Awesome Blab About #HCLDR Tweetchat Last Night! Great Insights For The Future

There was a wonderful discussion on blab last night after the HCLDR tweetchat (here’s Colin’s tee-up blog post about the HCLDR community and giving thanks) about how Blab and tweetchats can work together for the benefit of both. I was present at the beginning, but excused myself when my wife arrived from business trip. Much of the discussion is consistent with my pre-#HCLDR tweet chat blog post. I even drew a diagram of how Blab and a tweetchat might fit together, workflow-wise. 🙂

I listened to the blab twice. Once through and then a second time to transcribe and paraphrase those portions of the blab that were about how Blab and tweet chats might be combined. The following is NOT a word for word transcription (though bits and pieces occasionally may be). It’s a mashup of transcription, paraphrases, syntheses, and occasionally interjections (signified by brackets starting with CW as in [CW: ….]) I encourage you to watch the original. The material below reflects conversation starting about 12 minutes into the Blab.

By the way, I regard this as a seminal discussion. While I’ve seen about a half a dozen blabs so far in which these topics are explored, this is by far the most serious continuous exploration of how to combine Blab and tweet chats into single “thing”.

J: @Jimmie_Vanagon
P: @pfanderson
N: @Natrice
C: @Colin_Hung
CW: Me (@wareFLO, after the fact)

J (to C): Could Blab accentuate HCLDR tweetchats?

P: You’d need multiple moderators. Need best practices for viewers too. I like Twitter in foreground while listening to audio in background and then selectively respond. Others may prefer visual, but then they can’t tweet.

C: It is hard to blab and tweet at same time (when I participated in a previous Blab with Jim and Chuck during a previous HCLDR tweetchat)

N (to C): You did it with aplomb!

C: Dennis [over in the right hand audience activity stream] has interesting suggestion, how about adding T5 over a Blab? Kind of what we’ve been doing with Jimmie and Chuck, recapping the previous tweetchat. Blab allows for more reflection, exploration deeper into the topic. Certainly something we can investigate.

P: During Google Hangouts, tweets occur reactively to what is being discussed in the hangout. The Hangouts moderator is scanning the tweets and bringing them to the attention of the speakers. The guest speakers could then react to the posed Twitter chat questions. One can also ask viewers to live tweet some of the video. (I’m down to 3 percent: Bye!)

C: Blab could be a great way to organize a virtual conference

[CW: Thank Colin for mentioning The First Annual Blab & Periscope Healthcare Online Conference!].

The panel on screen could draw question and comments in from Twitter and other social platforms

[CW: interesting! Which other social platforms could work with Blab: Instagram? Pinterest? Co-host could hold tablet displaying image or video up the screen to get blabbers and tweetchat participant reactions]

[Blab and tweetchat together] might work. You’ve got live tweeting, tweeting snippets from the blab into the tweetchat, where the audience is larger. I could definitely see that work, especially when you have guests. You could have a more intimate discussion with them on the blab and that could generate a lot of tweets.

Patricia had a good idea about the host drawing questions in from the tweetchat.

J: Comparing blab to tweet chats, you may not have as many folks participate in the blab, but folks can watch the recorded video.

[CW: And I do! For example, I not only watched this Blab twice, I transcribed it and wrote this blog post. Frankly, I never read tweetchat transcripts after the fact.]

N: Recorded video can be shared afterward as well.

J: I realize you can storify a tweetchat, and create transcripts and so forth…

C: Blab and Twitter very different. Blab more like TV, like Meet the Press. I could become something. [cites example of Jim’s recent blab (number one in live viewers on Blab during that time slot) on Direct Primary Care]. Plus Dr. Nick brought up possibility of patient panels on Blab… that would be incredible.

[CW: as long as privacy issues are handled well, which was discussed at length during the blab in which Colin and Dr. Nick participated]

N: It really is powerful to see the faces (on Blab). Another thing, it advertises the tweetchat you just had. It might bring folks on blab to the tweetchat. Lots of people don’t understand how great Twitter is. Blab could help.

Also, sometimes things can seem offensive on Twitter. But on Blab you see the people and you hear their voice and you think, “Oh, he/she is not so bad after all!”

J: Good point. Maybe we can get people together from different social media, and they could connect and find commonalities they don’t even realize until they meet on Blab.

C: I get to go to a lot of conferences and meet tweeps face-to-face, but most don’t get to do that, so Blab is the next best thing.

[CW: I go to quite a few conferences too, and I actually go farther. I find Blab superior to meeting at conferences face-to-face in some ways. Blab discussions are longer, more on point, and vetted (by viewers) in ways that IRL (In Real Life) scarcely approaches.]

So you’re right Natrice. When you meet face to face, when you see their tweets, you can hear their voice.

N: I’ve met so many wonderful people through social media and I admire Colin because he seems quiet and shy, but once he gets going he’s rocking the beat too.

C: I get asked what’s the difference between Blab and Google Hangouts. Blab is more intimate because limited to four people on the screen at one time. Blab is like a panel while Google Hangouts is like a conference call. Hangouts seem much more formal.

[CW: Personally, I find Blab to be like a cocktail party, you join a small group, topics pivot and then pivot again, and folks overhear and interject and join and then leave.]

C: Again, I get to go to a lot of conferences and meet tweeps face-to-face and here on blab I get that same feeling, for example, even though I’ve not met you Jim, I feel like I know you.

