From Health IT Literacy to Health Workflow IT Literacy

Today’s #HITsm chat topic is near and dear to my heart: Health IT Literacy. I designed the curriculum for the first undergraduate degree in Medical Informatics/Health Information Science and that is exactly where I started! More specifically, I started with healthcare workflow as the conceptual foundation for health IT literacy. Today I’m raising awareness for the need for health workflow technology literacy along a variety of channels, blogs, Twitter, webinars, presentations, etc.


Health workflow tech literary is, in fact, an important, but not much unappreciated part of health IT literacy (oh the debates I’ve been in with the medical informatics folks…). So, below is my version of the five health workflow IT literacy questions.

Topic: Health Workflow IT Literacy

W1. Is health workflow IT literacy needed? If so, who is the audience?

W2: What type of health workflow IT literacy is required?

W3: Who should be involved in promoting health workflow IT literacy?

W4: How should health workflow literacy and health workflow IT literacy inter-relate?

W5: How will you promote health workflow IT literacy?

It should be an interesting #HITsm chat!



10 Part Workflow Interview: Vishal Gandhi of ClinicSpectrum, Booth #1256 at HFMA

It’s not often I meet someone as or (more?) obsessed with healthcare workflow as I am. I believe I’ve met my match in Vishal Gandhi of ClinicSpectrum. I’ve not done one of my multi-question, in-the-weeds, workflow interviews in a while … it feels good to be back in the saddle. Enjoy!


(Image from Vishal’s excellent video interview with @TechGuy)

BTW You can visit ClinicSpectrum in Booth #1256 HFMA (Healthcare Financial Management Association) conference this week in .

  1. How did you come up with “Empowering Cost Effective Workflow”?
  2. Do you have any competitors? How do you think about them?
  3. What’s your workflow “philosophy”?
  4. What is a “Hybrid Workflow Model”?
  5. What’s your educational background? Industrial Engineering?
  6. What do you mean by “PROCESS dependent practice rather than a people dependent practice”?
  7. Is ClinicSpectrum turning into a Population Health Management/Care Coordination platform?
  8. Do you have a portfolio of workflow solutions?
  9. What is the single most important demo for folks to see at your HFMA Institute booth?
  10. Are your cost accounting systems up to value-based healthcare?
  11. Where in the world has been your favorite place to travel to?
  12. Thank you’s and leave taking… nice guy!

1. Let’s start with your tagline, “Empowering Cost Effective Workflow.” I’ve read that taglines should be simple, memorable, and functional. How did you come up with it?

Empowering cost effective workflow was derived out of our organizational experience with transforming solo and individual practices over the past several years. Industry trends and healthcare changes after President Obama came into office leant toward saving money for healthcare from healthcare. This would only be possible through avoiding duplication of care, auditable billing activities and enforcing billing automation, thus providing major savings due to solving pre-existing issues of improper billing, low utilization and risk management. This is where ClinicSpectrum’s tagline or positioning statement of, “Empowering Cost Effective Workflow,” was born.

2. Do you have any competitors? How do you think about them?

I’ve never considered competitors, because no organization does what we do for healthcare service organizations with both back-office support and powerful software automation. Other back office service companies focus on providing back office resources, while our approach is to reengineer or restructure workflow with use of their local team, our technology team and our back office resources. As part of empowering cost effective workflow, we created custom tools, technologies and designed an ideal workflow plan for solo practices and large clinics to leverage and significantly reduce operational costs via three ways:

  1. Increasing productivity through self-accountability and benchmark within existing staff
  2. Enabling automation on some of the manual tasks
  3. Outsourcing some of the secretarial functions to back office team
    members with a salary range from $6.5/Hour to $9.5/Hour compared to local team starting with $14/hour

3. I think that “workflow” has so many interesting aspects and is so relevant to so many relevant healthcare and health IT problems and solutions. What’s your workflow “philosophy”?

When money gets tight, or in some cases tighter, organizations need to do more work for less money. So ultimately it boils down to automation or cost effective labor. There is no other way to do more work for less money while you are expanding or growing. One of the single most important functions in operational planning is reducing variable expenses as you scale up.

Workflow was built into our success as an ONC-certified EHR / Enterprise Practice Management / Revenue Cycle and Practice Consulting company. However we were restricting that knowledge for clinics only. Some of the companies we are consulting in for the past 12 years are in the practice management and revenue cycle management market as well, and so we have been exposed to several technology platforms that give us this experience in workflow planning.

One of my friends who owns a billing company mentioned one time during a discussion in 2009: “It is very hard for billing companies or practice management companies to survive just based on their knowledge domain. We need a knowledgeable team, technology and people to expand and grow.”

I told him, I can provide you with technology and people. You should focus on finding new business and retain your knowledge team. Leave the rest to me. In the last 5 years, the company has grown from the ground to more than 100 accounts, generating significant revenue for the practices we serve.

Creating a workflow plan using the three elements I’ve mentioned is a hybrid workflow model – knowledgeable team, automated technology, and back-office staff – because in which, we are using their team, our team and technology. I call this a triangle and it is called hybrid because the onus of performance is passed onto each element in the plan. Technology must work as desired. Back office team members must produce and deliver tasks accurately and the knowledge team must continue to audit and supervise.

Our technology platforms (4 of them have patent pending) are derived out of this hybrid workflow plan only.

