Why I Don’t Follow You on Twitter

How about a follow?

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Chuck Webster MD #HIMSS18 Social Media Ambassador

I sometimes get this request. If we have met personally, in IRL, I sometimes acquiesce. However, unlike Facebook, Twitter is an asymmetrical interest graph, not a symmetrical social graph. Most of the people I follow are not in health IT and do not follow me. It is literally true that only about 10% percent of the 6K I follow, about 600, actually follow me back. While I think it is nice you follow me, I will not feel offended if you feel that since I choose not to follow you back, at least for now, that you chose to unfollow me. We both have our reasons and principles for who we follow, and I respect yours, and hope you understand mine.

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Chuck Webster MD #HIMSS18 Social Media Ambassador

I’m sorry. I’m happy to explain further if you’ll direct me to that part of my DM that I did not make clear.

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No worries. Take care!

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Chuck Webster MD #HIMSS18 Social Media Ambassador

You too!

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Snow Crash, Social Virtual Reality, The Metaverse, and #HIMSS18: A Science Fiction #HTreads Tweetchat

[For the 2/27, 9:30PM EST #HTreads tweetchat…]

Recently I innocently posted the following tweet, whose replies, and replies to replies, garnered between 700 and 1000 tweets (I lost count around 700, but the conversation refused to die!).

I think it is really cool that so many health IT social media tweeps love science fiction so much. There’s even a science fiction meetup at the upcoming #HIMSS18 conference.

So a #HTreads tweetchat about science fiction before #HIMSS18 seems appropriate. And, to be more specific, and dearer to my personal sci fi heart, I’d like to focus on one book, and it’s most cool high concept.

Believe it or not, the most compelling idea and depiction of virtual reality was published a quarter of a century ago: Snow Crash, by Neal Stephenson. Not only is it on many lists of the top 100 science fiction novels of all time, it also appears in top 100 English language novels of all time. If you haven’t read Snow Crash (shame on you, especially if you claim to be a science fiction aficianodo), then at least take a couple minutes to skim this Wikipedia Snow Crash plot synopsis.

One could go on and on about how well (or how not well) Snow Crash not only predicted social virtual reality, but its then future society (our current society, today). Snow Crash was not omniscient; it was compelling. Many of today’s 3d environments depicting real or imagined worlds were and are deeply influenced by Snow Crash. Snow Crash popularized “avatar.” Snow Crash influenced Google Earth, with which we are all familiar. Even Quake (and so, Doom and Duke Nuk’em) was loosely based on Snow Crash. People read Snow Crash, the product of the imagination of a science fiction writer, and then they created similar technologies and worlds, influenced by Snow Crash.

Social virtual reality is about to take off in a big way. Especially when Ready Player One is released (set in my current hometown, Columbus, Ohio!).

You can also dip your (virtual) little toe in social virtual reality during the upcoming #HIMSS18 conference. I am hosting three, two-hour social virtual reality events on Monday, Tuesday, and Wednesday, at 3PM-5PM PST. (For instructions, see A New Venue Two Hours Each Day During #HIMSS18: Social Virtual Reality!)

Let my pull out five ideas from Snow Crash, to use as #HTreads questions/topics (all these are in the Wikipedia Snow Crash plot synopsis):

Let’s start with the title: Snow Crash. Stephenson was inspired by what a Mac screen sometimes looked like when it crashed, sort of like static on a TV. I am also reminded of many sci fi and horror movies and TV shows in which snowy, static-y TV screens in indicate proximity of scary things or communication from the beyond.

1. Can you think of any recent examples of TV or computer “Snow Crash” scenes (static-y visual white noise…)? (I can) #HTreads

A central conceit, which at the time I thought was the weakest Snow Crash idea, because it didn’t jibe with what I thought I knew about computer science and neuroscience, was a virus that could jump from the digital world to the human biological world, through the computer screen. Ha! I thought this was ridiculous. But I kept reading, everything else was to bloody good. Besides, I think I sensed, Snow Crash was a bit of a parody, kind of like Hitchhikers Guide to the Galaxy, which was also full of lovely ridiculous stuff. Little did I know, at least metaphorically, of today’s systematic manipulation of public opinion via fake news.

