Well Understood, Consistently Executed, Adaptively Resilient, and Systematically Improvable EHR Workflow

Short Link: http://j.mp/80VBlx

The key insight I hope to impart in this series of posts that started with 12 quotes is this: Well understood, consistently executed, adaptively resilient, and systematically improvable workflow *between* health care organizations is not possible without well understood, consistently executed, adaptively resilient, and systematically improvable workflow *within* health care organizations. Each post tries to achieve this goal in a different way.

This Week I Play With Words

My plan was to start with authoritative statements from both the primary care and workflow automation domains, and then systematically describe how the ideas they represent fit together. One way to do this is to take a quote from one domain, insert, delete, and substitute some words from the other domain, and see if the quote still makes sense (if this sounds a little flakey, hang in there). For example, “BPM suites coordinate tasks and synchronize data across existing systems,” becomes “EMR BPM suites coordinate clinical tasks and synchronize clinical data across existing systems,” and the phrase “work-in-progress” becomes “care-in-progress,” and so on.

You get the idea. Here’s quote 12 from the BPM domain:

  1. Papazoglou and Ribbers, “e-Business: Organizational and Technical Foundations”. J. Wiley & Sons, April 2006, quoted at S-Cube, last retrieved 11/10/09:
    1. “BPM suites coordinate tasks and synchronize data across existing systems. They also help coordinate human process activities, streamlining tasks, triggers, and time lines related to a business process, and assuring they are completed as defined by a process model. A BPM suite makes processes more efficient, compliant, agile, and visible by ensuring that every process step is explicitly defined, monitored over time, and optimized for maximum productivity.
    2. A true BPMS enables business users to:
      1. Model and simulate all interaction patterns between workers, systems and information sources to create shared understanding about how to optimize business processes and results.
      2. Coordinate and manage the handoff of work across boundaries.
      3. Provide real-time feedback to business managers about work-in-progress to support in-line business process adjustments.
      4. Monitor process outcomes to performance targets, and continuously refine and adjust process flows and rules.”

Here’s the BPM quote applied to the pediatric and primary care coordination domain:

  1. Webster, adapted from Papazoglou and Ribbers:  
    1. EMR BPM suites coordinate clinical tasks and synchronize clinical data across existing pediatric, pediatric subspecialty, and non-pediatric primary care EMRs. They also help coordinate clinical activities, streamlining clinical tasks, triggers, and timelines related to a care coordination process, and assuring they are completed as defined by a care coordination process model. An EHR BPM suite makes care coordination processes more efficient, agile, and visible by ensuring that every care coordination process step is explicitly defined, monitored over time, and optimized for maximum productivity.
    2. A true EHR BPM suite enables physicians and staff to:
      1. Model and simulate all interaction patterns between physicians and other clinical and non-clinical staff, systems, and information sources to create shared understanding about how to optimize care coordination processes and results. [CW: “well understood”]
      2. Coordinate and manage the handoff of patient care tasks within and across organizational boundaries. [CW: “consistently executed”]
      3. Provide real-time feedback to pediatricians and care coordinators about care-in-progress to support patient care process adjustments. [CW: “adaptively resilient”]
      4. Monitor care coordination outcomes to performance targets, and continuously refine and adjust care coordination process flows and rules. [CW: “systematically improvable”]

Sounds good! I’d consider such a product if I wanted to build a high-performance medical home system. Actually, I do. And you should too.

Several comments:

First, I emphasized “care coordination” rather than simply “patient care” or “healthcare” because I wanted to stress the relevance of workflow and BPM technology to the care coordination aspect of the health system as described in quote 3.

Second, I emboldened four bracketed phrases of my own contrivance (“well understood,” “consistently executed,” “adaptively resilient,” and “systematically improvable”) because they provide a useful checklist, so to speak, for comparison of traditional EMRs to process-aware EMRs (“process awareness” being a prerequisite for applying BPM to EMR processes).

And third, a caveat—EMR BPM doesn’t exist yet. You can’t simply buy a BPM suite and use it for EMR BPM. Right now the closest you can get to EMR BPM is an EMR workflow system. However EMR workflow systems have the process-aware foundations required for full-blown EMR BPM, that is, well understood, consistently executed, adaptively resilient, and systematically improvable EMR-mediated care processes.