4. What is a “Hybrid Workflow Model” and why have you gone so far as to trademark it?!


Our Hybrid Workflow Model is a workflow plan that encompasses three factors:

  1. Workflow knowledge team (local)
  2. Technology suite
  3. Back office team

Using the above three elements, we deliver a defined process, deliverable tasks with a timeline for success and an audit. Each one of the elements has specific duties and continuous monitoring for achievement of those duties. The ultimate objective of the Hybrid Workflow Model is to create a COST EFFECTIVE, ACCURATE and CONSISTENT workflow.

Knowledge is too powerful to just reside with just one individual.

All of ClinicSpectrum’s knowledge is replicable on a FAST TRACK basis through organized video recordings, process manuals and rule engines. So when a company gets a big assignment, adding new team members is easy to do.

An existing customer recently relayed to us that they may need an additional 12 resources in the next 2 months. They wanted to know how we would scale up that quickly to meet their needs.

We work with our clients to institutionalize knowledge of their business so new team members can be brought up to speed within a short period of time. This is what we call process dependent workflow plan, rather than people dependent.

5. In your video interview, you sound like an industrial engineer. What’s your educational background?

I have a Bachelor’s in Electronics Engineering, so you are correct I am an engineer. My specialization in engineering is System Design. I also have earned a Masters in Business Administration. Additionally, I am a certified healthcare auditor, certified medical collector and I am pursuing a “CHMBE” by HBMA.

Additionally, I think it’s important to mention that we have filed four patents for some of our unique automation tools or products. One of my most favorite is PRODUCTIVITYSPECTRUM.

ProductivitySpectrum is all about increasing productivity within existing team. As mentioned earlier, there are only 3 ways to do more work for less money. Either increase productivity or introduce automation or find cost effective work force.

ProductivitySpectrum focuses on first aspect of increasing productivity. For someone with subject knowledge and reasonable intellect, loss of productivity is due to

  1. Loss of focus or distraction due to social media, computer and other things
  2. Healthy competition or we call it BENCHMARKING

Above product has 2 components, MONITORING would take screen capture of their activities; identify resource wise time spent and employee desk time. So if they are wasting idle time due to NON PRODUCTIVE activities on computers, it would be streamlined. BENCHMARK comparison allows dynamic benchmarking through employee’s own best performance days. It keeps reminding of his/her efficiency against his/her best days and creates an automatic daily reporting for supervisory position.
It comes with smartphone app to monitor any employees’ activities on the fly.

6. On one of the slides in one of your PowerPoint decks, I saw the phrase: “PROCESS dependent practice rather than a people dependent practice.” Do you diagram and flowchart workflows? Even scribbled on a napkin! I think this kind of artifact wonderful evidence of what think of as a “workflow worldview.”

Below is a visual of our 3-step presentation, which defines an ideal front desk workflow plan. It has a graphical view built into it.


(Cool graphic!)

7. I also saw this: “Every task/office function gets audited randomly across the practice” “-Patients who are non-compliant clinically -Reminders for tests/procedures” When I read this I start thinking — Population Health Management, Care Coordination, etc. — which are really hot topics these days. Is ClinicSpectrum essentially turning into a PHM company or care coordination platform? Plans? Ambitions? Do you have your eye on any specific technologies to help you realize your vision?

ClinicSpectrum is not essentially turning into a PHM or CC platform, instead we provide all technology and resources required to do PHM and CC.

Most EHRs have a built-in feature to do risk management or identify and cluster patients based on conditions, procedures and other demographic parameters including hospitalizations.

In order to do an effective PHM and CC, you need following items

  1. Technology or EHR product that defines risk management index or area of concern for high-risk patients.
  2. An automation engine that would remind patients’ for required visits, tests and lifestyle changes so that they can be kept out of emergencies and non-compliance.
  3. Team of professionals who can review clinical guidelines and call the patient, explain things they need to take care of, and bring them back as required to physicians’ offices for better risk management.

ClinicSpectrum aims to provide an automation engine (as we own a messaging platform called MessageSpectrum) and back office team members who are trained in various pay for performance programs, quality measures and risk management. We are currently providing support to several practices that are part of ACOs and PCMH programs.

8. I also notice you use the phrase “Workflow Solutions to Increase Profitability and Decrease Cost.” Do you have a portfolio of workflow solutions? What are they? How do they fit together? I notice more-and-more health IT vendors and service providers talking about “workflow solutions”. I think this is a natural and to-be-expect evolution. Now that we have some much clinical and healthcare financial data, we have to do something with it: workflow! But I’d love to hear you elaborate on whether you agree or not…

We are in business of either increasing revenue or reducing costs for billing companies, hospitals, healthcare IT companies, consulting organizations, multi-specialty groups and small physician’s clinics.

Our technology products such as

  • “InvoiceSpectrum,”
  • “CredentialingSpectrum,”
  • “AutoCollectSpectrum,”
  • “ProductivitySpectrum,” and,
  • “MessageSpectrum”

provide some of the most essential technology pieces to design and implement a workflow plan for increasing productivity and decreasing costs. To add to that, soon we will also launch HumanResourceSpectrum , EligibilitySpectrum and WorkFlowSpectrum.

As deductibles become a perennial issue, our EligibilitySpectrum product along with our eligibility verification services will enable complete front end eligibility checking for hospitals, clinics and any other healthcare facility.

WorkFlowSpectrum is a web-based document management and work allocation and management platform so organizations, including clinics, don’t have to use Dropbox or any other cloud-based service. This offering is more dynamic and target driven.

If someone retains your services on a monthly retainer basis, with our InvoiceSpectrum product, you can automate your entire invoicing cycle. It applies to billing companies, consulting companies or any healthcare service management company.

Now, if you need a team to provide consistent and persistent AR follow-up for clients with outstanding payments, our team can help. So together, with InvoiceSpectrum and back office AR follow-up, we can automate any healthcare company’s accounting or invoicing department.