To me it’s a preference for medium. Some people like Instagram or Pinterest… just not me…

Blab feels like Twitter in its early days.

N: As a world, we need to draw together. The things that are happening in the world are really scary. The more we pull together…. its important, really important.

J: [Interesting discussion of how Jim was shooting a periscope of some Montana scenery. This was just after the recent Paris tragedy, and J. just wanted to put it out of his mind, but she wanted to talk about it. Which they did. And both benefited. From just a Periscope of some pretty scenery.]

I like Blab a bit more than Periscope because I can schedule Blab and tweet it out several times before hand.

However, tonight’s blab was completely spontaneous. We weren’t even going to do it, because Chuck’s wife would have been walking in his door when it started. But then Patricia expressed interest. In fact I think both Chuck and I started up blab at the same time!

[CW: LOL!]

J and N: Patricia seemed to like the blab by the end and she’d be great on blab.

C: Who will really like Blab are the podcasters. But unlike traditional podcasts, with blab you have the ability to have an open mike, so folks from the audience can participate.

N: Well, good night, it was a blast!

J: Thank you Natrice and Colin and everyone in the right for joining. And thank you for the tweetchat Colin, that was wonderful fun tonight.

[CW: Followed by more leave taking, funny thing about Blab, I’ve seen lots of Blabs that seemingly were about to end, multiple times, but then just keep going on and on! Cool!]

@wareFLO On Periscope!


I Am Thankful For Innovation, Workflow, Blab, Periscope, and HCLDR: Happy Thanksgiving!

What a great set of questions, Colin!

I am reminded of a blog post I tweet every year on Thanksgiving Day. It starts with this paragraph.

I publish this on Thanksgiving Day and give thanks for our American tradition of innovation. It is a unique product of personality (forbearers and forerunners), platform (laws and traditions,) and opportunity (Thanksgiving’s Land of Plenty).

Now, on to your questions!

T1 From a healthcare perspective, what are you most thankful for this past year? (personal health or industry development)

While I’ve been involved in healthcare workflow and workflow technology for decades, it’s only been about five or six years that I’ve systematically blogged and tweeted about it. Five years ago I started searching the website of every HIMSS conference exhibitor, looking for workflow and workflow tech content. Initially I found very little (less than two percent of about 1200 websites). Every year the percent doubled. This was the first year that I found so much great content that I ran out of time. I was ecstatic! There is so much interesting conversation about workflow these days, from startups to thought leaders to even old-guard health IT companies.

I think workflow and, more important, workflow technologies, are beginning to explode on the health IT scene. Since I invested so much of myself trying to help make this happen, I am very thankful to see this groundswell.

T2 When you think about the #hcldr community, what are thankful for? What impact has #hcldr had on you personally/professionally?

Frankly, at the beginning of this year I wasn’t a member of the HCLDR tribe. Healthcare Leadership is about way more than health IT, so I focused on the HITSM community. But then something interesting happened. Substantive discussions of workflow began happening outside of the health IT community. In particular, the workflow topics I am so interesting in began intersecting with a wide variety of discussions about patient experience, from wellness to cancer care to home care, workflow ideas, sometimes called life-flows, sometimes customer journeys or experience maps. And so I began to see HCLDR as a potential natural home. That is what I am thankful for, an astute and collegial audience willing to talk about workflow, in all its manifestations and appellations.

T3 What other online formats or in-person events would you like to see from #hcldr?

Obviously, more use Blab and Periscope in and around HCLDR tweet chats. I think we got off to a rocky start, fellow Blitter and Pwitter addict @Jimmie_Vanagon. 🙂 But I do believe that HCLDR can leverage these social video platforms in creative and useful ways.

In particular, I’d love HCLDR to take another (experimental) look at simulcasting the tweetchat and video. I’ve Blabbed and Periscoped both during and after HCLDR. But more important, I’m seeing more and more tweetchat folks on blabs and the topic invariably comes up: Wouldn’t it be cool if we could have the best of a tweetchat and the best of a Blab (or Periscope) and the same time! I really to think that (A) there are a small of best practices that could make this works, and (B) BOTH the tweetchat and Blab could benefit.

T4 In the next year what would you like to see #hcldr start doing/stop doing?

See T3! 🙂

@wareFLO On Periscope!


My Free 12/3 Webinar: Wellness Through Workflow: How Structured Messaging Contributes to Better Patient Experience

[BTW, I’ve scheduled a Blab about Workflow and Patient Experience (any angle!) immediately after the webinar, at 2PM EST, Thursday 12/3. Make both or either! Here’s the 1PM EST webinar registration link.]

At the very beginning of my three-decade love affair with healthcare workflow and workflow technology (hard to believe its been that long!) I studied “structured messaging” systems. They were academic research projects, not commercial healthcare products. In healthcare today, when someone hears “structured,” folks usually think of structured data, not structured workflow. Structured messaging is as much about structured workflow as it is structured data. And the usual word you hear before “messaging” is “secure,” for obvious reasons. However, recently, I’m hearing “structured messaging” more-and-more frequently.

So I was delighted when @TelmedIQ asked if I’d present a free online webinar about workflow, patient experience, and structured messaging, on Thursday, December 3rd, at 1PM EST. Here is the registration link and below are some of the details of what I will talk about.

