How Do We Get From Clickity-Click Checklists to Great EHR Workflow?

Periodically I “repatriate” lengthy comments I’ve made to other blog posts. Especially when a comment lacks a permalink, so I can’t refer to it on Twitter. Today’s opportunity presented itself in the form of online discussion of Why A Patient’s Story Matters More Than A Computer Checklist.

The stimulus for this repatriation was the following…


(The original, embedded tweets append this post.)

Here are my comments on the HIStalk blog about a workshop, sponsored by the ONC and NIST, on EHR usability.

Dr. Mostashari noted that the number one complaint he hears is that EHRs are driving users nuts with all the “clickity, clickity, click”. He emphasized that, ideally, an EHR is not just a documentation system, but, rather, a “workflow engine”. He emphasized this point: “It’s a workflow engine! And if workflow is working against users, making them do things that don’t make sense…That’s the number one challenge for EHRs to fulfill their full potential!” (Disclaimer: I added the quotes for emphasis. While it may not be word-for-word accurate, it is a very close paraphrase of what he said.)

As a long-time proponent of EMR workflow management systems and EHR business management systems, relying on workflow engines executing user-customizable workflow definitions, I couldn’t agree more.

User-centered design applied to EHRs with workflow engines and definitions will more quickly achieve more usable workflow than EHRs without workflow engines and definitions. In a later presentation, EHR event logs were mentioned as a potential source of data about user behavior. Workflow engines create even more detailed event logs full of time-stamped who-what-why-where-when-how information that can be used to spot usability problems. Techniques such as process mining should be brought to bear on these logs to improve workflow usability. What are the tasks that are taking too long (physicians staying late to complete records), aren’t being completed (potentially threatening patient safety), or are being completed incorrectly (also potentially threatening patient safety) or redundantly? (wasting financial resources)

Even if insights into the root causes of problems with EHR workflow usability can be teased out of EHR event logs and other data (such as from usability testing), without malleable workflow, there is no way to turn insight into improvement without expensive rewriting, recompiling, retesting, redeploying and (in some cases) retraining too. Many EHRs are customizable in many respects, but their workflows are not nearly as customizable as those of workflow management systems and BPM suites, from which healthcare IT should beg, borrow, or steal ideas and technology.

So, if the number one problem with EHRs is usability, and the number one problem with EHR usability is workflow, then Dr. Mostashari is right. EHRs are, or should be (and can be!) true workflow engines helping EHRs achieve their full potential.

P.S. I see considerable evidence for diffusion of BPM ideas and technology into healthcare IT. However, in comparison to hot topics such as mobile, social, and cloud, they haven’t burst upon the scene. I hope that current intense interest in improving EHR workflow usability will accelerate mainstream appreciation for the virtues of what BPM researchers call “process-aware information systems” or PAISs.

[later comment, responding to request for more information]

There’re lots of BPM vendors. Quite a few BPM vendor directories too.

Tough to isolate is the subset explicitly or obviously relevant to healthcare. Only a minority of BPM vendors have that content online, though the amount is steadily growing.

I use to tweet links at the intersection of EHRs, HIT, BPM, workflow, usability, safety and productivity … At I archive the best links (minus unrelated science, most popular culture, and all bad jokes). There’s over a thousand links [CW: now edging toward 2000!] to material at the interface between healthcare and BPM.

If you search for “BPM” within the webpage, there are a couple hundred instances. Many of these links lead to material about, and links to, specific BPM vendors. I also link to web content about EHR problems (workflow, usability, safety, productivity) that I feel might be solved by BPM tech. I’m thinking of creating a similar, more vendor-oriented, directory, as I’m beginning to find it hard to keep track all the potential players myself! Other folks may find it useful: Stay tuned!

[CW: Since then, I created the POW!HIT! directory, for People and Organizations improving Workflow with Health IT.]

For a general overview of BPM, BPM suites and relevance to health IT and EHRs I could do worse than cite my own blog posts on the topic.

EMRs and EHRs Need to Solve “The BPM Problem”: Why Not Use BPM to Help Do So?

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

Hope you may find some of the above helpful.