These are just a few examples of how combining software products, in conjunction with our back office services, automate a department with reduced costs.

CredentialingSpectrum has been a major attraction for several larger groups. As defined by one of our existing customers, it is one of the most comprehensive products for credentialing and contract management.

9. You’re going to be at the Healthcare Financial Management Association conference (HFMA National institute) in in Las Vegas. When attendees visit Booth #870 (I looked it up), what is the single most important thing for them to see? A demo? Of what? Something else? Also, what great list of speakers! I know you’ll be in your booth a lot, but who are you excited to hear and why?

  • AutoCollectSpectrum to manage and automate patient balance collection
  • CredentialingSpectrum to manage entire credentialing activity
  • EligibilitySpectrum to manage front end eligibility, while most insurance plans today have high deductibles.

And, of course, providing additional information on our back office services and Hybrid Workflow Model implementation.

I am sure that there are a number of speakers that I would l like to hear. Most of all I will be interested in any topic that shows an innovative way for practices to collect patient balances. While we hear so much about patient engagement on the clinical side for quality of care, it is critical that we do not overlook engaging with the patient on the financial side. I welcome being sent suggestions for talks to attend that address this.

10. Believe it or not, I was a pre-med Accountancy major (University of Illinois, Champaign-Urbana). I’m checking the ClinicSpectrum blog and I see lots of cost and financial accounting material (plus credentialing, patient education, and other good stuff). As healthcare moves from maximizing volume-based reimbursement towards value and cost improvement strategies, where do you see medical practice management systems evolving? Will managers ever get anywhere close to knowing the “true cost” of a specific procedure or patient encounter (say, door-to-door). Are your current systems up to it?

Yes in fact we are building a cost matrix in our enterprise practice management system currently that would do 2 things:

  • Allow to add all fixed costs: rent, utilities, malpractice and any other
  • Allow to insert monthly variable costs: salary, supplies, outsourced services, etc.

Even though the industry relies on an RVU based model, it is not accurate. Our system will create a procedure performance based on six months of trending data and derive, by procedure, reimbursements by payer or plan.

Our cost matrix will pick up all fixed and variable expenses and divide it among total number of patients and total number of procedures by visit code.

This will allow them to scale up or scale down depending upon this cost to revenue matrix, and also allow them to plan for both breakeven and revenue targets for new providers.

11. To round it out – where in the world has been your favorite place to travel to?

I cannot say that I have a favorite place, but rather that I like to travel to as many places as possible. I am going to Barcelona, Spain on July 17th. This will be my 9th country that I have traveled to. I am also a passionate photographer, so you can imagine, I would love to travel to one new country every year and capture beautiful images.

12. PHEW! Those questions were really in the workflow and processes weeds! I thank you so much for your patient consideration and answering of these relatively technical questions (which are, nonetheless, so important to the financial health of your medical practice customers!).

I thank you very much as well for spending so much time and being so thoughtful and thorough. I All of your questions were meaningful and relevant to current challenges in healthcare, and I enjoyed answering each one.

My #HITsm Health IT Business Process Management Success Story, Plus a Conference Report

While working on my BPM & Case Management Global Summit conference trip report, I saw this tweet about sharing health IT success stories at the Friday, 12 EST, weekly #HITsm Twitter chatup (Health Information Technology Social Media).

As I’ve just given a 45-minute presentation to a workflow tech audience about healthcare and health IT opportunities, I thought, maybe now would be a good time to reflect on progress being made. By the way, I created the following YouTube from my slides and audio from that talk on 6/16.

While I’ve been giving presentations about workflow tech in healthcare literally for decades, I joined Twitter in December of 2008 (averaging 25 tweets a day) and starting blogging in earnest in 2009 (about a post a week). An important part of my strategy has been to blog and tweet about health IT to attract workflow tech community interest and followers. And to blog and tweet about workflow tech to attract health IT interest and followers. And, most important, get both communities engaged, on social media and face-to-face, with each other. Have I seen more sophisticated thinking about workflow and more use of workflow tech close-and-closer to the point-of-care? Yes, I have.

For example, each year I look at every web site of every exhibitor at the yearly HIMSS conference. Sites mentioning workflow tech or emphasizing workflow went from 8 percent in 2013 to 16 percent in 2014. Last week I was honored when John Lynn, without a doubt the top and most trafficked health IT blogger, contacted me about blogging once-a-day about workflow on his website, while he went on a well-deserved vacation. Check out the comments from both health IT and workflow tech professionals. Then there was the BPM and Case Management Global Summit early this week near Washington DC. (BPM stands for Business Process Management). When I started going to BPM and workflow conferences four years ago, there were no health IT folks at all. And the workflow tech folks were just beginning to get curious about opportunities to solve healthcare’s many workflow problems.

This year, there was intense conversation among a variety of health IT and workflow tech thought leaders. In addition, I’ve seen more-and-more healthcare workflow, BPM, and case management success stories. I tweet them whenever I find them. And I archive links to many at http://EHR.BZ.

I was delighted to see @TechyDoc there! I could not agree more wholeheartedly with his tweet!

BPM and Case Management Global Summit Short Trip Report

Well, so far this post has been about counting healthcare workflow tech blessings. I’ve enjoyed it! But it’s back into the weeds, so to speak. The rest of this post focuses on presentations, conversations, and impressions from the recent BPM and Case Management Global Summit. Did I mention I spoke there? Oh, yeah. Please feel free to watch my slides paired with recorded narration, on YouTube. (There’s also this half-as-long outdoor rehearsal, in front of the Capitol dome, recorded with Google Glass, waving printed slides around on a windy day.)