By the way, right after the webinar, at 2PM EST, I’m hosting an informal Blab (kinda like Google Hangouts, but waay more fun! Here’s a bit of info about Blab, plus the related social video service Periscope). Please come to either or both. If you’ve not tried Blab yet, just go to this link to create an account automatically from your Twitter account, and then subscribe (so it will remind you when it starts).

Wellbeing Through Workflow:
How Structured Messaging Contributes to Better Patient Experience

Delivering an exceptional patient experience in modern healthcare environments is more critical than ever, and the number of opportunities to deliver it has increased exponentially. Modern patient experience extends far beyond traditional bedside manner, and now encompasses the sum of all interactions that influence patient perceptions across the continuum of care.

Specifically, I’ll cover:

  • The direct and indirect impact of healthcare workflow on patient experience
  • The systems, technology, and processes healthcare organizations can utilize to improve workflow
  • How structured messaging and healthcare communications platforms facilitate better patient care

One more thing! I’m so interested in workflow, I even make workflow art! This blog post begins with my artistic interpretation of workflow. Workflow is a series of steps, consuming resources, achieving a goal. The spheres are workflow tasks and activities, arranged as ascending steps, ascending toward a goal. The steps do not proceed in straight line, since real world workflows are sinewy and serpentine, figuratively speaking. The steps overlap, just as tasks and activities often do. Each step is supported by resources, namely the supporting columns.

After the webinar and blab, I will add the name or Twitter handle of whoever tweets most about the webinar or blab, and print and send them their prize. The hashtag? #POWHIT (click it, it’s really a hashtag!), which stands for People and Organizations fixing Workflow with Health Information Technology.

@wareFLO On Periscope!


Blab’s Extraordinary Potential For Healthcare & Upcoming Blabs

At 2PM EST today, @jimmie_vanagon is blabbing with @PopHealthChick (and whoever else shows up) about Direct Primary Care. From 12PM Noon EST to 1PM EST is the weekly #HITsm tweetchat (about Personal Health Records). So I thought I’d schedule a Blab from 1PM to 2PM. Here is that link: After #HITsm: Blab’s Extraordinary Potential 4 Healthcare, Plus Upcoming Blabs! If you’ve not tried blab, just click it and you’ll use you Twitter account to register. Subscribe for reminders, or just show up! Showing up means following the link at 1PM (and 2PM) in a Blab compatible browser. Folks seem to have the best luck with Chrome. Safari does not. Supposedly Firefox does (but I’ve had no luck).

Jim (“Johnny”) Legan’s blab is about alternatives to traditional insurance in providing primary care. I’ll be there, sort of “Ed McMahon” to Jim’s “Johnny Carson.” My blab just before his is about anything anyone shows up wants it to be about. I do hope it has something to to with healthcare or information technology or, ideally, both. But hey, I’m flexible. In fact, the most frequent topic of conversation on Blab seems to be about Blab itself: its potential in healthcare, its idiosyncrasies and workarounds, and just sort of friendly joking around.

By the way, there are interesting workflow angles to direct primary care.

“The DPC model demands software that is very different from traditional EHRs…. practice patterns are continuing to evolve particularly as new technologies open up care models that weren’t possible before. Consequently, the ability to easily modify workflow, templates, etc is vital.” (Direct Primary Care: Technology Trends Supporting DPC and Requirements)

And there are also interesting connections among direct primary care, personal health records (subject of the HITsm tweetchat), and patient portals. PHRs and portals are not the same, but are often confused (). I think there are some interesting patient and physician workflow issues here as well.

Regarding “Blab’s Incredible Potential For Healthcare,” I’ve been party to several fascinating discussions. The first thing many first-time blabbers remark about is, wow, wouldn’t Blab be great for including patients in discussions of their care with other members of the care team. And then just as immediately, wow, what about privacy issues! We’ve even had expert health IT lawyers give us their opinions without charging us a dime!

The second topic is a favorite of mine. It’s a very selfish topic. How can I use Blab, Periscope, Twitter, and blogging together to maximize my enjoyment, education, and networking with intelligent and fascinating people? Yes, it’s a selfish topic, but I think other’s are interested too. There’s a lot of interesting ideas and trial balloons being floated about in this regard…

For examples of lots of other uses of Blab and Periscope in healthcare see several of my recent blog posts.

I’d like to mention several other scheduled blabs you may be interested in.

And of course my own “bridge” blab between the end of HITsm tweetchat and the beginning of @Jimmie_Vanagon’s blab about Direct Primary Care. If no one shows up, I’ll just let it run and get some work done. If you show up, we can hang out in the “Green Room” waiting for today’s Healthcare and Health IT (I’m sure it will come up!) main event at 2PM EST.

Maybe we’ll even talk about some of what I’ve written about in this blog post!

@wareFLO On Periscope!


Patient Data Ownership Cannot Resolve Data Access Problems: But Workflow Technology Might

[Since I wrote this post, thanks to @LeonardKish and @JeffBrandt, I’ve learned about #blockchain, and become interested in its implications for healthcare workflow. My point in this post was that patient data is more about control of data workflow than data ownership in a traditional legal sense. However, blockchain certainly addresses important aspects of control over data workflow. Blockchain tech potentially makes some workflows obsolete. Blockchain’s smart contracts are state machines, fundamental representations of workflow. And, creating and interacting with blockchain applications can itself require complicated workflow, so workflow tech may also play an important supporting role here, as well.]

