our guide Buddiraj Rai (foreground) and the kitchen team

We’re were in Kathmandu last year and about to head home after another remarkable trek in the highest mountains on Earth.  That’s not hyperbole…this is the most vertical place you can find.  It has to be seen to be appreciated.  We’ve trekked through rice paddies and bananas trees as well as in deep snow and amongst Tibetan nomads…sometimes all within the span of a couple of days.  There is nowhere in the world like it.

Even more remarkable is the extreme attention to process that we enjoyed over our two weeks.  In a place where there aren’t really any of the conveniences (or safety nets) we take for granted, the ability to execute processes is far more valued than in our Western world of constant connectivity, 24×7 shopping, and dependable basic utilities like water and electricity.  They spend more time on the details and in doing the right things every time than most of us could hope for.  The end result of this focus is a trekking team of four customers and twenty staff of porters, cooks, and guides that performs like clockwork.

We were never awakened more than two or three minutes from the appointed time.  We never missed our tea and morning “washing water” even when at 4700 m. (14,570 feet, the same rough altitude as Mt Whitney).   Everything just worked out no matter the obstacles.  It was a completely reassuring experience in a country where anything can go wrong.   Where labor is so cheap ($10/day covers a porter up to 40 kilos/88 pounds), you’d think that the focus would be less on process, but even low labor cost is no excuse for sloppiness.  I’d even venture to say they are far more efficient and cost-conscious than our best Lean/Six Sigma shop.  Remarkable.

The reason it all worked was simple…there was a well-communicated and managed way for everything to be done.  From tent setup, assignment of loads to carry to delivery of purified water, the same processes were followed each and every time and by the same individual.  This eliminated waste and confusion and made the staff easily able to focus on serving the customer.  They were liberated from the everyday through excellent process and available to be truly excellent at going above and beyond.

Yes, there is BPM excellence in some of the most remote places on earth.  If they can have it, we certainly can, too.

Hats off to Buddiraj Rai for his excellent leadership of a great trek.

My career in healthcare started in the early 90s, and it was a crazy time for the industry. The Clinton version of healthcare reform had just hit and the industry was trying to react quickly to the change in reimbursement levels for inpatient and outpatient services. It was a great time for a consultant seeking job security, but a horrible time for a young professional who wanted to see his work actually come to fruition. I can’t tell you how many strategic and operational plans I had to update or abandon based on a change to the reimbursement rules.

Every time I tried to compare data from healthcare organizations with data or examples from other industries, I heard the same things: “We’re different…” “Yeah, but…” “They don’t have to…” Healthcare organizations did not accept a single case study, example, or data point I brought to the table as a valid point of comparison or example to learn from (even when I used examples from within the healthcare industry or other facilities within the same healthcare system). I left healthcare to work with other industries.

Guess what?

Healthcare organizations are no different than organizations in any other industry I work with. Most organizations have qualms about comparing their performance and productivity to other industries, but they tend to move past those qualms once they see other organizations successfully using cross-industry benchmarking to improve. Unfortunately, the majority of healthcare organizations still seem to resist and hold onto a “we’re different” mindset.

Yes, healthcare has to deal with patients, doctors, unions, politicians, community leaders, activists, the government, and more. But so do all organizations. Regardless of the industry, every organization contends with a different set of stakeholders. Education has students, parents, and communities. Government has the tax payers. Publicly traded corporations have shareholders, Wall Street, and unions. A multitude of factors impact businesses of all kinds, in every industry. The industries and organizations that move forward successfully simply recognize those factors and use them to drive new improvements. They don’t see stakeholders and other issues as barriers and excuses to remain stagnant; they see them as facts and sources of feedback that can help them survive.

In case study after case study, the first organizations to innovate and overcome significant market forces usually emerge as industry leaders that eventually acquire those organizations that react too slowly. No doubt, the healthcare industry is facing a huge number of challenging market forces in the coming years as it transfers to ICD-10 (and ICD-11) codes and adopts Electronic Medical Record (EMR) standards. I’m not trying to scare anyone, but being willing to look beyond the healthcare industry to improve these systems and processes could very well be the key to leading the competition instead of losing to it.