This is what the conference venue looked like. (At a Ritz-Carlton, very nice!)

Jim Sinur kicked off the conference. I especially like this slide about a spectrum of process styles.

I like how the Whitestein Living Systems Process Suite elegantly combines high-goals, organizational roles, and workflow automation. So, let’s say a workflow is executing but assumptions or conditions change. Workflows can also change, on-the-fly, based on reasoning about goals. LSPS is not (yet) used in healthcare, but I can imagine a future EHR workflow system actually helping patients and physicians think through, for example, quantity vs quality of life constraints and tradeoffs.

Here I am hanging out at the Whitestein Living Systems Process Suite booth.

I also enjoyed the Computas FrameSolutions presentation about its adaptive task management platform. I’d love to see FrameSolutions applied to clinical task management.

Nice overview of tasks in enterprises, including healthcare enterprises.

Users can create tasks, execute them, and assign them to others. Task can also be automatically created, assigned, executed, etc., all the while consulting organizational models (which, in healthcare, could include physician, nurse, tech, and so on).

Love it! Integrated tasks management and execution easily integrated with existing systems. Users can easily change the rules that fire, execute, adaptive tasks. Workflows can be programmed, but also “emerge” from user behavior. All the while all these activities are time-stamped and made auditable.

Here’s an interesting diagram. In traditional workflow management and BPM systems models of workflow and their execution are at their core. In other words, users and data are adapted to fit to these models. Of course, these models can be changed in ways that software without executable models (such as most health IT systems) cannot. However, adaptive case management puts data, about, for example, patients, at the core, and then automatically, semi-automatically, and manually triggers snippets of workflow. Instead of big workflow models (rigid during execution, though plastic during design), workflow is actually driven, moment-by-moment, during the work of problems solving, by data at hand, both from previous transformation and newly arrived from the outside world.

More on tasks as process snippets.

Users can create intelligent tasks.

Users can intelligently manage and share tasks.

I tweeted lots more slides from the FrameSolutions presentation, but I do want to get on to Keith Swenson’s presentation, a fitting windup for the conference from my perspective.

Keith has a seven-pillar model framework to compare and contrast different kinds of workflow software. All the way on the left, that’s traditional software development. On one hand, anything is possible since everything is simply a matter of programming. On the other hand, workflow is also “frozen.” To change workflow requires an expensive programmer, who won’t get it right, and even if they do, there will be bugs, so there’s a long and expensive cycle of testing, deployment, and training.

All the way on the right is email, phone calls, Twitter, etc., in which anything goes, but the user has to do all the work too. In between? Those are five general classes of workflow tech, from relatively rigid process models to relatively flexible models that just try to support and empower users, without getting in the way.

I’ll note I think of the seven columns more as rows of layers. On the bottom we have traditional server-based programs. On top of that bottom layer we have process models, starting out rigid and infrequently changed, but, as we ascend the stack, more flexible but also require more work and smarts from users, until we get to the top layer of emails, phone calls, Twitter, etc. All of these layers exist together, interacting, building on each other, but also causing occasional glitches. A programmer might be deep in the bowels of a Java program, but in the next moment tweet snippet of code to his programmer followers.

The following tweet lists the folks at the BPM & Case Management Global Summit with whom I tweeted most frequently. If you’re interested in any of the same things I am, I hope you’ll consider following them on Twitter.

And here is a special shout-out to Nathaniel Palmer, who organized the conference. He even coined the #BPMCM2014 hashtag, without which my above tweets could have been possible — literally!

BPM-based Population Health Management & Care Coordination: Workflow, Usability, Safety & Interoperability Perspectives

[If you arrived here via one of my National Health IT Week themed tweets, I hope you’ll also consider reading my more recent, Achieving Task and Workflow Interoperability in Healthcare: All Together Now!]

This post consolidates five of my guest posts on the EMR & HIPAA, one of the highest traffic blogs devoted to health IT. I also simply have to mention what Jerome Carter, MD, FACP, FHIMSS, said about this series: “when it comes to workflow in health care, I cannot think of anyone who has done more to get the word out than Chuck Webster. Last week, he wrote a series of blog posts that act as the perfect introduction to the benefits of workflow technology in health care.”

John Lynn is taking a well-deserved week off to attend a family function. He asked if I was interested in five EHR workflow guest blog posts, a blog post a day this week, on EMR and HIPAA. Of course I said: YES!

Here’s the outline for the week:

I blog and tweet a lot about healthcare workflow and workflow technology, but in this first post I’ll try to synthesize and simplify. In later posts I drive into the weeds. Here, I’ll define workflow, describe workflow technology, its relevance to healthcare and health IT, and try not to steal my own thunder from the rest of the week.

I’ve looked at literally hundreds of definitions of workflow, all the way from a “series of tasks” to definitions that’d sprawl across several presentation slides. The one I’ve settled on is this:

“Workflow is a series of tasks, consuming resources, achieving goals.”

Short enough to tweet, which is why I like it, but long enough to address two important concepts: resources (costs) and goals (benefits).

So what is workflow technology? Workflow technology uses models of work to automate processes and support human workflows. These models can be understood, edited, improved, and even created, by humans who are not, themselves, programmers. These models can be executed, monitored, and even systematically improved by computer programs, variously called workflow management systems, business process management suites, and, for ad hoc workflows, case management systems.