2. What do you think about the metaphor of fake news as a virus, traveling over digital social networks, leaping from human host to host? #HTreads

Read this description of the “Metaverse”:

“The Metaverse, a phrase coined by Stephenson as a successor to the Internet, constitutes Stephenson’s vision of how a virtual reality-based Internet might evolve in the near future. Resembling a massively multiplayer online game (MMO), the Metaverse is populated by user-controlled avatars as well as system daemons.”

Note, the Metaverse is much more than just networked virtual reality:

“The Metaverse is a collective virtual shared space, created by the convergence of virtually enhanced physical reality and physically persistent virtual space,including the sum of all virtual worlds, augmented reality, and the internet”

3. How might a “Metaverse” virtual reality-based Internet, resembling a massively multi-player online game, affect digital health? The Internet of Health? What about the Social Virtual Reality of Health?

Science fact: “Scientists have developed a brain-computer interface that reads the brain’s blood oxygen levels and enables communication by deciphering the thoughts of patients who are totally paralyzed and unable to talk.” (Paralyzed patients communicate thoughts via brain-computer interface)

4. The Metaverse is much more than VR (“virtually enhanced physical reality AND physically persistent virtual space”) how might the Metaverse be used to help patients who are totally paralyzed and unable to talk cope?

5. If you could write a science fiction novel that literally will change the world (just as Snow Crash began to do, 25 years ago), what would be it’s title? It’s scientific advance? The morale of your story?

Thank you for being interested, with me, in the realization of a cool, influential, science fiction idea, the Metaverse, or what I call, in its baby form, social virtual reality. I hope you’ll join me in this infant Metaverse during #HIMSS18. Just show up and follow the instructions!

A New Venue Two Hours Each Day During #HIMSS18: Social Virtual Reality!

[Looking for the event links? http://wareflo.com/himssvr/]

Whether you are in Las Vegas at #HIMSS18, or experiencing extreme FOMO elsewhere, you can hang out in social virtual reality with other virtually-present attendees, in a very cool meeting space, on a hill in a very cool park. In that meeting space (over my left shoulder) you can watch live video feeds from HIMSSTV. If you need a break from scintillating conversation with other #himssVR aficionados, wander around outside, listening to the chirping birds and the gurgling brook.

This post is mostly about mechanics of joining us in virtual reality during HIMSS18 (when and how). If you want to more about why, I’ve written a backgrounder: Shared Social Virtual Reality Networking for Health IT.

Pre-#himssVR workflow:

  • Sign up for AltspaceVR
  • Download the free PC or Mac “2D” clients
  • Visit the 24/7 Campfire event to practice controlling your VR avatar (top of your screen, after you log in)
  • Check out upcoming featured events (the eclipse-watching party was awesome!) & perhaps indicate your interest (you’ll be notified when they are about to start)
  • If you have a compatible phone, buy a Daydream or GearVR headset.
  • Of course, if you already have an HTC Vive, Oculus Rift, or Microsoft Mixed Reality headset, very cool!
  • But remember, the free 2D-clients do not require a VR headset to participate!

Now go to the landing pages for each of the upcoming #HIMSS18 #himssVR social VR events and indicate your interest! You’ll be notified when each event is about to start, but easy-to-remember http://wareflo.com/himssvr will get you there too!

Once you enter one of the #HIMSS18 V R events, here is a suggested workflow:

  • Look for me (the brunette in a blue shirt in the banner)
  • Move toward me (desktop arrow keys or mouse, zoom on tablet or smartphone, look and click in a VR headset)
  • Unmute yourself (look down & left, click the red mic symbol, swivel using right mouse button, see below for visual)
  • Say hi!
  • Click on me to pop up a dialogue box and friend me (or send a text message, if having tech problems).
  • As other VR avatars pop into existence, greet them too (ask them where they are from, etc: Mingle!)
  • Watch the meeting room screen… wander around outside (birds chirping, brooks burbling, leaves falling, so cool!)
  • Take a selfie (lower left, camera symbol) & post it to social media
  • Think about how cool this would all be if you had a virtual reality headset! (if you don’t already have a Vive, Rift, Mixed Reality, Daydream, or GearVR)

Here is a bit more orientation. This screen capture shows three useful things to understand.