Let’s Try It Again

Recall the topics of pragmatic interoperability and conversations between EMRs in a previous post? Quote 7, adapted from the original, described a conversation between the EMRs representing a community pediatrician and a pediatric subspecialist. Let’s further adapt it to a diagram of an “e-contract” (quotes 10 and 11) between two workflow management systems (circa 2000, though I was not aware of it at the time).

 medical-home-general-pediatrician4

Adapted from Figure 1 in Grefen, Aberer, Hoffner & Ludwig,
CrossFlow: Cross Organizational Workflow
Management inDynamic Virtual Enterprises, 2000.
(http://lsirpeople.epfl.ch/aberer/PAPERS/CSSE%20’00.pdf
[CW: you’ll need to copy and paste the link into your browser and
and then replace the single quote with a real one,  the one
on your keyboard should work, WordPress does not
appear to handle this character well], last retrieved 11/10/09)

Here’s quote 7 after I’ve inserted “Invoke,” “Monitor,” “Control,” and “Get Result” at the places in text that correspond to the arrows in the diagram:

“EMR workflow systems (WfSs) will need to coordinate execution of workflow processes among separate but interacting EMR WfSs. For example, when a general pediatric (GP) EMR workflow system (GP EMR WfS) forwards (“Invoke”) a clinical document to a pediatric subspecialist (PS) who is also using an EMR workflow system (PS EMR WfS), the GP EMR WfS eventually expects a referral report back from the PS EMR WfS. When the result arrives (“Result”), it needs to be placed in the relevant section in the correct patient chart and the appropriate person needs to be notified (perhaps via an item in a To-Do list). If the expected document does not materialize within a designated interval (“Monitor”), the GP EMR WfS needs to notify the PS EMR WfS that such a document is expected and that the document should be delivered or an explanation provided as to its non-delivery. The PS EMR WfS may react automatically or escalate to a human handler. If the PS EMR WfS does not respond, the GP EMR WfS may cancel its referral (“Control”) and also escalate to a human handler for follow up (find and fix a workflow problem, renegotiate or terminate an “e-Contract”). Interactions among pediatric EMR workflow systems, explicitly defined internal and cross-EMR workflows, hierarchies of automated and human handlers, and rules and schedules for escalation and expiration will be necessary to achieve seamless coordination among pediatric EMR workflow systems.”

The quote above is a “conversation” between two EMRs, one acting for a pediatrician, the other acting for a pediatric subspecialist. Similar sorts of diagrams are possible for a subspecialty-based medical home for pediatric patients that require regular visits to pediatric subspecialists, or for transfer of a patient’s records from a pediatric to an adult medical home. One of the advantages of workflow automation is that process definitions can change without resorting to rewrite of the programming code that makes EMRs possible. It should be up to pediatric, subspecialist, family medicine, obstetrics & gynecology, and other primary care stakeholders, to negotiate cross-practice EMR workflows and e-contracts consistent with their clinical and business objectives. They should not need to take into account the fragile, ambiguous, unscalable, frozen workflows of traditional EMRs (that is, EMRs lacking workflow management system foundations and BPM functionality).

When presenting a new concept (to my intended audience, I certainly didn’t invent the ideas, just this specific example of their application), it can be helpful to present the same basic idea in several different ways. The following is another diagram of a process shared across organizations.

workflow-engines-a-b21

This figure  is adapted from the introduction to the 2001 dissertation, The Contracting Agent: concepts and architecture of a generic software component for electronic business based on outsourcing of work. (Andries van Dijk. – Eindhoven : Technische Universiteit Eindhoven). Workflow Engine A kicks off workflow A1 through A5, but between A3 and A4 outsources steps B1 through B3 via Web services.

Rob Allen’s Workflow: An Introduction also covers communicating workflow engines at a basic level (pages 10-24) and is a useful overview of workflow in general.

I can’t resist my little word substitution game again. Dr. van Dijk also notes:

“An influential approach to the modelling of communicating information systems is called the language / action perspective (LAP). The basis for LAP was a growing awareness that linguistic theories are relevant for the design of communicating information systems. A cornerstone of the LAP approach is the linguistic theory of speech acts developed by Searle in 1969.”