Workflow tech, like health IT itself, is a vast and varied continent. As an industry, worldwide, it’s probably less than a tenth size of health IT, but it’s also growing at two or three times the rate. And, as both industries grow, they increasingly overlap. Health IT increasingly represents workflows and executes them with workflow engines. Workflow tech vendors increasingly aim at healthcare to sell a wide variety of workflow solutions, from embeddable workflow engines to sprawling business process management suites. Workflow vendors strenuously compete and debate on finer points of philosophy about how best automate and support work. Many of these finer points are directly relevant to workflow problems plaguing healthcare and health IT.

Why is workflow tech important to health IT? Because it can do what is missing, but sorely needed, in traditional health IT, including electronic health records (EHRs). Most EHRs and health IT systems essentially hard-code workflow. By “hard code” I mean that any series of tasks is implicitly represented by Java and C# and MUMPS if-then and case statements. Changes to workflow require changes to underlying code. This requires programmers who understand Java and C# and MUMPS. Changes cause errors. I’m reminded of the old joke, how many programmers does it take to change a light bulb? Just one, but in the morning the stove and the toilet are broken. Traditional health IT relies on frozen representations of workflow that are opaque, fragile, and difficult to manage across information system and organizational boundaries.

Well, OK, I’ll steal my own thunder just a little bit. Process-aware tech, in comparison to hardcoded workflows, is an architectural paradigm shift for health IT. It has far reaching implications for interoperability, usability, safety, and population health.

BPM systems are ideal candidates to tie together disparate systems and technologies. Users experience more usable workflows because workflows are represented so humans can understand and change then. Process-aware information systems are safer for many reasons, but particularly because they can represent and compensate for the interruptions that cause so many medical errors. Finally, BPM platforms are the right platforms to tie together accountable care organization IT systems and to drive specific, appropriate, timely action to provider and patient point-of-care.

The rest of my blog posts in this weeklong series will elaborate on these themes. I’ll address why so many EHRs and health IT systems are so unusable, un-interoperable, and sometimes even dangerous. I’ll argue that modern workflow technology can help rescue healthcare and health IT from these problems.

Interoperable Health IT and Business Process Management: The Spider In The Web

This is my second of five guest blog posts covering Health IT and EHR Workflow.

If you pay any attention at all to interoperability discussion in healthcare and health IT, I’m sure you’ve heard of syntactic vs. semantic interoperability. Syntax and semantics are ideas from linguistics. Syntax is the structure of a message. Semantics is its meaning. Think HL7’s pipes and hats (the characters “|” and “^” used as separators) vs. codes referring to drugs and lab results (the stuff between pipes and hats). What you hardly every hear about is pragmatic interoperability, sometimes called workflow interoperability. We need not just syntactic and semantic interop, but pragmatic workflow interop too. In fact, interoperability based on workflow technology can strategically compensate for deficiencies in syntactic and semantic interoperability. By workflow technology, I mean Business Process Management (BPM).

Why do I highlight BPM’s relevance to health information interoperability? Take a look at this quote from Business Process Management: A Comprehensive Survey:

“WFM/BPM systems are often the “spider in the web” connecting different technologies. For example, the BPM system invokes applications to execute particular tasks, stores process-related information in a database, and integrates different legacy and web-based systems…. Business processes need to be executed in a partly uncontrollable environment where people and organizations may deviate and software components and communication infrastructures may malfunction. Therefore, the BPM system needs to be able to deal with failures and missing data.”

“Partly uncontrollable environment where people and organizations may deviate and software components and communication infrastructures may malfunction”? Sound familiar? That’s right. It should sound a lot like health IT.

What’s the solution? A “spider in the web” connecting different technologies… invoking applications to execute particular tasks, storing process-related information in a database, and integrates different legacy and web-based systems. Dealing with failures and missing data. Yes, healthcare needs a spider in the complicated web of complicate information systems that is today’s health information management infrastructure. Business process management is that spider in a technological web.

Let me show you now how BPM makes pragmatic interoperability possible.

I’ll start with another quote:

“Pragmatic interoperability (PI) is the compatibility between the intended versus the actual effect of message exchange.”

That’s a surprisingly simple definition for what you may have feared would be a tediously arcane topic. Pragmatic interoperability is simply whether the message you send achieves the goal you intended. That’s why it’s “pragmatic” interoperability. Linguistics pragmatics is the study of how we use language to achieve goals.

“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.”

So, how does workflow technology tie into pragmatic interoperability? The key phrases linking workflow and pragmatics are “intended effect” and “specific order”.

A sequence of actions and messages — send a request to a specialist, track request status, ask about request status, receive result and do the right thing with it — that’s the “specific order” of conversation required to ensure the “intended effect” (the result). Interactions among EHR workflow systems, explicitly defined internal and cross-EHR workflows, hierarchies of automated and human handlers, and rules and schedules for escalation and expiration are necessary to achieve seamless coordination among EHR workflow systems. In other words, we need workflow management system technology to enable self-repairing conversations among EHR and other health IT systems. This is pragmatic interoperability. By the way, some early workflow systems were explicitly based on speech act theory, an area of pragmatics.

That’s my call to use workflow technology, especially Business Process Management, to help solve our healthcare information interoperability problems. Syntactic and semantic interoperability aren’t enough. Cool looking “marketectures” dissecting healthcare interoperability issues aren’t enough. Even APIs (Application Programming Interfaces) aren’t enough. Something has to combine all this stuff, in a scalable and flexible ways (by which I mean, not “hardcoded”) into usable workflows.

Which brings me to usability, tomorrow’s guest blog post topic.

Tune in!

Usable EHR Workflow Is Natural, Consistent, Relevant, Supportive and Flexible

This is my third of five guest blog posts covering Health IT and EHR Workflow.