First, I’m the skinny brunette guy in the blue shirt (VR is thinning!). Look for me! The reason you can see me is I am looking in a mirror at myself. Over my shoulder is the virtual reality meeting space. On the far wall, is a projection screen, currently showing the #HIMSS18 website. I can play videos on that screen. I’m hoping to stream some HIMSSTV live videos there. But the most important aspect to understand is the menu in the lower left. If you click in the center on the triangle thingy (AltspaceVR’s logo), you’ll pop up an other menu with lots of options, the most important of which is “Exit” (extreme upper right). When you first pop into existence in virtual reality, your microphone is muted. Click (or look at and tap) the topmost microphone symbol to unmute. Headphones are suggested! Then move toward me (or some other avatar) to say hi. Closer you are, the louder the possible conversation. Next, look at the laughing emoji the lower right. Click that and you can cause other folks to see emojis over your head: smileys, frownies, hearts (you like what you are hearing/seeing), as well as hands (as in, raising your hand to ask a question during a presentation). Finally, most important of all, on the left is a camera symbol, so you can capture selfies, or reverse the camera to take pictures.

I’m as excited about health IT networking in social virtual reality as I was when first discovered Twitter, 10 years ago. I am convinced that, in five to ten years, we will take for granted our ability to instantly teleport to all kinds of fantastical and practical environments, interact with many of the same folks on Twitter we currently follow and converse with now. I hope you’ll join me in the new social media Matrix!

PS Follow me, Chuck Webster, MD, on Twitter, at http://twitter.com/wareFLO!

Happy Valentines Day, Workflow, My Love!

Sometimes wonderful tweets get lost in the mist of time,
Sometimes they get archived in blog posts about rhyme!

Shared Social Virtual Reality Networking for Health, Healthcare, and Health IT Marketing

[This is a backgrounder for a series of social virtual reality events during #HIMSS18: 3PM-5PM PST, Monday, Tuesday, and Wednesday! Please participate. You don’t even need a VR headset! Head on over to http://wareflo.com/himssvr/ for further instructions.]

I’ve fallen in love with the potential of a new social media medium. First there was blogging. Then there was Twitter. About three years ago I fell in love with social video (Periscope, Blab, and Firetalk, RIP the last two!). And now I am gaga over shared social virtual reality networking! I know that is a mouthful. I’ve seen it called at least three things: social virtual reality, shared virtual reality, or virtual reality networking. So I decided to mash them all up, until one becomes the generally accepted moniker.

Think of it this way. There are these virtual characters in a virtual place: a meeting room or conference, a shopping center, or perhaps a beautiful windswept hill or floating somewhere in the stars. You’re wearing a virtual reality headset, and can see out of the eyes of one of these virtual characters. You control it. You move it, point it, and gesture with it. You can customize it to make it look like whatever you wish. (Yep, sometimes it gets freaky. @ReadyPlayerOne anyone?) And there are other people strapped in their virtual reality gear, controlling… stop. No, “controlling” is too detached. You literally feel like you are in this virtual space, interacting with virtual people. And they feel the same way. It’s amazing!

Consider the following quotes:

“Shared VR is about sharing your virtual experience with another human who is also in virtual reality. This is the next step in communication mediums.” (Shared VR Explained)

“Virtual Reality is one of the most social technologies ever created…. Meet people from around the world, attend free live events, and play interactive games with friends. Day or night, there’s always someone to hang out with.” (The Top Social VR Networks You Can Hang Out In Now)

“why the world’s biggest and most popular social network [Facebook, would pay $2 billion] to own a virtual reality company…. Social VR will be entirely about inhabiting virtual space together, and driven by real human interaction…. Social networking has grown from text-based communication to largely visual, through the sharing of pictures and videos…. Virtual Reality is therefore tailor-made to be utilized as a social platform. It is, at its very core, about communication” (Virtual Reality in Social Media: Introducing Next Level Networking)

Shared social virtual reality networking is relevant to health/care/IT marketing in several ways. First of all, virtual reality, itself, without the shared/social/networking aspect, is a great way for prospective clients to kick virtual tires. Outside of healthcare, it is taking off, allowing consumers to more viscerally and immediately experience furniture, cars, and real estate. In healthcare, VR is taking off for educational and clinical purposes from learning to perform surgery, to preparing for a specific surgery, to distracting patients from the pain of surgery. It’s only a matter of time before it comes to health, healthcare, and health IT marketing,

About 15 years ago I was put in charge of researching whether it would be possible to replace our annual EHR user conference with a virtual online conference. I was amazed at the ambitious platforms out there. Many actually simulated a 3d conference space, allowing participants to customize their avatars, and upload and present PowerPoint slides on virtual screens projected to from virtual projectors in virtual meeting rooms. But there were three problems: expense, stability (ambitious but immature software), and lack of the virtual reality experience. It was like playing a game in which you controlled a character on the screen. But it was not immersive. You didn’t feel like you were actually “there”. Today is completely different. I’ve researched a bunch of shared social virtual reality networking platforms. Free: check! Stable: Tolerable (occasional crashes). Virtual reality? Check!