Embedded tweets:

Enterprise Process and Workflow Automation to Enable Coordinated Healthcare

One of the best ways to predict the new future, technology-wise, is to watch job listings. I pay attention to job ads involving workflow and/or workflow technology in healthcare. The following job listing (just excerpts, see original) is consistent with what I’ve been writing and tweeting about workflow, business process management and healthcare. Bolded material is my added emphasis.

I so delighted to see this direction being taken by more and more health IT organizations.

“West Health is an independent, one-of-a-kind initiative whose mission is to lower health care costs by creating innovative, patient-centered solutions that deliver the right care at the right place at the right time….

A prioritized strategy of West Health is the development of a cost-lowering, health care ecosystem architecture that drives “low-end, disruptive” innovation into the current state of US health care. We call this WESTECH; an acronym for “Wireless Engagement Systems That Enable Coordinated Healthcare”. This vision is intended to shift historical supplier power to the consumer, as has happened in other industries (e.g., retail shopping, banking, travel and entertainment). The WESTECH team will develop a patient-centric, cloud-based, digital analytics/triage and communications/logistics engine. This will enable the shifting of the caregiver, the site of care and the time of diagnosis/treatment of chronic disease…. (see

West Health Institute is looking for a creative and hands-on BPM Architect with expertise in BPM tools and workflow automation to lead the development and implementation of a BPM and process solution across the healthcare industry. This is an excellent opportunity to help define and launch an emerging field and work across all aspects of Medical and Clinical Informatics, Connectivity, Networking and Process software….

The BPM Architect will be responsible for the design and coding of a web-based process automation platform. The position is responsible for different aspects of clinical workflow protocols as well as process modeling within the health care enterprise. The candidate must be able to adapt quickly to different web software, protocols, workflow and process automation, algorithms, solutions, interfaces and techniques. He/she will interface with other third party clinical teams and review standards to contribute to ground-breaking prototypes and software designs. He/she will be also responsible for staying informed with the latest developments and standards in web technology, process automation and medical informatics….”

Delighted! I look forward to seeing and hearing about the process-aware ecosystems and platforms West Health aims to create.

My Upcoming Presentation: Google Glass & Healthcare Information & Workflow

February 23rd, in Orlando, I’m presenting about Google Glass and healthcare workflow (and demoing, that’s the exciting part, see below) at the Society for Health Systems meeting. The name of the conference is Healthcare Systems Process Improvement Conference 2014 and is so appropriate. Glass has great potential to improve both provider AND patient workflows and processes. I hope you’ll register and show up. Regardless, I’ll be around that week, since HIMSS ’14 follows immediately.


Here’s my presentation abstract:

Google Glass and Healthcare
Information & Workflow

Google Glass is a small, sensor-equipped, head-mounted display connected to the Internet. How can Glass improve healthcare information management and EHR workflow? Dr. Webster, a Glass Explorer, will have Glass on hand to demonstrate, explain, and predict. Depending on audience size, attendees can try it out!

Google Glass, a small, sensor-equipped, head-mounted display connected to the Internet, promises many uses in many industries, from healthcare to law enforcement to education. Glass also aims at consumers. Its 3D games are surprisingly immersive. Immediate gratification (“I don’t even have to reach into my pocket!) and real-time social sharing (“Look I what I’m seeing!”) are seductive.

While it’s too early to predict killer apps and judge most compelling use cases, it’s not too early to try on Glass, build some prototypes, and speculate. In this presentation I will address the relevance of Glass to healthcare information management and workflow.

Due to billions of dollars of federal subsidies, a majority of physicians now use electronic health records (EHRs), some enthusiastically, some grudgingly. The greatest single complaint is workflow. Glass startups in health IT believe as much as 25 percent of current computer-related tasks can be potentially offloaded to Glass.

The speaker will have Glass on hand. After a short introduction to the basics, several prototypes and mockups will be demonstrated. Depending on the size of the audience, each attendee will experience several minutes of Glass demo “facetime” to better understand Glass’s potential and limitations.