Workflow technology has a reputation, fortunately out of date, for trying to get rid of humans all together. Early on it was used for Straight-Through-Processing in which human stockbrokers were bypassed so stock trades happened in seconds instead of days. Business Process Management (BPM) can still do this. It can automate the logic and workflow that’d normally require a human to download something, check on a value and based on that value do something else useful, such as putting an item in a To-Do list. By automating low-level routine workflows, humans are freed to do more useful things that even workflow automation can’t automate.

But much of healthcare workflow requires human intervention. It is here that modern workflow technology really shines, by becoming an intelligent assistant proactively cooperating with human users to make their jobs easier. A decade ago, at MedInfo04 in San Francisco, I listed the five workflow usability principles that beg for workflow tech at the point-of-care.

Consider these major dimensions of workflow usability: naturalness, consistency, relevance, supportiveness, and flexibility. Workflow management concepts provide a useful bridge from usability concepts applied to single users to usability applied to users in teams. Each concept, realized correctly, contributes to shorter cycle time (encounter length) and increased throughput (patient volume).

Naturalness is the degree to which an application’s behavior matches task structure. In the case of workflow management, multiple task structures stretch across multiple EHR users in multiple roles. A patient visit to a medical practice office involves multiple interactions among patients, nurses, technicians, and physicians. Task analysis must therefore span all of these users and roles. Creation of a patient encounter process definition is an example of this kind of task analysis, and results in a machine executable (by the BPM workflow engine) representation of task structure.

Consistency is the degree to which an application reinforces and relies on user expectations. Process definitions enforce (and therefore reinforce) consistency of EHR user interactions with each other with respect to task goals and context. Over time, team members rely on this consistency to achieve highly automated and interleaved behavior. Consistent repetition leads to increased speed and accuracy.

Relevance is the degree to which extraneous input and output, which may confuse a user, is eliminated. Too much information can be as bad as not enough. Here, process definitions rely on EHR user roles (related sets of activities, responsibilities, and skills) to select appropriate screens, screen contents, and interaction behavior.

Supportiveness is the degree to which enough information is provided to a user to accomplish tasks. An application can support users by contributing to the shared mental model of system state that allows users to coordinate their activities with respect to each other. For example, since a EMR  workflow system represents and updates task status and responsibility in real time, this data can drive a display that gives all EHR users the big picture of who is waiting for what, for how long, and who is responsible.

Flexibility is the degree to which an application can accommodate user requirements, competencies, and preferences. This obviously relates back to each of the previous usability principles. Unnatural, inconsistent, irrelevant, and unsupportive behaviors (from the perspective of a specific user, task, and context) need to be flexibly changed to become natural, consistent, relevant, and supportive. Plus, different EHR users may require different BPM process definitions, or shared process definitions that can be parameterized to behave differently in different user task-contexts.

The ideal EHR/EMR should make the simple easy and fast, and the complex possible and practical. Then ,the majority/minority rule applies. A majority of the time processing is simple, easy, and fast (generating the greatest output for the least input, thereby greatly increasing productivity). In the remaining minority of the time, the productivity increase may be less, but at least there are no showstoppers.

So, to summarize my five principles of workflow usability…

Workflow tech can more naturally match the task structure of a physician’s office through execution of workflow definitions. It can more consistently reinforce user expectations. Over time this leads to highly automated and interleaved team behavior. On a screen-by-screen basis, users encounter more relevant data and order entry options. Workflow tech can track pending tasks–which patients are waiting where, how long, for what, and who is responsible–and this data can be used to support a continually updated shared mental model among users. Finally, to the degree to which an EHR or health IT system is not natural, consistent, relevant, and supportive, the underlying flexibility of the workflow engine and process definitions can be used to mold workflow system behavior until it becomes natural, consistent, relevant, and supportive.

Tomorrow I’ll discuss workflow technology and patient safety.

Patient Safety And Process-Aware Information Systems: Interruptions, Interruptions, Interruptions!

This is my fourth of five guest blog posts covering Health IT and EHR Workflow.

When you took a drivers education class, do you remember the importance of mental “awareness” to traffic safety? Continually monitor your environment, your car, and yourself. As in traffic flow, healthcare is full of work flow, and awareness of workflow is the key to patient safety.

First of all, the very act of creating a model of work to be done forces designers and users to very carefully think about and work through workflow “happy paths” and what to do when they’re fallen off. A happy path is a sequence of events that’s intended to happen, and, if all goes well, actually does happen most of the time. Departures from the Happy Path are called “exceptions” in computer programming parlance. Exceptions are “thrown”, “caught”, and “handled.” At the level of computer programming, an exception may occur when data is requested from a network resource, but the network is down. At the level of workflow, an exception might be a patient no-show, an abnormal lab value, or suddenly being called away by an emergency or higher priority circumstance.

Developing a model of work, variously called workflow/process definition or work plan forces workflow designers and workflow users to communicate at a level of abstraction that is much more natural and productive than either computer code or screen mockups.

Once a workflow model is created, it can be automatically analyzed for completeness and consistency. Similar to how a compiler can detect problems in code before it’s released, problems in workflow can be prevented. This sort of formal analysis is in its infancy, and is perhaps most advanced in healthcare in the design of medical devices.

When workflow engines execute models of work, work is performed. If this work would have otherwise necessarily been accomplished by humans, user workload is reduced. Recent research estimates a 7 percent increase in patient mortality for every additional patient increase in nurse workload. Decreasing workload should reduce patient mortality by a similar amount.