You would surely agree that an EMR is an “information system,” and that “interoperating” is an instance of “communicating,” so replace “communicating information systems” with “interoperating EMRs” and you get:

“An influential approach to the modelling of communicating information systems is called the language / action perspective (LAP). The basis for LAP was a growing awareness that linguistic theories are relevant for the design of interoperating EMRs. A cornerstone of the LAP approach is the linguistic theory of speech acts developed by Searle in 1969.”

I previously mentioned relevance of linguistic theory to EMR interoperability–I rest that case.

An Obvious Question

 An obvious question occurs. If there is such a great “fit” between what EMRs need and what workflow systems and business process management do, why hasn’t it happened yet? I myself have been puzzled by this. I think there is an element of NIHism (Not Invented Here-ism). The United States is a remarkable generator of new information technologies, from the large high tech companies to the university spin-offs to inventors who start in a garage. Much workflow research took place, and many commercial BPM products created, outside the US (as I noted previously).

However, EMR workflow management systems are not prevalent in Europe either (the Soarian system, initially developed in Germany, being the sole exception of which I am aware). So I have another theory, which I will hold for a later post.

Nonetheless, workflow management systems and business process management technology is diffusing into the healthcare industry at an increasing rate. Some day most pediatric and primary care (and other general-purpose and specialty-specific) EMRs will be EMR workflow systems, although by then I expect the phrase “workflow system” to disappear. It will be the non-workflow system EMRs that will require qualification, much as we use “analog watch” or “silent movie” today (so-called retronyms) to distinguish them from their modern descendants.

Workflow-Related Interoperability Requirements for the High-Performance Medical Home

Short Link: http://j.mp/5v2fzq

Last week I posted 12 quotes, three from primary care sources, five from computing sources, and four from me. What was my purpose?

My purpose was and is (as usual) to raise the profile of workflow management systems and business process management with respect to the important goals of increasing the effectiveness and efficiency of, and participant satisfaction with, healthcare processes. So far, my posts have alternated among praising WfMS and BPM technology, arguing that EMR systems need to rely on process-aware foundations, and asserting that traditional EMRs lack this critical prerequisite for systematic improvement of effectiveness, efficiency, and satisfaction. I chose these 12 quotes about key concepts to make a point: The central problem we face in improving healthcare and “bending the cost curve” is the need for better coordination.

So far, the most comprehensive vision of care coordination is the medical home model (quote 1). So far, the most comprehensive technology for coordinating complex interdependent activities is workflow management systems and business process management. I wanted to start with authoritative statements (quotes 1-12) from both domains and then systematically describe how the ideas they represent fit together. I hope to convince you (if not in this post, then perhaps in a future post) that the high-performance medical home requires coordination infrastructure that is not, and in fact cannot, be provided by traditional EMRs. However, EMR workflow systems are prime candidates for providing important portions of this infrastructure.

chuck-likes-workflow

May I regress? When I was a graduate student in Intelligent Systems I took courses in linguistics, including phonetics, morphology, syntax, semantics, pragmatics and discourse analysis (plus computational linguistics and natural language processing and generation). These courses were about communication between humans–and between humans and computers. It turns out that syntax, semantics, and pragmatics (and possibly discourse analysis as well) are also relevant to communication between computers, including EMRs.

Much is made of the need for EMRs to interoperate with each other and other information systems (as well it should). Current efforts focus on syntactic and semantic interoperability. Syntactic interoperability is the ability of one EMR to parse (in the high school English sentence diagram sense) the structure of a clinical message received from another EMR (if you are a programmer think: counting HL7’s  “|”s and “^”s, AKA “pipes” and “hats”). Semantic interoperability is the ability for that message to mean the same thing to the target EMR as it does to the source EMR (think controlled vocabularies such as RxNorm, LOINC, and SNOMED).

Plug-and-play syntactic and semantic interoperability is currently the holy grail of EMR interoperability. We hear less about the next level up: pragmatic interoperability (AKA workflow interoperability). As soon as, and to the degree that, we achieve syntactic and semantic interoperability among general pediatric, pediatric subspecialty, and other primary care EMRs, issues of pragmatic interoperability will begin to dominate. And they will manifest themselves as issues about coordination among EMR workflows.