I had an interesting Twitter debate last week about whether patient ownership of patient data is the silver bullet so many seem to think. During that debate I Googled, “patient data ownership legal theory” (without the quotes). The top-ranked document was a law article in the Harvard Journal of Law & Technology titled Much Ado About Data Ownership (a reference to Shakespeare’s Much Ado About Nothing, so you can probably tell where this is going…).

The author has degrees in electrical engineering and law, plus a Ph.D. from Stanford, and directs the Center on Biotechnology & Law at University of Houston. The piece is interesting but heavy going (footnotes take up half the article!). I am not a lawyer (though I did take a three-credit undergraduate course in business law), so I’d love to get some comments from some lawyers in health IT on some of the following quotes.

“The urge to propertize health data needs to be weighed skeptically and with a clear understanding of how property rights actually work. If pursued, data ownership may disappoint many of its proponents”

“Statements such as “[w]hoever owns patient data will determine whether its benefits can be tapped” overstate the importance of controlling one raw material input to a complex, multistage production process.”

(BTW, “complex, multistage production process”? That’s workflow. Efficient, effective, flexible, and transparent management of complex, multistage production processes is exactly what workflow technology does.)

“Creating property rights in data would produce a new scheme of entitlements that is substantively similar to what already exists, thus perpetuating the same frustrations”

“Data propertization proposals fail because patients’ raw health information is not in itself a valuable data resource, in the sense of being able to support useful, new applications. Creating useful data resources requires significant inputs of human and infrastructure services, and owning data is fruitless unless there is a way to acquire the necessary services”

“Simply owning data will not ensure an adequate supply of data resources without access to the necessary services. Proposals that fail to address these realities cannot resolve the data access problem.”

“raw health data are just one of many inputs for creating useful data resources”

“Data holders do not have unlimited personnel and data processing resources to respond to queries”

“The fact that the necessary services are costly and in finite supply has ramifications for system design”

(Workflow exists in an economic context, which is why I like my definition of workflow: “Workflow is a series of tasks, consuming resources, achieving goals.” Consuming resources? That’s cost. Achieving goals? Those are benefits. Different stakeholders obtain different benefits from different workflows (see next quote). When economic context changes, workflow usually needs to change. This is one of the major problems with much current health IT technology. Without actual models of work and workflow, to be interpreted, executed, and systematically improved, ability of IT systems to change when their environmental context changes, is severely limited.)

“the optimal infrastructure to supply data resources for one use may not be optimal for supplying other uses”

“Data propertization proposals assume that if encounter-level patient data were simply assigned to the right owner, the market would be able to figure out the right price to pay for useful data resources such as [Longitudinal Health Record (LHR) and Longitudinal Population Health Data (LPHD)], and this price would cover the cost of necessary infrastructure and services to create those resources. This is not a safe assumption”

“Why Data Propertization Proposals Fail

To summarize, encounter-level patient data are an input that can be transformed into high-valued data resources — LHRs and LPHD — for use in clinical care, research, and public health activities. Making these data resources also requires inputs of human and infrastructure services — that is, data provisioning services. In theory, it is possible to produce LHRs for use in clinical care under a patient-controlled system. Such a system would subject all transfers of encounter-level patient data to consensual ordering, which would require permission of the patients whose data are involved. There are major limitations to such a system, however. Because of consent bias, the system cannot supply unbiased LPHD for use in research and public health projects. Research and public health users thus cannot be counted on to cross-subsidize the costs of developing patient-controlled LHRs. Unless the costs of developing patient-controlled LHRs are justified by the value they create in clinical care, a patient-controlled system may not be financially viable.”

“Access to raw patient data is necessary, but not sufficient, to ensure an adequate supply of useful data resources. Data provisioning services also are required. The prospective provision of services is inherently consensual in our system of law. The state’s police and eminent domain powers only allow non-consensual transfers of property; there is no similar mechanism to compel non-consensual provision of services”

“data holders have only limited capacity to supply services and need discretion to refuse. Nonconsensual access to data is possible whether under a property regime or under the regulatory regime provided by the Common Rule and HIPAA Privacy Rule. Nonconsensual access to services is not possible under either regime. Access to infrastructure services, rather than the unresolved status of data ownership, is thus the key impediment to data availability.”

Much Ado About Data Ownership covers so much more ground than what I have focussed on above, especially regarding privacy, research, and public health concerns. I encourage you to read the entire piece.

Regarding how workflow technology can help, I refer you to several of my recent blog posts. The Workflow Prescription: Patients Need Zapier, Workflow, and IFTTT-like Control Over Self-Care Workflow Automation At Home argues patients want workflow, not data. And Give BPM A Chance: Medical Informatics Should Add Business Process Management To Its Toolkit argues medical informatics research should focus more on workflow technology, not just workflow.

@wareFLO On Periscope!


Give BPM A Chance: Medical Informatics Should Add Business Process Management To Its Toolkit

The American Medical Informatics Association (AMIA) conference occurs this week in San Francisco. I’ve attended and occasionally spoken at this annual gathering of several thousand thought leaders. Ever since SCAMC (out of which the conference evolved) I’ve watched ideas go from gown (academia) to town (industry) over-and-over again.

There is a remarkable exception to this pattern, though. The health IT industry is considerably further along in adopting workflow technology than medical informatics professional are at studying it. And workflow technology, variously referred to as process-aware information systems (PAISs), Business Process Management (BPM), and Workflow Management Systems (WfMSs) is considerably further along outside of healthcare than in health IT. WfMSs have literally been around for decades, but have been little used or discussed in health IT.