Common language

The single largest issue I have seen hamper an organization’s ability to learn and adapt is not having a common language. APQC recognized this in the mid-1990s and developed our Process Classification Framework (PCF) (www.apqc.org/pcf). The PCF is a document that outlines the exact activities that occur in major organizational processes. For example, whether you call it “IT,” “information technology,” or “whatever those guys on the 10^th floor with all the laptops are doing,” the PCF calls it “7.0 Manage Information Technology.” The PCF then names and numbers every process group, process, and activity that occurs in 7.0. The PCF is intended to help organizations to understand and describe how work actually gets done—within organizational walls, beyond those walls, or even (dare I say it) outside their industries.

The original PCF is a cross-industry framework, but we have also developed industry-specific PCF documents. We fully recognize that although the basics of the payroll process are fairly consistent across industries, there will be significant differences between how a bank delivers services to their customers and how a downstream petroleum organization produces product for their customers. For that reason, when a significant transformation occurs in an industry and the leaders in that industry want to get ahead of the game, they often reach out to us, and we work with them to create these industry-specific PCFs.

Challenge

So, here is my call to action for you, healthcare industry:

Yes, you are different and unique, but so is everyone. Way too many issues have piled up, and you can’t afford to wait any longer. It’s time to grow up, put on your “big boy” pants, and buckle down, and get the work done in a logical, efficient, and effective manner. I would offer a common language (or framework) as a first logical step.

If you know of any process frameworks or other industry process standards for healthcare, please include them in a comment below. I don’t want to reinvent anything that already exists. I’m also willing to do my part. If you want to help develop a healthcare-specific version of the PCF, please let me know by commenting or by going to www.apqc.org/contactus.

The level of passion is remarkable. As a member of the LinkedIn Group Healthcare Information and Management Systems Society, AKA HIMSS, I’ve watched the post, “Top ten reasons why EMR/EHR implementations are failing” draw 2,542 responses as of the time of this writing. The responses run the range of medical doctors insistent that electronic records could never capture the “nuances” of patient health, to vendors blatantly promoting their products and approaches. There is cynicism, opportunism and a few other ‘isms as well.

Passion

This passion is a great sign of how ready we are to tackle these issues. If it were ‘All Quiet on the Western Front’ with deadlines approaching, that would be a concern. The level of emotion is the best indication that we’re going through a painful change that can result in a much better way to manage healthcare in the US. With so much at stake, it has to be this way. Transformation can’t happen without passion as its engine and motivated leaders as the driver.

Goals

According to the HIMSS Enabling Healthcare Reform Using Information Technology  report that was issued in May 2009, there are two IT-related themes for healthcare reform:

• Provide a solid infrastructure for health IT that harnesses strong federal leadership and the standardized electronic exchange of health information; and
• Apply health IT as a means of increasing consumer and provider access to healthcare services and information, optimizing the efficiency fo care payments, and protecting the privacy and security of health information.

These are noble goals that it would seem everyone can support. The problem arrives in the ‘how’ of it all. No one solution has arrived to dominate the scene, and that’s not surprising considering where system development has been headed over the past couple of years. Monolithic systems are out. The new themes are light, flexible and adaptable.

• Leave what you have in place and don’t create unnecessary risk. Replacement = risk.
• Leverage the systems you have as part of the solution. Add capabilities where necessary.
• Layer other technologies on and around existing systems. Social is a great example.

This is the formula for transformation that minimizes the risk, maximizes the reward and keeps the cost as low as possible. The three L’s are the pattern that is powering development at Apple and other very successful technology companies, and the same principles apply within technology consumers as well. With technology moving so fast, this approach allows for the most flexibility without being on the bleeding edge. That sounds like a good spot to be.

Healing healthcare

If healthcare were a patient itself, it would be receiving ongoing, expensive treatments from many physicians who never talk to each other. The bills would be paid by an accountant in another state who only has a fax machine. There would be shady salespeople promising miracle cures at the front door.

The numbers coming out of the National Healthcare Expenditures  (NHE) fact sheet are grim. In 2009, the last year published, NHE grew 4 percent to $2.5 trillion, or $8,086 per person, and accounted for 17.6 percent of GDP. Projected growth is 6.1 percent per year through 2019, putting the health share of of GDP at 19.3 percent in seven years. These numbers are especially alarming when you consider that this wont produce infrastructure like ports, roads and bridges that increase production capacity and create jobs but simply keep an aging population at a break-even level of health.

Plan of attack

For healthcare reform to be anything less than putting out spot fires with software ‘tanker drops’, the way of doing business needs to transform. It needs to be a coordinated attack that changes the everyday work of people and brings a new look at technology. Shortchange the process challenges and the result will be wasted time and money spent on dysfunctional automation. Software ‘cures’ that don’t support broad solutions are modern snake oil.