What about shared social virtual reality networking and health IT marketing? Set aside marketing virtual reality products in healthcare. Obviously, allowing someone, from the comfort of their home or office to experience a virtual reality product, while guiding and interacting with a them, will be a great tool. But consider marketing non-virtual reality products. How might virtual reality be used to market an EHR? A patient experience management platform? Imagine being an EHR vendor and being about to “spin-up” an entire virtual reality hospital and clinic, and allow clinicians (and patients!) to wander around and see how the health IT affects healthcare workflows and experiences!

And, further, imagine creating an entire health IT marketing conference one can attend in virtual reality! All (well most, forget the food) of what we love about real-life health IT conferences can be replicated (within a modest time frame, as the VR tech evolves, I am convinced!), from the milling around, to serendipitous bumping-intos, to lectures and panels. And, they can inexpensively be held in exotic places from Hawaii …. to Mars!

OK, enough palavering about the insanely exciting possibilities of shared social virtual reality networking. What are the nuts-and-bolts of getting started, now?

My First Attempt at Hosting a Shared Social Virtual Reality Networking Experience

Since the summer eclipse (during which I attended an eclipse watching party in virtual reality) I attended occasional events in virtual reality via AltspaceVR. When I realized I could, for free, host my own virtual reality event, I began thinking about hosting a health IT marketing VR event. So, about an hour before a recent #HITsm tweetchat, I decided to jump in with both feet. I actually didn’t expect anyone to show up. But what the heck, at least I could still always be able to say I tried it first.

Luckily, Lisa, and then Becky, saved me from failure. I tweeted out a link to the virtual reality space, plus two links to PC and Mac clients to download, install, and join me. Now, these are not full-blown VR experiences. They are 2D AltspaceVR clients. They remind me of the 3D user conference software I investigated 15 years ago. However, I am convinced, once one experiences the 2D experience, I think you’ll consider some extra investment to get the 3D VR headset and experience the full 3D immersive experience.

Let’s start with a short (17 second) video. I’m welcoming Lisa, who’s appeared in the doorway of the meeting space (customized! Nice outfit!). I’m in a blue shirt looking up. I’m actually shooting the video from @MrRIMP’s AltspaceVR’s account, so I can capture myself in the third person. Then, in the middle of the video, Becky materializes behind me (to the left of Mr RIMP). Becky and I successfully got our audio to work. Lisa and I didn’t. But you can text between avatars by clicking on someone and popping up a text box.

We all agreed, it was very cool, and worth trying again. Becky has a Samsung S7 so I pointed her toward the Samsung Gear V R (about $100). Both participants looked around the meeting space (and Lisa wandered around a bit outside the meeting space building).

Here is what I tweeted in order to invite folks to install the necessary software and join me in virtual reality.

Don’t bother clicking that link to the virtual realty space. It was just temporary. But do, if I tweeted out a link during a tweetchat, find THAT link to join me in social VR. Click and download a PC or Max 2D AltspaceVR client. Perhaps visit the “Campfire”, an always on virtual reality space, where newbies pop in and out, trying to figure our how to control their VR avatars. Got to events to see what happening, right now, or register your interest (so you’ll be notified when one is about to start): music, comedy, science, software development (especially VR), current events like eclipses or rocket launches. Just hang around in the back of the crowd, if you are shy. Then ask someone near where they are in the physical world to start a conversation.

Some Caveats about Shared Social Virtual Reality Networking

“Meeting a friend in a space like this is not the same as real life, it is something quite different but it still makes you feel “in touch”. When used with realistic expectations, social media should satisfactorily accompany real life interaction. Virtual social media offers the same benefits, but is more sensory…. Virtual Reality will probably not replace physical interaction – there is too much to be gained from being “with” a person in real time and space. … You dip into it, and it’s as fun to play as it is relieving at times to come out of. Personal interactions through virtual reality will, at best, serve to supplement our social lives as social media already does” (Social VR: Will Virtual Reality Increase Or Decrease Loneliness?)