Here are succinct descriptions of semantic versus pragmatic interoperability:

Semantic interoperability is concerned with ensuring that a symbol has the same meaning for all systems that use this symbol in their languages. Symbols are real world entities indirectly (i.e., through the concept they represent). Therefore, the semantic interoperability problems are caused either by different abstraction of the same real-world entities or by different representations of the same concepts….”

Pragmatic interoperability is concerned with ensuring that the exchanged messages cause their intended effect. Often, the intended effect is achieved by sending and receiving multiple messages in specific order, defined in an interaction protocol. Pragmatic interoperability problems arise when there are differences in the meaning of data in the exchanged messages (e.g., semantic problems) or there are differences in the interaction protocols of the systems that exchange these messages.” (p 44, Pokraev, Model-driven semantic integration of service-oriented applications. PhD thesis, Univ. of Twente, 2009)

I’ll return to issues of semantic interoperability between pediatric EMRs and between pediatric and non-pediatric primary care EMRs in a future post. But in this post, I’ll focus on pragmatic interoperability as it relates to the high-performance medical home model.

Pragmatic interoperability is not possible without semantic and syntactic interoperability, and semantic interoperability is not possible without syntactic interoperability. Makes sense; you and I (and EMRs, intelligent systems all–eventually) have to parse what we hear (download, import, etc.) before we understand it, and we need to understand what we parse before it can have its intended effect, which is often to cause us to act in coordination with the source of the message.

(If a “conversation” ensues, we’re getting into theories of discourse analysis. I do think that EMRs eventually will indeed “converse” among themselves, engaging in the equivalent of “coherent sequences of sentences, propositions, speech acts or turns-at-talk”. In fact, one of the first theories of workflow relied on speech acts (see this early tutorial on “Coordination-based Workflow” [emphasis not in original]) and one of the first workflow management systems relied on this theory. The conversational metaphor is already being exploited within the SOA (service-oriented architecture) community and eventually will surely diffuse into discussions about EMR-to-EMR and EMR-to-non-EMR interoperability. Of course, individual “sentences” will most likely be based on an artificial language, perhaps a future version of HL7, not natural human language.)

OK, back to the high-performance medical home. It won’t be possible without coordinated pragmatic interaction among multiple primary care, specialty and subspecialty EMRs. Note that I did not say interaction among primary care physicians, specialists, and subspecialists. Yes, the medical home concept is possible without EMRs. It just won’t be high performance, that’s all. Without automated communication between EMRs the high-performance part of the pediatric medical home simply won’t be possible. Humans, including physicians (and their staff), are slow (no offense!), inconsistent (no offense!), and expensive (no offense!), compared to automatically communicating information systems.

EMRs have the same problems that motivated the best known process-aware information system—BizTalk Server.

“With the integration and communication infrastructures complete our applications can now ‘speak’ to other applications over the Internet, but we don’t have a good mechanism for telling them when and how to say it. We have no way of representing the process. Today the ‘process’ is spread throughout the implementation code of every participant involved in the process. This mechanism for representing the process of business interactions is fragile, prone to ambiguities, does not cross organizational boundaries well, and does not scale. The larger the process gets and the more participants that are involved, the more static the process is and the harder it is to propagate changes and new players into the process” (BizTalk Orchestration – a new technology for orchestrating business interactions, Microsoft Research, 2000, quoted in Andrade et al, Coordination for Orchestration, Arbab and Talcott, Coordination Models and Languages, 2002, my emphasis)

By the way (just so you don’t get the wrong idea), simply adding a BizTalk adaptor to a traditional EMR won’t turn it into a process-aware EMR workflow system. That’s not my point. My point is—use of traditional EMRs to implement the care coordination infrastructure required by the medical home model will result in fragile, ambiguous, unscalable, frozen cross-organizational workflows, the opposite of a “high-performance” medical home. Even Microsoft agrees with me (although it would be more pragmatically accurate to say I agree with Microsoft).

More, much more, later…

  • Politician: It’s the coordination, stupid!
  • Real Estate Agent: Coordination, coordination, coordination!
  • Chuck Webster: Coordination is what EMR workflow systems do.

