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

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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.


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.

1 thought on “Workflow-Related Interoperability Requirements for the High-Performance Medical Home”

  1. I wasn’t aware of Vince Kuraitis’ July post Geek Wisdom: Interoperability Must Include Process Collaboration until just now. I substantially agree with Vince that “After the geeks’ work is done and technical and semantic interoperability is achieved, there is still much to do in achieving process interoperability,” with one more admonishment (though not to Vince!). Part of the responsibility of geeks is to give clinicians and care coordinators easy-to-use clinical groupware, workflow management, and business process management tools necessary for them to negotiate, define, manage, and systematically improve their own intra- and inter-organizational automated workflows. And part of the responsibility of geeks also is to get beyond current shallow concepts of usability applied to traditional EMR/EHRs and on to the systematically optimizable deep usability of the next generation of process-aware clinical information systems.

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