Another area of workflow technology that can increase patient safety is process mining. Process mining is similar, by analogy, to data mining, but the patterns it extracts from time stamped data are workflow models. These “process maps” are evidence-based representations of what really happens during use of an EHR or health IT system. Process maps can be quite different, and more eye opening, than process maps generated by asking participants questions about their workflows. Process maps can show what happens that shouldn’t, what doesn’t happen than should, and time-delays due to workflow bottlenecks. They are ideal tools to understand what happened during analysis of what may have caused a possibly system-precipitated medical error.

Yet another area of particular relevance of workflow tech to patient safety is the fascinating relationship between clinical pathways, guidelines, etc. and workflow and process definitions executed by workflow tech’s workflow engines. Clinical decision support, bringing the best, evidence-based medical knowledge to the point-of-care, must be seamless with clinical workflow. Otherwise, alert fatigue greatly reduces realization of the potential.

There’s considerable research into how to leverage and combine representations of clinical knowledge with clinical workflow. However, you really need a workflow system to take advantage of this intricate relationship. Hardcoded, workflow-oblivious systems? There’s no way to tweak alerts to workflow context: the who, what, why, when, where, and how of what the clinical is doing. Clinical decision support will not achieve wide spread success and acceptance until it can be intelligently customized and managed, during real-time clinical workflow execution. This, again, requires workflow tech at the point-of-care.

I’ve saved workflow tech’s most important contribution to patient safety until last: Interruptions.

An interruption–is there anything more dreaded than, just when you are beginning to experience optimal mental flow, a higher priority task interrupts your concentration. This is ironic, since so much of work-a-day ambulatory medicine is essentially interrupt-driven (to borrow from computer terminology). Unexpected higher priority tasks and emergencies *should* interrupt lower priority scheduled tasks. Though at the end of the day, ideally, you’ve accomplished all your tasks.

In one research study, over 50% of all healthcare errors were due to slips and lapses, such as not executing an intended action. In other words, good clinical intentions derailed by interruptions.

Workflow management systems provide environmental cues to remind clinical staff to resume interrupted tasks. They represent “stacks” of tasks so the entire care team works together to make sure that interrupted tasks are eventually and appropriately resumed. Workflow management technology can bring to clinical care many of the innovations we admire in the aviation domain, including well-defined steps, checklists, and workflow tools.

Stay tuned for my fifth, and final, guest blog post, in which I tackle Population Health Management with Business Process Management.

Population Health Management and Business Process Management

This is my fifth and final of five guest blog posts covering Health IT and EHR Workflow.

Way back in 2009 I penned a research paper with a long and complicated title that could also have been, simply, Population Health Management and Business Process Management. In 2010 I presented it at MedInfo10 in Cape Town, Africa. Check out my travelogue!

Since then, some of what I wrote has become reality, and much of the rest is on the way. Before I dive into the weeds, let me set the stage. The Affordable Care Act added tens of millions of new patients to an already creaky and dysfunctional healthcare and health IT system. Accountable Care Organizations were conceived as virtual enterprises to be paid to manage the clinical outcome and costs of care of specific populations of individuals. Population Health Management has become the dominant conceptual framework for proceeding.

I looked at a bunch of definitions of population health management and created the following as a synthesis: “Proactive management of clinical and financial risks of a defined patient group to improve clinical outcomes and reduce cost via targeted, coordinated engagement of providers and patients across all care settings.”

You can see obvious places in this definition to apply trendy SMAC tech — social, mobile, analytics, and cloud — social, patient settings; mobile, provider and patient settings; analytics, cost and outcomes; cloud, across settings. But here I want to focus on the “targeted, coordinated.” Increasingly, it is self-developed and vendor-supplied care coordination platforms that target and coordinate, filling a gap between EHRs and day-to-day provider and patient workflows.

The best technology on which, from which, to create care coordination platforms is workflow technology, AKA business process management and adaptive/dynamic case management software. In fact, when I drill down on most sophisticated, scalable population health management and care coordination solutions, I usually find a combination of a couple things. Either the health IT organization or vendor is, in essence, reinventing the workflow tech wheel, or they embed or build on third-party BPM technology.

Let me direct you to my section Patient Class Event Hierarchy Intermediates Patient Event Stream and Automated Workflow in that MedInfo10 paper. First of all you have to target the right patients for intervention. Increasingly, ideas from Complex Event Processing are used to quickly and appropriately react to patient events. A Patient Class Event Hierarchy is a decision tree mediating between low-level events (patient state changes) and higher-level concepts clinical concepts such as “on-protocol,” “compliant”, “measured”, and “controlled.”

Examples include patients who aren’t on protocol but should be, aren’t being measured but should be, or whose clinical values are not controlled. Execution of appropriate automatic policy-based workflows (in effect, intervention plans) moves patients from off-protocol to on-protocol, non-compliance to compliance, unmeasured to measured, and from uncontrolled to controlled state categories.

Population health management and care coordination products and services may use different categories, terminology, etc. But they all tend to focus on sensing and reacting to untoward changes in patient state. But simply detecting these changes is insufficient. These systems need to cause actions. And these actions need to be monitored, managed, and improved, all of which are classic sterling qualities of business process management software systems and suites.

I’m reminded of several tweets about Accountable Care Organization IT systems I display during presentations. One summarizes an article about ACOs. The other paraphrases an ACO expert speaking at a conference. The former says ACOs must tie together many disparate IT systems. The later says ACOs boil down to lists: actionable lists of items delivered to the right person at the right time. If you put these requirements together with system-wide care pathways delivered safely and conveniently to the point of care, you get my three previous blog posts on interoperability, usability, and safety.