Now here is the thing. I can talk about Glass all day, show you all kinds of stuff, but you won’t really understand Glass until you put it on. Two minutes of Glass ON your face is worth more then two hours of me pontificating IN your face. So, I’m aiming to devote the last twenty minutes of my presentation to on stage personal demos. I’ll call volunteers to come up and give Glass a spin, while audience looks on at the projected image of what the Glass wearer sees. (If the deities in charge of multimedia, USB, and Bluetooth smile on our efforts.)

Even when there are too many attendees to give every person a personal demo, the reactions of folks trying out Glass are kind of use (“Wow!” “Font is very crisp.”). And watching folks quickly move from awkward to fluid navigation of the Glass user interface is educational too.


Afterwards, depending on the number of interested attendees, we can move to more informal interactions in the hall. In fact, if you see me wearing Glass, and you didn’t come to my presentation, please, please ask to borrow them for a minute or two, while I coach you through the user interface (usually takes all of about 30-60 seconds, to get the initial side-of-head touchpad interaction down).


Finally, even if you’re not going to the Healthcare Systems Process Improvement conference, and you’re also not even going to be in Orlando for HIMSS’14, keep an eye on this space. Once a self-imposed embargo is over, I’ll post a link to my presentation here (slides and audio, just as I did for my 2012 presentation) . You’ll miss out on the personal on-your-head subjective experience part, but it’ll still be worthwhile. In fact, I highly recommend you search your local Meetups for Glass-related events. We Glass Explorers will give you a personal Glass demo at the drop of a hat. Hey, “drop of a hat…” 🙂

As my Twitter timeline is increasingly becoming my external memory, I’ve used Twitter’s new custom timeline feature collect tweets directly or indirectly relevant to my presentation. In fact, I’d love to get some pre-presentation and post-presentation conversation going. Heck, maybe even during-presentation conversation! I’ll be wearing Glass, you can just tweet me!

Healthcare and BPM: 10 Questions for Quest Diagnostics and ChartMaxx on Appian Partnership

I’ve giving presenting a free webinar on November 6 at 2 EST about Enterprise Content Management & Business Process Management: A Healthcare Game Changer. I’m taking advantage to continue to press for more use of business process management technology in healthcare. I’m also taking advantage of this opportunity to pepper Quest Diagnostics (@QuestDX) and the ChartMaxx (@ChartMaxx) with questions about BPM and their partnership with Appian (@Appian), a leading BPM company based right here (near) Washington DC.


Over the next few days, between now and November 6, I’ll periodically add a question and an answer to this blog post. Then I’ll tweet it from @wareFLO!

1. Let’s start off with your recently announced partnership with Quest Diagnostics. It made a splash at HIMSS, enough so I created a POW!HIT! Profile for Quest Diagnostics. (POW!HIT! stands for People and Organizations improving Workflow with Health Information Technology.) Tell us about what each of you bring to the partnership and what you intend to accomplish together.

The commitment of Quest Diagnostics and the ChartMaxx team to provide the very best tools and solutions for our clients was the driving force in our strategy to partner with the very best technology producer in BPM (Appian), instead of trying to build it on our own.

This unique collaboration marks a significant advancement in the healthcare IT industry. By combining the award-winning ChartMaxx software with the mobile and social process management capabilities of Appian BPM software, hospitals can improve work efficiencies and collaborate in real-time.

Appian brings the power of a top ranked Business Process solution with flexible, quick workflows that can reach across systems and departments, and that don’t require programming experience. It is the quickest and most cost-effective option to create native mobile apps from workflow processes. Appian has a deep understanding of process improvement and quick deployment technology.

ChartMaxx has the power of more than 20 years of experience in healthcare market, and is 100 percent focused on hospital workflows, processes, regulations, compliance concerns and the challenges hospitals face every day. Both Appian and ChartMaxx teams have a thorough understanding of the regulated and high-pressure environment where facilities are challenged daily to provide the best evidence-based care while cutting costs, working with a large amount of information in various formats/systems, and striving to provide the best experience for the patient.

We believe that the combination of these two highly focused organizations results in a 1+1=3 relationship – combining Appian’s powerful process technologies with the experience, domain knowledge and passion for customer service that the ChartMaxx team exhibits. Together, Appian and ChartMaxx create a unique solution that offers hospitals meaningful interactions with their information, timely collaboration and the tools necessary to bring people and processes together – bringing the next generation of ECM tools to the healthcare market.