I ended up focusing on health IT marketing, but social virtual reality has great potential for non-health IT folks, such as healthcare provides, patients, anyone interested in health, to get together to chat about common interests. I hope using virtual reality as part of social media becomes an easy and commonplace experience. And I think one important role for the health IT social media community will have will be to help support the less technical, but nonetheless enthusiastically interested, network in shared social virtual reality!

From Big Data to Smarter Care: The Workflow Dimension

One of the best things about being a HIMSS Social Media Ambassador (four years in a row!) is being asked to write about anything that has anything to do with healthcare workflow. It is both flattering and satisfying. So, when I was had an opportunity to write about the upcoming Big Data & Healthcare Analytics Forum (Boston, 10/23-24) I jumped at the chance! Also, please join the #PutData2Work Twitter Chat (today, 1PM EST, immediately after #KareoChat).

The relationship between data and workflow in healthcare is an interesting one. The Forum illustrates this. It emphasizes “action” based on data: “actionable information,” “actionable strategy,” and “actionable insights.” Action is part of the definition of workflow, since workflow is a series of actions, consuming resources, achieving goals. In fact, big data, data science, machine learning, and business intelligence platforms are helping to bring sophisticated process automation tools to healthcare.

In my three-series just before the HIMSS17 conference, I describe how workflow technology makes modern machine learning and data science initiatives possible. It is simply no longer practical, to manually download, transform, then put into a format causing useful action at the point of care. Data sets so large they cannot fit on puny desktop drives, and then so slow to upload and download and upload again, force us to, essentially, model data workflows and then execute these models, in the cloud, without continuous, direct, manual, human intervention. I discussed this at length in A guide to AI, machine learning and new workflow technologies at HIMSS17 Part 1: Machine learning and workflow.

In particular, I hope you’ll pay attention to the following three presentations at the Big Data & Healthcare Analytics Forum…

…and ask yourself:

  1. How does workflow and process automation help make machine learning and smart systems practical?
  2. How does workflow and process automation make generated insights “actionable”?

I’ll close with a quote from Hal Wolf, President And Chief Executive Officer, HIMSS:

“We want to maximize the patient experience at each clinic, and thus it’s important that we not be too rigid about workflows and systems. The clinics have room for flexibility and innovation.”

Most folks think of workflows in terms of day-to-day tasks of clinicians and staff. Obviously these “flows” influence patient experience. However, data-flow is also a kind of workflow. These workflows exist as both models of data flow, and executions of these models by various kinds of engines (workflow, process, orchestration, and data pipeline engines). Big data, business intelligence, and machine learning platforms have, at their core, sophisticated models and engines necessary to strike the right balance, between efficiency through best practice standards, and flexibility for healthcare organizations to innovate.

I also hope to see you at the #PutData2Work Twitter Chat: Building a More Informed Healthcare System, at 1PM EST, on October 12,

with @HealthITNews, @SullyHIT, @ShahidNShah, and @drstclaire!

Viva la workflow-powered data, and data-powered healthcare workflow!

If you are interested in the fascinating relationship between healthcare data and healthcare workflow, I hope you’ll follow me on Twitter at @wareFLO (for soft(ware) work(FLO)w).

3rd Annual NHITweek Firetalk: 3Dprinting in Healthcare w/@Brouwers_3D & @wareFLO

It was great! 18 viewers and 56 comments! Watch, learn & enjoy! (more details after the embedded Youtube archive of the Firetalk, tho here is original link https://firetalk.com/events/BkEvXDesW)

#3Dprinting in Healthcare! @Brouwers_3D @wareFLO: 3rd Annual #NHITweek #Firetalk

Hosted By: Charles Webster MD ⎌ Tuesday, October 03, 2017, 10:00 AM to 10:30 AM

10:00AM EST on Tuesday, Oct. 3rd, during National Health IT Week (http://www.healthitweek.org) I’m excited to speak with Lars Brouwers, MD, MS (almost PhD!) about 3D-printing in healthcare. I hope you’ll join our Firetalk, make comments, ask questions, and even take a video seat! (I’ll publish your best segments as mini Youtube videos, and tweet them out during the rest of National Health IT Week!)