Recently, however, BPM and WfMS technology has begun to more rapidly diffuse into health IT. I know this because every year for the past five years I search every website of every exhibitor at the annual HIMSS conference (for example). I search for such phrases as “BPM”, “workflow management”, “process orchestration”, and “workflow engine” (an important software component of these systems, whatever they are called). Five years ago, starting with HIMSS11, there was very little evidence of workflow technology. But then the number of exhibitor websites with interesting workflow and workflow tech storied essentially doubled every year, all the way from two percent to over a third. At this year’s HIMSS15 in Chicago, five percent of exhibitor websites (~75) mentioned “workflow engine” someplace (technical documentation, user forums, sometimes even marketing or on their home page!).

There is something else I do every year. I search the entire AMIA proceedings (over 2000 pages and 100M pdf!) for the same sorts of content (Workflow-Related #AMIA2014 Papers and Posters). I find more-and-more “workflow”s (509 hits this year, not counting hyphenated “work-flow”s due to line breaks and the unfortunate “work flows”). But still very little, if any, evidence of workflow technology. There were only two instances of “Business Process Management” this year. Both were in the titles of references. One was to my 2012 EHR Business Process Management: From Process Mining to Process Improvement to Process Usability. The other was right next to me, to a 2010 workshop about BPM in healthcare. This workshop was, notably, held abroad. Historically, most BPM academic research has not occurred in the US, possibly explaining some of it’s relative lack of penetration into medical informatics research.

Every year during the AMIA conference, I engage tweeps monitoring and tweeting on the conference Twitter hashtag, this year #AMIA2015. Last year I precipitated some interesting debates about whether medical informatics has sufficiently paid attention or workflow technology. I’ve lots of tutorial content on my website (for example, my Workflow Interoperability in Healthcare series), and I offered up this links (another example, BPM-based Population Health Management & Care Coordination: Workflow, Usability, Safety & Interoperability Perspectives). I think I did get a couple dozen #AMIA2015 tweeps to follow me and to continue the conversation after the conference. Thank you! (You know who you are.)

In this post I’d like to point you to two recent articles. One is a traditional (to medical informatics academic eyes) research paper measuring the effects of workflow technology on organizational performance. Several of the surveyed organizations are in healthcare. The other article is about a particular BPM product. I chose it because as much as I love research, it will be actual for-sale products and services that will bring true modern process-aware workflow technology to healthcare customers, employees, and independent providers.

This is the research paper, The Effectiveness of Workflow Management Systems: Predictions and Lessons Learned, is the first longitudinal study of the effective of workflow technology and organizational performance. To follow (and follow-up) so many real-world organizations over so many years must have taken an extraordinary amount of work.


“Workflow management systems are widely used and reputable to improve organizational performance. The extent of this effect in practice, however, is not investigated in a quantitative, systematic manner. In this paper, the preliminary results are reported from a longitudinal, multi-case study into the effectiveness of workflow management technology. Business process improvement is measured in terms of lead time, service time, wait time, and resource utilization. Significant improvement of these parameters is predicted for almost all of the 16 investigated business processes from the six Dutch organizations participating in this study. In addition, this paper includes lessons learned with respect to the simulation of administrative business processes, data gathering for performance measurement, the nature of administrative business processes, and workflow management implementation projects.”

The second paper recently appeared in an IT trade publication, notably Integration Developer News (notable due to the importance of “integration” to interoperability). I highlight this article for three reasons.

  • I am familiar with the Appian BPM platform. They are headquartered in the Washington DC areas, where I currently live.
  • Appian consistently ranks extremely high in both modernity of its technology and ability to execute.
  • What this article discusses is squarely situated among many current medical informatics topics (or, in several cases, should be). The following are the articles tags: agile, Appian, apps, BPM, CEP, data, deploy, devices, integration, mobile, OSGi, platform, SOAP, REST

The title of this second paper is, Appian Modernizes BPM; New Platform Creates ‘Agile Apps’ That Share Any Data, Run on Any Device.

Here are key quotes:

“app platform combines BPM’s power to build apps ‘drawing a picture’ with easier ways for apps to share data and run on multiple devices – often with little or no coding”

“flexible any-to-any environment for apps, data, devices and users”

  • “Faster, visual ways to build apps
  • The ability for apps to retrieve and share data from hundreds of outside sources.
  • Apps the capability to deploy without complex coding on any device, including PCs, laptops, phones, tablets and even wearables and IoT devices.”

“Breaks Silos, Eases Integration … any app should be able to get any data and run anywhere”

“In the old [custom app] vertical model, every app has its own data source and its own interface,” … Today, with so many more data sources and device interfaces, a new ‘horizontal’ model for how apps work is necessary” (play attention SMART on FHIR folks)

“every time you plugged in new data or new users, all those assets became available to the entire universe of users”

“Library of system-specific connectors to established enterprise apps, including SAP, Oracle Siebel, Microsoft Dynamics, Microsoft SharePoint, and Content Management Interoperability Services (CMIS).”

‘Pre-built library of integration options for SOAP and REST web services. These include the ability to model and build complex orchestrations.”

“Complex event processing (CEP) to let users combine and correlate events from multiple systems. CEP will also recognize patterns, as well as define process-based responses and notifications.”

“Data parsing and transformation via data extraction and manipulation tools. These parse and transform content between systems in automated processes.”