The High-Performance Medical Home and Primary Care EMR Workflow Systems: Key Ideas

Short Link: http://j.mp/6iUspT

This is the first of several posts about the important role pediatric and primary care EMR workflow systems and business process management will play in achieving the high performance pediatric medical home model. A series of quotes sets the stage for further discussion in later posts. Here, I only editorialize a little bit, mostly through the material I choose to embolden.

quotes-400-web

By the way, you will notice that quotes 9 and 11 refer to workflow management systems (WfMSs) while quote 10 refers to business process management (BPM) suites. As WfMS vendors added additional products, which work in conjunction with workflow engines and process definitions to extend, monitor, and optimize automated processes, the “WfMS” industry became the “BPM” industry. You will also encounter the phrase “process aware” in the literature, though not in the particular quotes I have chosen to highlight here.

  1. “A medical home is defined as primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective.” (www.aap.org/healthtopics/medicalhome.cfm, last retrieved 11/10/09)
  2. “The major question appears to be ‘Can we bend the cost curve?’ so we can afford to provide all people access to high quality healthcare in a medical home.” (David Tayloe, MD, 2008-2009 AAP President, Presidential Address, 10/17, 2009 AAP NCE):
    1. “We need changes to ensure that all private and public payers compensate general pediatricians and pediatric subspecialists per member per month fees on top of fee for service and based upon the complexity of our patient population to provide real medical homes for all patients.
    2. We need changes to make sure that families have community based care coordination, not 800 numbers. These are personnel in our communities to assist them in caring for their special needs children.
    3. We need changes to ensure all pediatricians utilize electronic health record systems that ensure that all patients have comprehensive, up to date, longitudinal health records, interoperability with other components of the larger system of care, and the efficient collection of data that facilitates quality improvement.
    4. We need changes to ensure that subspecialists develop care paths for children with chronic illness and then share those care paths with community pediatricians to ensure comprehensive, continuous, high quality, cost effective care.
    5. We need changes to ensure that subspecialists have the care coordination resources they need to provide medical home leadership for that subset of pediatric patients that require regular visits to pediatric subspecialists.
    6. And finally, we need changes to ensure that all children have 24/7 care in a medical home that is supervised by a qualified physician.”
  3. Antonelli, McAllister, & Popp, Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework, The Commonwealth Fund, 2009, last retrieved 11/10/09 [“coordination” occurs 256 times in this 26 page whitepaper, as well it should!]:
    1. “We conclude that integrated care coordination infrastructure is essential to create and sustain a high performance pediatric health care system
    2. “A functional information technology infrastructure can enable health care teams to reach their potential in supporting care coordination processes
    3. “Nearly all the expert informants describe the primary care ‘hub,’ health care home, or medical home as the logical and effective center for care coordination.”
    4. “Pediatric care coordination is a patient- and family-centered, assessment-driven, team-based activity designed to meet the needs of children and youth while enhancing the care giving capabilities of families. Care coordination addresses the interrelated medical, social, developmental, behavioral, educational, and financial needs in order to achieve optimum health and wellness outcomes”
    5. “An important component of care coordination is the creation of individualized care plans, informed by a comprehensive needs assessment and including a clear delineation of goals, roles, and responsibilities and expected outcomes.”
  4. Coordination is managing dependencies between activities.” (Malone & Crowston, The Interdisciplinary Study of Coordination, ACM Computing Surveys, 1994, last retrieved 11/10/09)
  5. “The simple capacity to connect and communicate data is insufficient. You need to connect, communicate, and coordinate. EMR workflow systems are all about coordination. Workflow engines execute process definitions in order to coordinate the accomplishment of tasks.”
  6. “Within pediatric subspecialties (such as allergy, endocrinology, neurology, gastroenterology, rheumatology, and pulmonary) creating and executing workflow process definitions for each different specialty, provide specialty-specific workflows against a common patient database. With respect to related primary care specialties (such as family medicine, general internal medicine, and obstetrics and gynecology) the same holds true. In both cases workflow process definitions span specialty or subspecialty boundaries to coordinate multi-disciplinary care.” (Pediatric and Primary Care EMR Business Process Management: A Look Back, a Look Under the Hood, and a Look Forward, 2009 whitepaper)
  7. “EMR workflow systems (WfSs) will need to coordinate execution of workflow processes among separate but interacting EMR WfSs. For example, when a general pediatric (GP) EMR workflow system (GP EMR WfS) forwards a clinical document to a pediatric subspecialist (PS) who is also using an EMR workflow system (PS EMR WfS), the GP EMR WfS eventually expects a referral report back from the PS EMR WfS. When the result arrives, it needs to be placed in the relevant section in the correct patient chart and the appropriate person needs to be notified (perhaps via an item in a To-Do list). If the expected document does not materialize within a designated interval, the GP EMR WfS needs to notify the PS EMR WfS that such a document is expected and that the document should be delivered or an explanation provided as to its non-delivery. The PS EMR WfS may react automatically or escalate to a human handler. If the PS EMR WfS does not respond, the GP EMR WfS may cancel its referral and also escalate to a human handler for follow up (find and fix a workflow problem, renegotiate or terminate an “e-Contract”). Interactions among pediatric EMR workflow systems, explicitly defined internal and cross-EMR workflows, hierarchies of automated and human handlers, and rules and schedules for escalation and expiration will be necessary to achieve seamless coordination among pediatric EMR workflow systems.” (adapted from EHR Workflow Management Systems in Ambulatory Care, 2005 HIMSS Proceedings published submission)