Healthcare Reform addressed this through CORE, a set of healthcare operating rules for interoperability. We can spend time on what CORE was meant to change, but it is essentially about reaping the benefit of all of the work done for Reform to date. For CORE to be truly successful, it needs to liberate data. CORE is meant to allow healthcare organizations to:

Improve outcomes

• Equip medical staff with faster and more accurate access to patient records
• Allow decision making based on data in motion, not data buried in a database
• Ensure care plans are being followed (the 99% of the time a patient isn’t in treatment facility, office)

Reduce cost of care

• Prevent duplicated tests and treatments
• Proactively score patients for their risk of readmission

Reduce administrative costs

• Automate the flow of information and take it off paper and telephone
• Avoid the penalties of old or incorrect data

Facilitate collaboration

• Allow quick and easy communication with the confidence that all the right people are getting the right messages
• Make collaboration secure and reliable

Ensure compliance throughout

• If we change everything but break HIPAA rules and disrupt revenue, we’ve accomplished nothing

What’s being described is reliant on collaboration, new levels of cooperation, new processes and new ways of applying technology. The old ways of doing business will prevent organizations from meeting the Healthcare Reform deadlines in the near term, and will create survival risk in the future as the savvy swallow up those unable to change.

If we think Reform will go away, think again, “…no matter who wins the White House this year, the U.S. healthcare system wil be reformed, and more likely transformed, in the near future…” The approach that makes sense will be the one that creates a platform for ongoing change.

The insurance industry, as it grew, developed standard codes to allow healthcare providers (such as doctors, clinics, hospitals) to bill for discreet services. There are 15,000 codes in the ICD-9 standard and it still isn’t enough.

10x

The new standardized codes, ICD-10, have ten times the number for a really good reason; there has been a shift to more outpatient, home and long term care. There are advances in medical technology and procedures that demand new classification. There is also a greater need to define non-acute conditions.

On the quality side, there needs to be greater reporting around healthcare outcomes, trends need to be tracked, quality analyzed, comparison of outcomes from different treatment methods and much more sharing internationally. The rest of the world is way ahead of us on this, leaving us unable to share research and co-manage global disease.

Looming deadline

It would be a big mistake to think this is a simple translation issue and has been described by an industry insider as a realization that, “This was a people issue, an awareness issue. This was a change in the way we did just about everything.” With a deadline of October 1st, 2013, it represents a significant revenue risk to healthcare organizations and patients.

Think of healthcare payers and providers as ‘trading partners’ that conduct transactions that affect revenue for each…revenue keeps the doors open and the lights on.

Lest we forget, there’s also a risk to patients who might be charged incorrectly or have services wrongly denied. For the industry, patient billing issues cause expensive manual intervention, low patient satisfaction and drive up the cost of doing business.

Coordination

To successfully reach the end of ICD-9 intact, those trading partners will need to coordinate change in unprecedented ways. If you consider the need to be ready well before the deadline, there is only the next year for significant cooperation to take place.

That level of coordination will require news ways of doing business…outside-in thinking. It won’t be solved by implementing a single software system but by using automation to make cooperation easier across multiple parties and systems. There’s an enormous opportunity for the application of social technology.

Long haul

This doesn’t all go away on October 1st. Maintenance to the code standards will make this an ongoing change management exercise that will push IT systems and the people that perform the work of healthcare. By 2015, CORE Operating Rules need to be in place. When an individual walks into an ER or Hospital, the facility must have point-of-service knowledge of eligibility, out of pocket costs, and what’s covered.

Once in the facility, accurate and timely data must be available to ensure the best patient outcome. That data should be predictive and on-demand. Outside of acute care, data must be equally available as a predictive and preventative tool. With most data trapped in silo’d applications, that’s a tall order. There’s never been a stronger need for a transformation platform that enables ongoing change in process and technology.

With many healthcare organizations struggling with getting EMRs in place and the change from 4010 to 5010 standards for transmitting claims, it will be an interesting year.

Up next: CORE and healing healthcare

There are real challenges with Electronic Medical Records (EMR) beyond getting doctors to write things down (a feat in itself). Healthcare providers are being pushed to adopt EMR, but few are at Stage 7, shown at right. Because certification at lower levels doesn’t mean system interoperability, EMR ends up a fenced-off island in a sea of medical information. EMR systems are being implemented as applications sitting on static data.