“A secure data store to make it easier to govern data integration, to ensure data is only shared where there are permissions.”

OSGi framework-compliant plug-ins and capabilities for custom extensibility.”

“Appian is also enlisting support of many third-party partners for its new app platform. Just last month, the company launched its Appian App Market, a collection of ready-built business apps and components for the Appian platform.”

I don’t know about you, but wearing my medical informatics hat — I designed the first undergraduate program in medical informatics in the early 90s — all the above, all, is extremely on-point regarding today’s medical informatics and health IT challenges. If you read the research paper and trade journal article together, you see two things. First, using workflow technology (AKA BPM) is nontrivial but worth it. Second, from a (potentially) health IT and medical informatics perspective, you see specific software capabilities of a leading BPM platform.

If you are attending this week’s AMIA conference in San Francisco, or simply monitoring the #AMIA2015 hashtag, I hope you’ll, to paraphrase a Beatle, “Give modern BPM a chance.”

@wareFLO On Periscope!


Click the following to see the entire conversation…

Radiology, Service Design, Servicescapes, and Scenography: The Workflow of Patient and Family-Centered Care

I’m delighted to see @Jim_Rawson_MD on the Healthcare Leadership tweetchat this week, having met him this spring at the Healthcare Systems Process Improvement Conference. He tweeted something very nice about me, which I cannot resist embedding here! 🙂

I reviewed materials supplied by @Colin_Hung at the end of his blog post Radiology + Patient & Family-Centered Care and I was struck by the relevance of, guess what … wait for it… workflow! No, really, let me make my case.
Take, for example, In the Patient’s Shoes. Radiologists Question and Evolve the Patient Experience With Input Straight From the Source.

I could quote at length, about waiting rooms, waiting for results, complete patient experience from appointment to followup, turnaround times, and especially “Rawson helped adjust the department’s entire workflow.” But you get the idea.

In fact, other aspects described, such as wall colors, anxiety, calm, and recovery rooms are also about workflow, if you think of workflow in terms of my personal and favorite definition:

  • “A series of activities, consuming resources and achieving goals.”

Sometimes I talk about tasks or steps instead of activities, but activities works best here, because we more naturally think of patients as involved in activities than tasks or steps. Consuming resources, that’s costs, including, perhaps especially, costs to the patient, from financial to physical to mental and emotional. Goals, those are self-evidently patient goals, from a patient-centered perspective.

However, I wish to discuss workflow from a slightly different perspective, from that of the fascinating disciplines of service design, servicescapes, and scenography.

  • Service design is a form of conceptual design which involves the activity of planning and organizing people, infrastructure, communication and material components of a service in order to improve its quality and the interaction between service provider and customers”
  • A servicescape is “the environment in which the service is assembled and in which the seller and customer interact, combined with tangible commodities that facilitate performance or communication of the service”
  • Scenography is the seamless synthesis of space, text, research, art, actors, directors and spectators that contributes to an original creation.” (Also see Scenography: A Ritz-Carlton Secret For Creating A Magical Customer Experience)

All and any of these three Ss (alliteratively reminding us of “Service”) are relevant to Patient and Family-Centered Radiology. A major contributor to imaging patient experience is their visit to the radiology department or imaging center and their interaction with staff there.

But here is the thing. If you read about service design, servicescapes, and scenography, you’ll see workflow ideas popping up over and over!

Let’s start with service design. You’ll see the phrases, “sequences of actions and actors’ roles”, “temporal sequences” and “time sequences” in a service encounter over and over. One of the roles of service design professional is to literally, visually, draw out current and alternative workflows. One of the important tools of service design is “specification and construction of processes.” AKA workflows. Then there is the “service blueprint”: “to map the sequence of events in a service and its essential functions in an objective and explicit manner.” AKA workflow diagrams and process maps. Now consider “service drivers”: functions make work “fluent” and clarity requires each step to be assigned a simple understandable role. The “customer journey” is often literally drawn as a workflow diagram or process map.

How about servicecapes? One of its most important ideas it to essentially use the physical environment to direct sequences of activities of staff and customers. This can range from painting arrows on walls and floors to much more subtle clues, such as using aesthetic signals (people tend to move toward more attractive locations than less attractive locations). The physical environment can be literally used as a workflow engine to propel and funnel human activity.

Scenography (applied to non-theatrical venues) is about using the theater arts to turn service environments into “stages” on which “actors” “play” “roles.” Used mostly in the hotel industry, it’s about making you a star in your favorite movie (Bogart and Becall in the hotel in Key Largo, Sponge Bob in your undersea neighborhood). Just like in servicescape, props are not random, we expect them to be used — that fancy pen on the desk expects to be used, and that computer kiosk expects to be used. And the order of use is a workflow just as a play’s script has stage directions that turn into three-dimensional tableaus facing an audience.

Practically speaking, what does all this mean? Folks who understand the above ideas need to meet and observe and understand the patient. And one person who is a natural, who deals with workflows all the time is what used to be called the hospital “management engineer.” In the old days these were trained as industrial engineers (my MSIE). Today they sometimes called health systems engineers, though increasingly many non-industrial engineering professionals think in terms of workflows.

I could stop here. We need people trying to improve radiology patient and family imaging experience to think in terms of “workflow.”