  8. “Consider the three “Multis” of workflow management. Ask: Do you have multi-specialty workflow management, in which different specialties and specialists can rely on different workflow definitions? Do you have multi-site workflow, where medical practice sites in different parts of town can share in workflow definitions? Do you have multi-encounter workflow, especially important for chronic disease management? (Electronic Medical Record Workflow Management: The Workflow of Workflow, 2003 whitepaper)
    1. Think of multi-specialty workflow in terms of analogy to rail mass transportation in a major city such as London or New York. Subway lines start in different places, end in different places, stop in different (but also similar) places along their way, but work together in a globally coherent system. Each specialty has its own collection of workflow definitions, whose constituent tasks may or may not be shared with each other (sort of like subway stops, to continue the analogy). Patients enter one workflow (subway line) but may switch to another workflow during the course of consultation between specialists. Specialty workflows start and stop in different places while sharing resources and working together in a globally coherent system.
    2. Consider multi-site workflow management. The same specialist may be at one medical practice location one day but at another the next. Can specialty workflow definitions be shared across sites, eliminating the need for creating separate, basically identical, workflow definitions for each site? Alternatively, can different sites create their own site specific workflow definitions? Can each site track its patients in its local office layout, but can a supervisor also easily see what is happening at another site? (“Hey! I’m calling from the Eastside office to ask why Mr. Smith has been waiting an hour for his vitals.”) Can workflow definitions span sites, so that a patient can be seen in one office but show up at another office for testing that is only available there?
    3. Multi-encounter workflow management includes the following: follow-ups, a step in one workflow definition triggers application of a future workflow definition (such as returning for a specialized test); referrals, in which a workflow definition triggers a future review of an intervening external consultation; and recurring activities such as screening tests and chronic disease management.”
  9. “In today’s businesses, the application of workflow management systems (WFMSs) is widespread. [CW: Not yet in healthcare! And this quote is 10 years old!] The use of WFMSs ensures a well-structured and standardized management of processes within organizations [Geor95]. Traditionally the emphasis of workflow management has been on homogeneous environments within the boundary of a single organization. In the context of close cooperation between companies, where companies combine their efforts and become virtual enterprises, processes crossing organizational boundaries have to be supported [Lud99a]. This implies extending the functionality of workflow support so that workflow management systems in different organizations can be linked to management integrated cross-organizational processes.” (Grefen, Aberer, Hoffner & Ludwig, CrossFlow: Cross Organizational Workflow Management in Dynamic Virtual Enterprises, 2000, http://lsirpeople.epfl.ch/aberer/PAPERS/CSSE%20’00.pdf
    [CW: you’ll need to copy and paste the link into your browser and and then replace the single quote with a real one,  the one on your keyboard should work, WordPress does not appear to handle this character well], last retrieved 11/10/09)
  10. “An e-contract is the computerized facilitation or automation of a contract in a cross-organizational business process.” (Cheung, Chiu, and Till, A Three-Layer Framework for Cross-Organizational e-Contract Enactment, 2002, last retrieved 11/17/09; terminology is evolving, but the “contract” metaphor is a great way to introduce the general idea of explicitly modeled, automatable, and monitorable cross-organizational workflow)
  11. “As companies use automated workflow systems to control their processes, a way of linking workflow processes in different organizations is useful in turning the co-operating companies into a seamless operating virtual enterprises…contracts [are] a way to find suitable partners, connect WFMSs of different kinds, control outsourced workflow, and share an abstraction of the workflow specification between the partners” (Koetsier, Grefen, and Vonk, Contracts for Cross-Organizational Workflow Management, 2000,  last retrieved 11/11/09)
  12. Papazoglou, and P. M. A. Ribbers, “e-Business: Organizational and Technical Foundations”. J.Wiley & Sons, April 2006, quoted at S-Cube, last retrieved 11/10/09:
    1. “BPM suites coordinate tasks and synchronize data across existing systems. They also help coordinate human process activities, streamlining tasks, triggers, and time lines related to a business process, and assuring they are completed as defined by a process model. A BPM suite makes processes more efficient, compliant, agile, and visible by ensuring that every process step is explicitly defined, monitored over time, and optimized for maximum productivity.
    2. A true BPMS enables business users to:
      1. Model and simulate all interaction patterns between workers, systems and information sources to create shared understanding about how to optimize business processes and results.
      2. Coordinate and manage the handoff of work across boundaries.
      3. Provide real-time feedback to business managers about work-in-progress to support in-line business process adjustments.
      4. Monitor process outcomes to performance targets, and continuously refine and adjust process flows and rules.”