Here are couple quotes from Lars:

“3D-printing is the most important invention after internet. I use it on daily basis”

“Our goal is to investigate the added value of 3D-printing, and implement a low-cost workflow for many hospitals worldwide”


Later in the week Lars is speaking about his 3D-printing in surgery research in Vancouver, Canada, at the Orthopaedic Trauma Association’s 33rd Annual Meeting. So we are lucky to have this opportunity. Check out a recent article in Physician’s Weekly, “Implementing In-Hospital 3D Printing”, to learn more about Lars’ exciting use of 3D-printing to improve surgical outcomes.


If you are a patient, or a health IT professional, who’d like to learn more about 3D-printing and how it will affect your life or profession, this is a great opportunity to peek into your near future. Please join us, first watch and listen, and then to take a video seat and probe further and express your opinion.

By the way, this is the third time I’ve hosted a Firetalk group social video during National Health IT Week. It’s always fun, and it will be even more fun this year, during this years 2017 National Health IT Week!

2016 National Health IT Week Blab, I Mean Firetalk, Was Fun! 23 Participants, 50 Comments (w/@MichaelGaspar)


Replay Mid National Health IT Week Blab: Many Thanks to Participants!


Drones In Healthcare: Lessons and Imaginings From Harvey and Irma! #KareoChat 9/14

Imagine ordering fresh food, clothing, & batteries from Amazon, while sitting on your roof due to a flood. Imagine, lying on your roof in the dark and cold and rain, and being addressed by a friendly drone offering assistance. Imagine that drone calling in a big brother drone, large enough to airlift you to safety. Imagine waterproof drones fanning out and sampling floodwaters for unhealthy substances and organisms. Imagine being a quadriplegic and being able to fly like Superman, remotely piloting a drone while wearing telepresence goggles.

All of the above possibilities are technically possible, or folks are actively working to make these possibilities possible. In fact, during Harvey and Irma I saw dozens of news articles about the use of drones.

During the upcoming (Thursday, Noon EST, Sept. 14) #KareoChat tweetchat about drones in healthcare, I’ll tweet examples of all of the above, and more! Drones can deliver to your phone using its GPS coordinates. Drones can find people in the dark and cold using thermal imaging. Drones can talk to onlookers (think, drones + Alexa). Drones large enough to lift people exist, and are being proposes as air ambulances. Quadriplegics are learning new careers as drone pilots.

I’m saving most of my links to cool uses of drones in healthcare for the actual #Kareochat tweetchat, but I encourage you to watch these two videos.

Immersion Drone Piloting for People with Disabilities

Quadriplegic flying Quadcopter FPV (First Person View)


T1 Did you see any news about drones during Harvey & Irma? About what? Any controversies? #KareoChat

T2 If you were bed-bound, and could return anymore in the world for a drone’s eye tour, where & why? #KareoChat

T3 Drones are cool w/great potential, but what kinds of problems might they cause? Any ways to fix?

T4 If medical supplies could be delivered anywhere, within minutes, for virtually zero transport cost, how disruptive might that be?

T5 How can FEMA (Emergency) & FAA (Aviation) best work with thousands of enthusiastic drone pilot hobbyist who want to help during disasters?


What’s The Fix For Healthcare? How About A Workflow Magic Wand?

[This post is written in preparation for the What’s The Fix? A Free Health Care Conference for Everyone!]

What if I claimed to you that the most important thing to fix in healthcare is workflow? Think about it! Think about all the usual culprits: experience, usability, cost, interoperability, and on-and-on. What do they all have in common? Workflow!

Now, what if I further claimed that I had a magic workflow wand, which, if I waved it, and said the proper incantation, would magically fix healthcare workflows? If successful, if workflows everywhere in healthcare were fixed, then all and more of the following would be greatly improved: experience, usability, cost, and interoperability (and on-and-on!).

Now, what if I went even further and claimed this magic wand actually exists? I imagine you’d say, Chuck, Chuck, stop this game! I humored you. I put up with you. But, no, THERE IS NO WAND TO FIX HEALTHCARE WORKFLOW!

You’d be right. There is no magic wand. Magic wands exist only in bedtime stories and Harry Potter books. But there is the next best thing: workflow technology.