I’ll close here with my seven advantages of BPM-based care coordination technology. It…

  • More granularly distinguishes workflow steps
  • Captures more meaningful time-stamped task data
  • More actively influences point-of-care workflow
  • Helps model and understand workflow
  • Better coordinates patient care task handoffs
  • Monitors patient care task execution in real-time
  • Systematically improves workflow effectiveness & efficiency

Distinguishing among workflow steps is important to collecting data about which steps provide value to providers and patients, as well as time-stamps necessary to estimate true costs. Further, since these steps are executed, or at least monitored, at the point-of-care, there’s more opportunity to facilitate and influence at the point-of-care. Modeling workflow contributes to understanding workflow, in my view an intrinsically valuable state of affairs. These workflow models can represent and compensate for interruptions to necessary care task handoffs. During workflow execution, “enactment” in BPM parlance, workflow state is made transparently visible. Finally, workflow data “exhaust” (particularly times-stamped evidence-based process maps) can be used to systematically find bottlenecks and plug care gaps.

In light of the fit between complex event processing detecting changes in patient state, and BPM’s automated, managed workflow at the point-of-care, I see no alternative to what I predicted in 2010. Regardless of whether it’s rebranded as care or healthcare process management, business process management is the most mature, practical, and scalable way to create the care coordination and population health management IT systems required by Accountable Care Organizations and the Affordable Care Act. A bit dramatically, I’d even say business process management’s royal road to healthcare runs through care coordination.

This was my fifth and final blog post in this series on healthcare and workflow technology solicited by John Lynn for this week that he’s on vacation. Here was the outline:

If you missed one of my previous posts, I hope you’ll still check it out. Finally, thank you John, for allowing to me temporarily share your bully pulpit.

Workflow In ONC’s 10-Year Vision to Achieve an Interoperable Health IT Infrastructure

I do what I always do, when a major health IT strategy white paper appears: count ‘workflow’s! 🙂 In the case of Connecting Health and Care for the Nation: A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure, just released by the ONC, workflow is mentioned in four passages.

And here they are.

“One size does not fit all. Interoperability requires technical and policy conformance amongnetworks, technical systems and their components. It also requires behavior and culturechange on the part of users. We will strive for baseline interoperability across health IT infrastructure, while allowing innovators and technologists to vary the user experience (the feel and function of tools) in order to best meet the user’s needs based on the scenario athand, technology available, workflow design, personal preferences, and other factors….

We will work with stakeholders to refine standards, policies, and services to automate the continuous quality improvement process and deliver targeted clinical decision support that fits into a clinician’s workflow to close care gaps and improve the quality and efficiency of care….

We will encourage the development and use of policy and technology and workflow practices to advance patients’ rights to access, amend, and make informed choices about the disclosure of their electronic health information….

We will work to improve standards, technology, and workflow that enable the electronic collection and management of consent as well as the electronic exchange of related information within existing legal requirements (including notice of redisclosure restrictions).”

Accomplishing these aims will require workflow technology. My most relevant blog posts are:

Attending Upcoming Future of Wearable Technology In Healthcare Conference

A.S. (opposite of P.S.!)

I’m bringing my buddy Mr. RIMP. He’s a wearable robot controlled by Google Glass! Kids love him. And he even has a Twitter account!

July 25-26, in Indianapolis, The International Society of Wearable Technology in Healthcare is putting on what promises to be tremendous conference on wearables in medicine. Predictably, Google Glass is well represented, with at least eleven presentations out of a nineteen (some of which are TBA, so could be Glass as well).


I’ll be there, to add to my over 2000 #GoogleGlass tweets, a many blog posts and trade journal articles. This is a place to for me highlight speaker Twitter accounts and tweets. Below are just those I could find.

I also created the Twitter list Wearable Tech Conference.

  • @ZGJR Rafael Grossmann, MD, FACS Surgeon, Eastern Maine Medical Center in Bangor, Maine United States
  • John Scott, Founder and CEO, ContextSurgery by Context Aware Computing Corporation (not Twitter account, but interesting website)
  • @PaulSzotekMD Paul Szotek, MD Assistant Professor of Clinical Surgery Trauma&Acute Care Surgery / Abdominal Wall Reconstruction Indiana University Health, Indianapolis United States
  • @TGrantcharovMD Teodor Grantcharov MD PhD FACS Associate Professor of Surgery University of Toronto. Scientist Keenan Research Centre of the Li Ka Shing Knowledge Institute Canada
  • @ChrisVukin Christopher Vukin Team Evermed/Medright “How to use wearables with your EMR workflow”
  • @MarliesSchijven Marlies Schijven MD PhD MHSc Associate Professor of Surgery Academic Medical Center Amsterdam, The Netherlands
  • @NoorFSiddiqui Remedy – or how to save lives with Google Glass
  • @DrMartineau On Glass and challenges in hand surgery
  • @drtom_kareo Kareo CMIO, passionate about helping small medical practices successfully leverage technology
  • @kylesamani of @pristineIO How to obtain success with google glass
  • @Geek_Nurse of @SocialHealthIs Development & design of wearable devices for the ecosystem

I’m glad to see Rafael Grossmann, MD kick off the conference with the appropriately titled “In the Beginning…” By the way, @ZGJR was featured on Drudgereport! 🙂

And Kyle Samani of PristineIO, see my 10 Questions for Glass in Healthcare Pioneer Kyle Samani of

Here are some of my own articles about Google Glass in healthcare:

The first describes my project interfacing Google Glass with a state-of-the-art business process management system to manage hospital housekeeping tasks.