But I won’t stop here. Just as data without date technology is foolish, workflow without workflow technology is foolish. In fact, radiologists were early adopters of workflow technology. They use it to collect images, to customize imaging workflow, to intelligently distribute images to remote viewers for reading and so on. In fact, the speech (and increasingly, natural language) technology radiologists use to transcribe and create value from transcriptions also has some of the most sophisticated workflow technology in the heath IT industry.

Radiologists need to use their knowledge of workflow technology to include patients in the workflows they design, manage, and participate it.

So, to summarize this post I say this: Look at radiology patient and family imaging experience not just through the lens of physician, staff, and patient workflow, in all its senses, including physical environments. Also think about how to use workflow technology in build workflows that include patients, systematically collect data, and continually improve patient and family imaging experience.

I am looking forward to tonight’s #HCLDR twitter chat!

P.S. I encourage you to read all of @Colin_Hung’s Healthcare Leadership tweetchat tee-up blog post Radiology + Patient & Family-Centered Care including @Jim_Rawson_MD‘s content and questions.

@wareFLO On Periscope!


Low-Code Cross-Device Native Mobile Health Workflow Apps via Business Process Management

One of the things I love about HIMSS mHealth conferences are all the resources for software developers of mobile apps for health. In line with that theme I’d like to describe a new (to healthcare) way to create great mobile health apps with great workflow (Hey, I wouldn’t write about it otherwise!).

Start with the healthcare workflow!

Now, I don’t mean understand healthcare workflow and then dive into Swift (iOS), Java (Android), or HTML5. I mean draw the workflow in a workflow editor. Draw the forms you want to appear at certain steps in the workflow. Popup some dialog boxes to connect your mobile health app to healthcare data and to customize business logic. Then push a button to generate native mobile apps running on multiple mobile platforms. What is this sorcery? Business Process Management (BPM).

What could be easier?

This sort of low-code development has been around for years outside of healthcare. It’s just taken this long for it to finally diffuse into healthcare, where we need it badly. Think about it, most healthcare software development is caught between the horns of a dilemma. Either we use existing software someone else has written, usually from scratch, which may or may not fit out workflows, or we write healthcare software from scratch ourselves. In the first case, we are dependent on someone else, who may or may not understand (or even care) about our workflow, and who may or may not keep that software up to date. In the second instance, you are often stuck with a mess. Healthcare organizations typically don’t have full time mobile programmers. If you hire someone to create an app, it’s expensive to create and then often even more expensive to maintain.

Instead, if you invest in the right Business Process Management (BPM) infrastructure, you have a third alternative. You can draw your workflows and automatically turn them in to real, live, mobile applications, and native and cross-platform to boot (that’s software pun).

If you don’t believe me, seeing is believing. Let me introduce two examples into evidence.

The first example of drawing a mobile health app was a couple years ago when I was a Google Glass Explorer (by the way, Glass is not dead, at least not in healthcare). The following three pictures go from chicken scratching on whiteboard to workflow diagram on the computer to some of the screens I saw when using the mobile glass app. It was a workflow system for hospital environmental service personnel (housekeeping is a really really important contributor to patient experience). It took an hour to create the workflow diagram in the first place, and then an hour to have it demoed for me and then tweaked a bit more.












In this second example Doug demos how to create an awesome health plan mobile provider membership app… WITHOUT HAVING TO WRITE ANY COMPUTER CODE! Sorry, I had to all caps that… This is exactly what I am taking about when I blow the workflow technology horn, AKA modern BPM application platform. (BPM stands for Business Process Management).

If you are a mobile health app developer, PREPARE TO BE WOWED! 🙂 (Read more about what I have to say about BPM-based low-code mobile development here here and here.)

Be sure to increase your video resolution to the max, because you’ll want to pause it at various points, to more closely examine the application designer screens.

OK! Let sum it up. Healthcare software development, including mobile health app development, needs to start creating software in a completely different manner to which we are historically accustomed.

  • Don’t buy expensive software that doesn’t fit your workflow, and which may abandon you high-and-dry.
  • Don’t create software from scratch, in geeky computer languages such as Java and Swift. You won’t be very good at it.
  • Do create custom workflow software, running natively across multiple mobile devices, by drawing your workflows.

That is all!

@wareFLO On Periscope!


Workflow Usability Principles for Health IT Tools: EHRs, Apps, Platforms

This post is prompted by [#HITsm Chat 11.6.15] Usability Principles for Health IT Tools. I’ll be simulcasting using Periscope during the #HITsm chat and will post link here, once it exists! 🙂 (Unlike Blab, Periscopes can be scheduled yet.)

As usual, I interpret the questions within a healthcare workflow technology context.

Relative to workflow usability principles, take a look at my 2009 EHR/EMR Usability: Natural, Consistent, Relevant, Supportive, Flexible Workflow.

Topic 1: What problems in health have you seen that seem to be caused by, or at least exacerbated by, poor Web or mobile interface design?

Non-adoption due to inefficiency and ineffectiveness.

Topic 2: Which EHR vendors and health-related Web sites making effective use of modern, interactive Web and mobile interfaces? Examples?

Ironically, some of the pre-Meaningful Use EHRs had more modern user interfaces! This was because there was great variety and experimentation. The one I know best won the first three consecutive HIMSS Davies Awards (2003-2005). On small screens observing Fitts and Hicks laws is essential. I wrote about that in The Cognitive Psychology of EHR/EMR Usability and Workflow.