How would you put this material together? In future posts I’ll do my best to do so.

Does Your EMR’s Form Follow Function, or Does Its Function Follow Form?

Short Link: http://j.mp/6e1aoC

This Saturday I spent a pleasant day with my wife in New York’s Central Park watching the leaves, dogs, and people compete for attention. The dogs won.

My mind wandered to an offhand remark I made several weeks ago about “form following function.” I know that some dogs are bred for show and others are bred for performance. Might there be an analogy between dog breeds and EMRs? (Yeah, I know, bit of a stretch, “wandered” might be an understatement.)

I found the following at Canine Diversity FAQ on dogdimension.org:

What is meant by “form follows function”?

When we say “form follows function” in a dog breeding context we mean that the most efficient physique for a particular breed purpose will, over time, be produced simply by mating dogs that successfully fulfill that purpose, with no need for breeders to hold theories about the relative lengths and angular relationships of bones of the skeleton, or to breed according with such theories. The most successful examples of dogs able to fulfill their purpose will automatically be the ones that are best adapted physically to that purpose.

Novice breeders sometimes fall into the fallacy of believing that in order to breed a good working dog, it is necessary to practice canine engineering, attempting to construct a physical machine according to a plan or blueprint laid out in the breed standard. This amounts to an inversion of “form follows function” into “function should follow form.” In practice, the most critical factors in working dog performance are usually mental, behavioral, and metabolic; the dog must have a mentality, behavioral traits, and energy metabolism adapted to breed purpose. These things are far more important than theories of “conformation,” many of which are often far removed from the form that is actually most efficient for a given purpose.

Many EMRs conform to stereotypes and checklists. In contrast, what you really need is a “good working dog.”

Enough deep thoughts—here are the photos.

 pink

“Right side! That’s my good side. Must remember to lick to the right!”

tail

“I know what my best side is!”

watchful

“While he sleeps, I watch.”

cutie1

“You think I’m cute?…”

lunge

“…I AM ‘WHITE FANG’!”

ball1

“How do I feel about my owner today? Does she deserve the ball?
What’s in it for me? I’m teetering on a knife edge here folks…”

glances

“Paparazzi! Pleh! Can’t they leave us alone?!”

[flv:http://www.chuckwebster.com/video/cutie/cutie.flv 320 240]

“White Fang: The Movie”
(small dog! best viewed in full screen
mode, black square lower right)

 Next week, back to more serious stuff. Thanks for indulging me!