Imagine instead a world without information silos where healthcare Providers and Payers understand data in motion, meaning it can be interacted with to make sure it is helping the right people make the right decisions at the right time and most importantly, in the right context.

EMR and EHR

Discussions of electronic medical records commonly use two acronyms, EMR and EHR. The difference is part concept, part marketing: EMR refers to the electronic record of an individual that is created and stored for the purpose of treatment, while EHR is a collection of EMRs across multiple healthcare organizations. The goal is to make use of EHRs built from EMRs. These two together are the intended target of healthcare reform, but are we making meaningful progress? Not if we’re reliant on the latest patch/version of a particular EMR/EHR software.

HIE

Enter the Health Information Exchange (HIE). HIEs are intended to solve the issue of fragmented data across healthcare organizations by hosting data on a third-party platform. There is debate around whether this should be a centralized or federated model. Response? An HIE that doesn’t allow for the liberation of data merely creates another layer of fragmentation, centralized or not. HIEs serve their purpose as consolidators of data, but just like EMR and EHR, end up as silos of data that won’t improve the quality or cost of healthcare. The data needs to be available when it matters and not locked down in a database waiting to be queried.

Carrot and stick

How did we get here? It was pretty clear from the beginning that realizing EMR goals wouldn’t be easy, so the Federal Government created a carrot and stick approach. The carrot is cash payments to hospitals and clinics as they certify they’ve accomplished the previously mentioned  levels of EMR. Hospitals have the carrot of their need to control costs and grow market share. For ambulatory care, economic stimulus funding was an early driver.

The stick for everyone (hospitals, clinics and ambulatory care) is that Medicaid and Medicare, the single biggest Payers, will reduce payments to facilities not meeting EMR timelines by 1% starting in 2015, 2% in 2016 and 3% in 2017. With most healthcare facilities operating at 2% margin, that won’t be a pain tolerated for long. But that doesn’t ensure we’ll get to the true nirvana of driving healthcare decision as events occur so that outcomes can be optimized.

Just as with systems to manage and move data (EMR, EHR and HIE), the trick is data interoperability and the carrots and sticks in place don’t address that in a meaningful way.

Vendors

There are currently four big EMR software players: Epic, Cerner, Meditech and McKesson and many HIEs that are both independent and government/regional.

Each has a solution designed to capture electronic patient records. Does that mean they can connect to other solutions in place in healthcare facilities? Not necessarily. While healthcare organizations are chasing incentives, they’re not rewarded for integrating the wide array of systems that are part of patient-facing healthcare. By some estimates, for every one EMR system being certified, there are 100′s of others that aren’t bringing data together. This fragmentation won’t change by constantly rewriting silo’d software or simply connecting to exchanges. The solution is to see EMRs and HIEs as just one aspect of data capture and management while allowing for more nimble and event-driven platforms to manage data in motion.

Success?

EMR implementation rates are showing gradual rise with about half of all facilities reaching some level of adoption. But is it meaningful adoption? Several web sources report that “…only 20.4% of all physicians reported using a system described as minimally functional…” If this is true, EMR implementation isn’t driving the benefits hoped for. It would mean that the error reduction, reminders and alerts, clinical decision support and other benefits aren’t being fully realized.

This isn’t surprising when you consider that the systems being implemented capture and produce data but don’t act as event monitors, social media tools, and data integration points between systems. What needs to happen is for doctors and patients (yes, patients) to see data in motion. Only then can outcomes be driven more effectively by the system making contextual recommendations to the healthcare staff.

Mobile and Social EMR

Beyond silo’d data, limiting healthcare data to a work station would be a shame considering the wave of mobile and social technology that is coming to the workplace. Healthcare data needs to be available wherever needed and in the proper context. We have social platforms that are fast and easy to implement with security and are the most meaningful way to share protected data, and not just with between care professionals, but with the patient and their support community (family and friends they designate).

This is an answer to the some of the biggest challenges facing healthcare. Mobile and Social combined with ‘liberated’ data in motion provides access and convenience where we currently have little transparency and plenty of manual work.

Electronic records are only a first big step in healthcare transformation. Data needs to be mobile, social and event-enabled for healthcare transformation to take place.