2. What is Business Process Management? What is an Intelligent Business Process Management Suite? How are they relevant to issues facing healthcare today?

Excellent question! Search CIO defines Business Process Management as “a systematic approach to making an organization’s workflow more effective, more efficient and more capable of adapting to an ever-changing environment.”

Business Process Management is the concept, Intelligent Business Process Management suite is the toolkit that brings the concept into the day-to-day workings of healthcare organizations. The Business Process Management suite is the toolkit that includes the ability to quickly define processes that are flexible, system agnostic and that can be created, modified and maintained without the need for a programmer and/or programming language. That is just the front end of the process. The toolkit also includes timers, alerts and mobile apps so that users gain actionable, bring-your-own-device access to the information, as well as the unprecedented ability to collaborate quickly and effectively.

What has stood out is that although hospitals may have a common set of problems, the way they need to solve these problems is highly unique to the specific environment. This is where a BPM suite comes into play. You can provide a template that may solve 80% of the problem but it is that last 20% that can be a real challenge. With BPM and the ChartMaxx toolset, we not only provide the 80% template solution, but also the ability to rapidly complete the last 20% of the total solution.

3. Let’s start with the Cloud. Essential to any BPM system is an “engine” that executes, or enacts, user-to-user, user-to-application, and application-application workflows and processes. And what are advantages of putting this workflow engine in the cloud?

The advantage to making much of the user experience web and mobile device based is that the user has the information where and when they need it and they are also able to act on it right now. There is no need to be tied to a terminal within the hospital’s network in order to receive notifications or take action. Another very important topic for hospitals is security. The way that ChartMaxx accesses and displays the information is very secure – users only see data that they have permission to access and information is only displayed on the destination device, not stored.

As more and more hospitals are acquired by larger organizations, the need for either a public or private cloud environment becomes more acute as the overhead of maintaining separate systems becomes too cumbersome.

4. How does Appian add Mobile technology to this mix? How can this help healthcare?

Appian’s mobile application technology is unique. Once a workflow process is defined, it takes literally one click in a checkbox to make that process work natively across the most popular mobile platforms. This eliminates the need for a specialized programming staff with the knowledge to program on each of these platforms, and speeds up the development process by a factor of months.

This common build environment also eliminates the subtle differences and unique bugs that creep into multiple development efforts where different platforms need to be kept in functional synchronization.

Forrester has estimated that development of a mobile app can cost upwards of $250,000 per platform. Such projects also take months of planning, testing and refining effort. Imagine reducing all that to a single click! Combining the power of the ChartMaxx healthcare workflow expertise and Appian mobile accelerates actionable information to remove bottlenecks and streamline workflows. Also the mobile technology allows us to build workflow applications for areas that are well suited for mobile devices like Wound Care where photos of the wound can be taken using a smart device and quickly uploaded as part of the patient file. Another example is Home Health and the ability to capture a patient signature on a mobile device.

5. What is “WorkSocial”? How does Appian deliver it? How can healthcare benefit?

The benefits of social platforms are that they are immediate, intuitive and virtually effortless. One of the ways that the Appian executives like to introduce the technology is to launch the app and hand their device over with an invitation for the newcomer to just try it out. The newcomer discovers that they can navigate, interact and fully understand the interface instantly. No training, no bulky screens with uncountable buttons or menus.

The advantage to bringing these social tools into the healthcare business world through our ChartMaxx ECM platform is that the processes themselves are simplified, letting the background rules-based processing do the heavy lifting and routing, while the human interactions are limited to the actions that really require a human to review, approve, analyse and/or react in some way – and the human interacts in a focused and intuitive fashion.

WorkSocial not only capitalizes on this commonly used social user interface paradigm, but also extends that paradigm by adding control and actions to the data that is presented. Where social sites can provide a great place to talk about issues, WorkSocial actually solves the issues that are being discussed with both accountability and timeliness.