What? Isn’t healthcare already using workflow technology? Well, I admit it is starting to… I’ve been tracking the flow of workflow engines and editors and analytics into health IT and healthcare for almost three decades. The obsession comes from getting a degree in Industrial Engineering on the way to a degree in Medicine. You see, an IE degree is essentially a degree in workflow. For most of those decades workflow technology simply didn’t exist in healthcare, except for an occasional, tiny, non-consequential pocket here-or-there. However, seven years ago I started searching every HIMSS exhibitor website for workflow-related material. (I’ve also done so for the AHIP conference for the last three years.) The uptick in workflow thinking, and, to a smaller degree, actual workflow technology, is gratifying. But this trend needs to happen much faster, to have to kind of system-wide qualitative and quantitative impact we need in the areas of experience, usability, cost, and interoperability (and more!)

Popular (or should I say, unpopular) aspects of healthcare are frequently blamed for broken healthcare include:

  • Cost
  • Experience & Usability
  • Interoperability
  • Incentives

Let’s start with healthcare cost.

The single largest healthcare cost is expensive, professional, manual human labor. If you look as “service lines”, such as an annual physical or having your appendix out, I’ve seen estimates of cost between 60 and 80 percent being labor. Besides that Industrial Engineering degree I mentioned earlier, I should also mention my premed undergraduate degree. It was a BSA in Accountancy, from the University of Illinois, which is frequently ranked number one in Accounting. What did I emphasize during my course electives, besides biology, chemistry, and physics, to get into medical school (yes, they thought I was an odd duck too!)? Management Information Systems (MIS) and cost accounting. Guess what? That educational background (plus three decades of toiling in the health IT groves) has convinced me…

We won’t control healthcare costs until we measure healthcare costs at the level of individual healthcare tasks and workflows. (I could go into a great deal of tedious detail about why I believe this, and, indeed, I will be happy to do so, however, in the interest of brevity, I thought I’d just argue from authority!)

Now let’s tackle experience!

I frequently define workflow as a series of steps, consuming resources (costs!), achieving goals. All purposeful human activity relies on workflow. Which is exactly why fixing workflow can fix so much about healthcare. I also sometimes point out that “steps” can range from tasks, computer screens, activities, other workflows, and even experiences. From a strictly (and perhaps simplistic, but intentionally so) systems engineering view, patient experience is what happens to the patient and patient engagement is what the patient does back.

Increasingly, what happens to patient is facilitated by information technology. This is not to say that experiences are necessarily devolving into digital touchpoints. Rather, sometimes the IT happens in the background and frees healthcare staff to spend more, and better, time with patients, thereby creating more, and better, patient experience.

The problem with current health IT is this. It has no model, representation, means, or way to actually reason about patient experience, because it has no way to reason about the workflows at least partially determining patient experience. Current health IT is relatively workflow-oblivious. In contrast, modern workflow technology (including business process management, the exemplar of workflow tech), actually has models of workflow. These models are interpreted and executive by workflow engines. Just like the engine in your car, workflow engines do work. And, by doing work, they save drivers, users, and patients, from having to do the work themselves.

In effect, because healthcare lacks the kind of intelligent workflow engines that are more prevalent in other industries, patients have to become their own workflow engines. They puzzle over care plans and medication lists and attempt to compensate for a healthcare system that lacks the basic workflow thinking, tools, and infrastructure, to imagine, create, and maintain otherwise.

Yes, we need to be nicer to patients. However, only forty to sixty percent of patient experience is due to face-to-face interactions with staff. The other forty-to-sixty percent are due to “The Systems Behind The Smiles.” And these system currently disserve their users, whether they be patients interacting with healthcare staff, or physicians interacting with Meaningful Use mandated EHRs.

What about interoperability?

Isn’t interoperability really the issue? Even if we had instant data interoperability, which is 99% of health IT interoperability today, costs and experience would still suck. Health IT is almost completely missing the notion of “workflow interoperability” (technically “pragmatic interoperability”).

Data interoperability is about what linguists call syntax and semantics. (Oh, by the way, did I mention I’m also ABD, or All-But-Dissertation in Computational Linguistics? :)) Syntax moves the data. Semantics makes sure it means the same. But linguistics has one more area of research: pragmatics. Pragmatics is about how humans use language to achieve goals. Goals! Wasn’t that part of my definition of workflow? Why, yes it was!