Up Next: ICD-9 to ICD-10 challenges

These will be on of the biggest process and technology transformations in our history. If we’re smart, we’ll involve events, rules, social, mobile, continuous improvement, supply chain and every other ‘new’ way of doing business. You’ll find the details in the following three articles, but before you fall asleep reading the titles, read below:

• Part 1 -  EMR shortfalls (Electronic Medical Records)
• Part 2 – ICD-9 to ICD-10 challenges
• Part 3 – CORE and healing healthcare (AKA: the big payoff)

Each one of these ideas is a critical part of where healthcare is going in the future and will very much affect everyone’s treatment and its price. All of this change will be an enormous undertaking for the healthcare industry (Insurers AKA ‘Payers’ and Providers). Nothing this big happens easily.

Outcome vs. fee-for-service

The greatest transition is the move from health care providers as stand-alone silos of increasingly costly service to a cohesive network of organizations measured by patient health outcomes. You can’t dispute that this is a necessary thing, but why is it so difficult?

For starters, medical professionals have been compensated for discreet services that have an associated fee. This was the reason for the creation of the ICD-9 codes that are now obsolete (more on that in Part 2). Measuring outcomes is an attempt to end ‘coin-operated’, silo’d healthcare. Restructuring this model from a payment and technology angle is an enormous challenge.

Healthcare collaboration

Breaking down treatment silos also means being able to move data in a privacy-protected way (those privacy protections are known as HIPAA regulations). Electronic Medical Records are the first step and will be covered in Part 1. This is much more than reducing the stacks of paper in storage. When doctors notes, treatment plans and prescriptions are on paper, there’s no way for that information to be used by the physiologist, the radiologist or the outpatient facility. It is very difficult to expect a collaborative outcome if there isn’t a modern, protected way for everyone involved to share information. The outcomes are also much more difficult to compare and analyze. Keep in mind collaboration doesn’t have to be through traditional means (nor should it be).

Secure, enterprise-level social media is powerful form of EMR and a brilliant collaboration platform that can bring together the patient, the medical professionals and the patient’s support community (i.e. non-medical).  This is game-changing and needs to be thought through.

Information transparency

Once everything becomes electronic, it can be moved between applications in a standard way. This won’t happen if traditional healthcare technology vendors continue to build applications and systems that won’t expose data easily so that it can be shared.

At some point, avoiding this becomes a critical part of the healthcare reform plan (more on that in Part 3). Many systems have been built on keeping data ‘inside the walls’, which coincidentally ensures that healthcare IT customers are forever stuck with software. This practice is known as vendor lock-in. The traditional ‘vaults’ of information need to be opened or replaced, and that won’t happen without a fight.

A recent TechCrunch article compared the state of healthcare IT to where Newspapers were a few years back…acquiring, taking on debt, and not modernizing.

OK, now you’ve gotten the overview of the storm that’s coming. When the dust settles, we should have something better than today, regardless of political issues.

Next up, Part 1 – EMR Shortfalls

From Ian Gotts' "Common Approach, Uncommon Results"

So many initiatives, so little time.  I was recently at UPS working with them to make sure their many initiatives ‘stick’ within the company.  Their executive made of the most important statements I’ve heard in a very long time, “There is one of me, and there are hundreds of thousands of them.”

There was something very real in his semi-joking statement.  Leadership is greatly outnumbered.  The best ideas for the bottom and top line and most critical initiatives, like customer focus, quality, cost reduction, safety, environmental and others are launched and fail to find critical mass because the actual behaviors within the organization never change.  Sound familiar?

Making strategy stick

There are really two ways to make strategy into reality:

• Organize to change the day-to-day behavior in key parts (or all) of the organization. You can only do this when you have a handle on the day-to-day behaviors.

• Find a way to measure the change in a way that shows where change is taking place and where it isn’t. Then put resources into the game where they can affect the outcome.

Within the typical organizational ‘pyramid’, the sheer numbers of people who need to be aligned to a new idea or way of doing business means that companies launching initiatives without knowing what they do (and a healthy portion of automation) are fighting an uphill battle.  We can rely on charismatic leadership combined with luck to gain the upper hand…or we can make a real investment in how well we understand, communicate and measure how things are really being done. I recommend the second approach as it leads to consistent success.

Years have been spent automating the way data moves around an enterprise, and it is fair to say that we’re in a cycle of diminishing returns when it comes to pushing the envelope on transactional automation.   We now know exactly how many transactions are being done and where they take place, but many companies have yet to align the day-to-day work of the people in a way that allows initiatives to become reality.

If we put the same focus on knowing and measuring and improving the real activities of (less-predictable) people that we took with (highly predictable) transactions, a few can lead the many. This isn’t years out of reach…it is happening in some of the best companies.

Strategy is only real when it affects the behavior and mindset of the majority of the enterprise.