6. Healthcare conferences, such as the recent HIMSS conference, have lots of presentations and exhibiting vendors focusing on Clinical & Business Intelligence. Tell us about ChartMaxx’s BPM Analytics. Are there analytics, available in BPM software but might not be available in non-BPM software, of particular interest to healthcare audiences?

Our customers tell us that one of their biggest challenges isn’t storing the information; it’s getting it out of the various systems and using it meaningfully. When a healthcare organization installs ChartMaxx ECM, it provides them with SOA technology that enables them to fetch data in real time without having to make copies of the data into yet another system, the data always resides in its home system. The BPM workflows can then sort, aggregate and filter the information as needed for the specific use case. This eliminates the deluge of report data that has no relevance to the task at hand. This intelligent, customizable data processing provides significant performance increases and can quickly highlight the important from the mundane. The data gets to the right person at the right time.

7. Considered separately, Social, Mobile, Analytics, and Cloud technology all seem poised to diffuse throughout healthcare. However, Appian integrates SMAC technologies into a single iBPMS platform. Tell us how this combination works together and how its combination benefits to healthcare.

Combining tools including workflow processes, social interfaces, and mobile access enables healthcare organizations to use business rules and processes to access and sift through the mountains of data, then present only the focused, important information in an actionable form to the executive, clinician or staff member who needs to know or take action. Hospitals are rightly concerned that the dark side of interoperability is the resulting “data tsunami”. Once all that information is available, how does an organization laser focus into the information that is vital for the purpose at hand?

Whether that is population health metrics, on boarding a new employee, registering a patient, tracking implantable devices or collecting funds from insurance companies, these combined tools enable each specific user to have a customized experience where they can access the information they need in order to keep the process going. It is important to note that ChartMaxx ECM processes and tools are easy to modify, so the organization will be able to continue to refine their processes as they discover additional steps, information or other refinements. You develop the solution once and it runs everywhere without having to keep multiple systems in functional synchronization. ChartMaxx ECM also allows the customer to taylor his own solution so that the customer is not bound to the whims of the vendor development cycle.

8. Some of healthcare’s workflows are frequent and routine. Some are infrequent and highly variable, perhaps even one-of-a-kind. How does ChartMaxx support this spectrum from predictable to unpredictable workflows?

As always, the predictable will be easy. Simply have a user describe the process and a Business Analyst level resource can quickly (we are talking hours to days here) map the entire process out as a graphical workflow. The user and management can use the process, communicate refinements and see the results of the refinements quickly. For predictable processes the real win is the quick time to value, elimination of the need to involve IT/programming resources, and the ability to continue to refine the process on an ongoing basis.

A highly variable or infrequent process will experience those advantages too. Prior to these tools, it may not have been cost effective to automate a highly variable or infrequent process – it would absorb too much time, money and resources to make it worthwhile. With the new tool kit from Appian infused into ChartMaxx ECM, the investment in time and resources is minimal, so there is no reason not to automate an infrequent or highly variable process. Once these processes are automated, the facility might reap unexpected gains by having visibility into the process and significantly shorter turnaround times.

9. Do you have any other partners and case studies in the healthcare space you could tell us about or to which you could direct our attention?

ChartMaxx team would be happy to share two new case studies from 2013, as well as two additional client updates. ChartMaxx is also working on bringing our first two sites live on the new BPM-based tools. Stay tuned for more exciting details.

10. Will you have a booth at the next HIMSS conference?

Yes, ChartMaxx will have a booth focused on the launch of our 7.0 release which includes some significant BPM capabilities to empower organizations to improve processes and deliver better outcomes. We would like to discuss potential speaking opportunities at the event with you!

That’s fantastic. I am so excited to see what academics called “process-aware information systems,” or PAISs for short, finally coming to healthcare in such a big way. I’m looking forward to our webinar Enterprise Content Management & Business Process Management: A Healthcare Game Changer tomorrow!

That’s it! I’ve been predicting and looking forward to partnerships between great health IT companies and great BPM companies for years. So I am so delighted to finally see this beginning to happen. And I look forward to hearing great things emerging from the hybrid vigor of this partnership between Quest Diagnostics’ ChartMaxx and Appian.