Health IT is not currently serving patient or healthcare workers goals well. To the degree that healthcare and health IT moves beyond mere data interoperability (which we are not doing well anyway), toward true workflow interoperability (AKA pragmatic interoperability), health IT will begin to, imagine, create, and maintain systems that more directly and intentionally serve our collective healthcare goals.

Finally, incentives….

There are those who claim that one hundred percent of fixing the “healthcare system is broken” solution is changing the incentives that reward and penalize behavior (at all levels, from patient to EHR vendor to CEO). Perhaps in the very long run this is true. But in the short run, it is false.

Even if we could wave a magical healthcare incentives wand, and “fix” all healthcare incentives everywhere (which, by the way, I have to interject, is a nonsensical notion, there is no perfect system of healthcare incentives), the current system of healthcare workflows is so entrenched, so frozen, so … immutable in the short term, we’d have a classic case of an irresistible force (incentives) meeting an immovable object (current healthcare workflows).

Only by unfreezing healthcare workflows, making them malleable, and then applying incentives, can we change the healthcare system workflows determining patient experience. And what kind of technology is exactly the kind of technology you need to create transparent and flexible workflows? You got it! Workflow technology!

Anyway, thank you for letting me rant on-and-on about healthcare workflow. I look forward to the What’s The Fix For Healthcare Conference! By the way, last night the Healthcare Leadership Blog tweetchat featured discussion of themes relevant to the What’s The Fix Conference. Here are my answers to four #HCLDR questions.

T1 What aspect of healthcare is most broken/What would you fix first? Why?


T2 What solution, technology or process do you feel holds the most promise for fixing healthcare?

Workflow technology!

T3 Is there an effective alternative to social media, for patient advocacy? Or has SoMe supplanted all other channels?

Healthcare social media and other communication channels (video, F2F/IRL, email, phone, etc.) are merging into a single “funnel” from unstructured entertainment and socializing to structured communication and collaboration to achieve common goals.

T4 Patient stories are powerful, how could their impact be increased without saturating the space?

Guess what? Stories are workflows! (See my Patient Narrative and Healthcare Workflow: Story Informatics!)

How can we use this insight to increase impact without over-saturation? First of all, social scientists are increasingly analyzing stories to create workflow-like representations. These are life-flows. We need to understand more about real-life, outside healthcare, personal workflows, and then to understand how they interleave with healthcare workflows. Second, we need better ways to walk a mile in each other’s shoes. I happen to think workflow technology can play a role here too, but these ideas are nascent (half-baked!) so I’ll save them for future post (hint: combine virtual reality with workflow technology!)

I’ll see you at the What’s The Fix? A Free Health Care Conference for Everyone!

P.S. One more thing. I’m a big believer in EHR and health IT users making their own workflows. Guess what! Patients will also design the very healthcare workflows that in turn drive patient experience! Viva la workflow! Onward workflowistas!

@wareFLO On Periscope!


Is eClinicalWorks 100% At Fault? No, Ultimate Culprit Was Meaningful Use

While not excusing eClinicalWorks, they were trying to help their customers get the meaningful use subsidies, by gosh or by golly. So, I imagine, if ECW clients reflect on this, they may sympathize with ECW and stick with them… for a while. If the government attempts to claw back those meaningful use payments, possibly as a stick to get ECW customers to migrate to alternative certified EHRs, I’m sure ECW will lose some clients.

On the other hand, while moving data from one EHR to another EHR is difficult enough, migrating workflows from one EHR to another EHR will be even more problematic. Once users customize EHR workflows, or force themselves to adapt to EHR specific ways of operation, they are loath to move to another EHR, if only to avoid another painful training, configuration, and go-live process again.

In the long run, if the financial penalties and additional requirements of the settlement result in diminishing ECW ability to add new features, and support existing ones, then ECW will find it more-and-more difficult to compete in the EHR marketplace.

While I am likely in the minority view here, I think blaming ECW (and other EHR vendors) for this sad situation is shortsighted, unless one also acknowledges the role of the entire meaningful use program, in distorting not just the EHR market, but also the ethical and moral principles of many EHR vendors. It was an expensive mistake, the unintended consequences of which we will be living with for many years.

@wareFLO On Periscope!