I’ve been collecting what healthcare leaders say when they talk about the problems that keep them up at night in conversations, in replies to this newsletter, in sidebars at conferences.

They’re describing their reality. And their reality keeps clustering around the same themes.

PX leaders describe improving parts of the patient journey while the whole thing still feels disconnected. They talk about patients navigating systems rather than journeys. About access that works in one channel and breaks in another. About patients repeating themselves at every touchpoint because nobody carries context from the last interaction.

That’s the Accessibility signal and the Continuity signal working in parallel. Can patients reach you on their terms? And when they do, does the system remember who they are?

The infrastructure challenge underneath this is real. The typical health system runs 16 or more essential software categories, and contact center agents often toggle between three to five disconnected screens per call. An ONC analysis of U.S. hospital interoperability found that while 70% of hospitals now engage in all four domains of data exchange (send, receive, find, integrate), only 42% of clinicians routinely use the external information that’s available to them. The pipes exist. The practice doesn’t.

Nobody’s going to solve this overnight with a platform purchase. But a trust strategy that considers the end-to-end experience starts to shape what the infrastructure should look like. And technology is closing some of these gaps faster than people realize. TEFCA now connects over 14,000 healthcare organizations with more than 600 million documents shared since late 2023. FHIR-configured apps are enabled in 70% of U.S. hospitals. The interoperability barrier that felt permanent five years ago is becoming permeable.

The question isn’t whether the technology will catch up. It’s whether your strategy is ready for it when it does.

This is the question that should worry every executive team in healthcare. And the data behind it is getting harder to ignore.

An Accenture survey of 8,000 U.S. adults found that roughly one in five consumers switched healthcare providers in the prior year. Nearly 90% of those who switched said the organization was “hard to do business with.” Not hard to get good care from. Hard to do business with. Administrative friction, confusing billing, poor digital experience.

A peer-reviewed study of nearly 1,700 patients confirmed something the Trust Algorithm was built to address: patient satisfaction has no direct relationship with patient loyalty. The relationship is fully mediated by trust. Satisfied patients without trust still leave.

Your HCAHPS score tells you how patients rated the experience inside the system you’ve built. It doesn’t tell you whether the system was built to earn trust. That’s the measurement blind spot. And it’s what PX leaders are describing when they say feedback doesn’t translate into improvements, or that insights arrive too late to act on.

This is what the Proactivity signal and the Recovery signal are designed to surface. Are you reaching patients before they have to chase you? And when something goes wrong, does your recovery build loyalty or just close a ticket?

The tension between AI and empathy is real. And leaders are describing it with surprising consistency: the experience works operationally but doesn’t feel personal. The clinical team is excellent but the operational layer is where trust breaks. Staff want to deliver great care but they’re constrained by systems and time pressures that make every interaction feel rushed.

The numbers reflect the tension. The AMA reports that physician AI adoption jumped from 38% in 2023 to 66% in 2024, with more than 80% now using AI in some capacity. But Pew Research found 60% of patients would feel uncomfortable with providers relying on AI, and 57% believe it would worsen the patient-provider relationship.

And the broader trust environment makes this harder. A national survey of over 443,000 U.S. adults documented that trust in physicians and hospitals dropped from 72% to 40% between 2020 and 2024. That’s a 32-point collapse across all demographic groups. The 2025 Edelman Trust Barometer found that no institution type, whether business, government, media, or NGO, is trusted to address health needs globally. The one bright spot: individual doctors remain trusted at 82%. Trust is personal. It’s earned in the interaction, not on the letterhead.

This is the Resolution signal. Do patients leave interactions with confidence? Not confidence that the system ran correctly. Confidence that someone heard them, understood the problem, and resolved it. AI can make that easier if it’s designed to surface context and reduce burden on the people having those conversations. It makes it worse when it replaces the conversation entirely.

The 3A Framework exists for this reason: Automate the routine. Augment the human. Amplify the relationship. Most organizations are stuck in stage one, automating for efficiency without designing for trust.

Leaders describe language barriers, digital access gaps, and the growing awareness that designing for the “average patient” excludes the patients who need the system most.

This is where the Trust Algorithm’s concept of Community Trust Fit becomes critical. The five signals don’t measure trust in general. They measure whether you’re building trust for the specific population you serve. Accessibility means something different for an aging rural community than for a young urban immigrant population. When you design your access channels, your outreach strategy, and your recovery protocols for the patient with the most barriers, you build infrastructure that works for everyone.

Equity isn’t a sixth signal. It’s the lens through which all five signals either work or fail for the patients who most need them to work.

These themes aren’t coming from one system or one region. They’re coming from leaders across the country, in systems of every size. And every one of them maps to a Trust Algorithm signal.

Fragmented journeys? Accessibility and Continuity. Scores that don’t match behavior? Proactivity and Recovery. Automation that doesn’t feel caring? Resolution. Equity gaps? All five signals, viewed through the lens of the community you serve.

The leaders doing this well aren’t running assessments in isolation. They’re building cultures where the question “are we building trust or processing transactions?” gets asked in routine meetings. That shift, from measurement event to measurement culture, is what separates a profitable system from an at risk one.

I can’t build that culture for you from a newsletter. But I can tell you what it starts with: knowing your score. Knowing which signals are strong and which ones are quietly eroding. And having an honest conversation about the gap.

In two weeks, I’ll be at IPX Congress in New York. The talk I’m giving is built around the five signals and the patterns I’m hearing from leaders across the country. If you’re in the room, I want to hear what you’re wrestling with. If you’re not, the assessment gives you the same starting point.

Over a thousand healthcare leaders have been reading about trust measurement. They don’t describe their struggles using framework language. They describe fragmentation, delayed insights, automation that doesn’t feel human, equity gaps they can’t close.

Every one of those struggles has a name in the Trust Algorithm. And every one of them is diagnosable.

You’re measuring satisfaction inside a system that was never built for trust. The leaders who are starting to measure trust instead are the ones who can tell their boards a different story next quarter.

Take the Trust ROI Calculator. See how much trust erosion is costing your organization in real dollars. Five minutes. One number your CFO will want to see.

Book a Discovery Call. If any of these themes sound familiar, let’s talk about what your score surfaces and what to prioritize first. Schedule here.

Reply to this email. Which of these themes hit closest to home? I read every reply.

Let’s get to work,

Ebony