I’ve not heard much praise for any Meaningful Use certified EHR with reasonable-size user base. My further impression is that users take health-related websites pretty much for granted, even when they work well. For example, folks are so used to quickly searching, finding, and using health info, that they really do take it for granted, which perhaps is a form of praise. In the mobile health app space, there are some reference apps that get high marks. But there are no app-based EHRs I know of that have anywhere near the functionality of top desktop EHRs. And where they exist, I suspect user will find their workflows nearly as complex.

I think on needs to point out that comparing an app to a desktop EHR is a bit like comparing one of the simpler screens of that EHR to the entire EHR. In other words, don’t over estimate modern web/mobile UIs.

Heads down high productivity data and order entry workflows require chaining screens, apps, web pages, etc. And this is exactly why current systems, mobile, web or otherwise, do terribly. Why? Because there is not inter-task, inter-screen, inter-app infrastructure with a model of the work or workflow to execute, consult, and interpret user actions.

By the way, check out No More Isolation: Why Apps Cooperate More (love “app thrashing”!) and my Twitter conversation with its author (click date to expand conversation).

Topic 3: What do you think is holding back vendors from doing as well as good e-commerce sites?

Complexity of data and workflow. What’s the solution? Software that can model data and workflow. Most current health IT software basically models data and hardcodes workflows. By modeling the data we can change the kinds of data and relations among data to fit the needs of a particular domain. However, we can’t do the same for the workflows.

On a typical e-commerce site you authenticate, search, read, browse, purchase. The workflow is simple and the same no matter what you buy. In an EHR workflows are complicated and different from each other. When I use to design and support EHR workflows, a single workflow might consist of a couple dozen or more screens. I think the most complicated workflow was something like 30-40 steps and screens in a pediatric EHR for in an adoption clinic. The large number of tasks was due to children who had literally never been seen by a pediatrician, so there was a lot of catch-up work.

Topic 4: Are consultations with clinicians during EHR and app design sufficient to take clinician needs and workflows into account? What more could developers do?

Consultations with clinicians during app design may be sufficient. Apps have much more simple workflows than EHRs, which can almost be thought of as collections of dozens of apps working together against a common database (which today’s apps don’t do).

In contrast, consultations with clinicians during EHR design are usually insufficient. There are too many different possible workflows. There is no way for all of that knowledge to pass from the real world through the clinician’s brain through the programmers brain and into the collection of supported EHR workflows. This is why EHR should be based on workflow platforms. On a workflow platform not only can clinicians help design individual workflows (divide and conquer) but approximately correct workflows can be pushed out to the field and then tweaked by users in an iterative cycle of workflow improvement (see BPM life cycle).

Use workflow tech so user can change workflows after implementation w/o having to go back to programmers and recompile, test, reinstall, etc.

See my Citizen-Soldier, Citizen-Developer, User-Programmer, Physician-Informaticist for more on this topic.

Topic 5: Which open source solutions in health IT are making significant inroads in the industry? What gaps should the open source communities fill in health IT?

There are not yet a lot of open source workflow tools for use in healthcare (tho see first link below for a list). Keep in mind they are just the beginning, so there is not a lot out there to compare to yet. However I think we need to distinguish among open source vs open data versus open workflow. There are closed source proprietary workflow platforms, which nonetheless support relatively open workflows. Not only is are the workflows open to inspection, these workflows can sometimes also even be exported and re-imported into other workflow platforms.

@wareFLO On Periscope!


From Bed Management To Workflow Management and Experience Orchestration

What kind of conference do I enjoy most? Apparently, a TeleTracking 2015 Client Conference, which I attended last week in Nevada. As a premed-accounting major (only one I’ve ever heard of), TeleTracking was full of customer success stories about reduced costs and increased revenues. With an MS in Industrial Engineering, TeleTracking was full of IE concepts (cycle time, throughput, capacity management, and utilization rates). Plus an MS in Intelligent Systems (medical informatics), TeleTracking was full of health IT, interoperability, and care transition technology.

Big picture: TeleTracking was about two areas rapidly gaining prominence in thinking about healthcare and health IT: productivity and experience. There is an important connection between these two concerns. What is the connection? I am sure I will surprise no one who follows my tweets or who has read this blog before: Workflow.

You may have heard of the cocktail party effect? It occurs when you hear something just sort of pops out at you, punching through a noisy environment. It’s usually a word or sound that has special significance to you. Your name. Your baby crying. Or, in my case, I’ve never been anywhere where I heard, over the crowd noise, all the “workflow”s I heard at TeleTracking. In my opinion, this is a very good thing.

TeleTracking 2015 occurred in a great location: Lake Las Vegas, Nevada.

At TeleTracking the following statistics stood out.

  • Baptist Memorial reduced time to admit a patient 75 percent, from one hour to 15 minutes.
  • Health First reduced time to discharge a patient 81 percent, from 9.1 hours to 1.7 hours.

There were actually many impressive statistics. I’ll focus on just the above, because I don’t want this blog post to be too statistics heavy. Just know this: I saw hundreds of statistics about improved overtime; dirty bed response times, turnaround times; missed transfers and transfer volumes; unplanned discharges, avoidable discharge delays, calls per day between nurses, pharmacists, and front desks; transport request durations, incoming transfers, patient throughput times and satisfaction scores; and a lot more.

I’ve used a variety of “workflow informatics” technologies for several decades. The statistics I saw and heard are consistent with my previous experience. However, workflow tech is still relatively rare in healthcare. And I’ve not seen it applied as the scale TeleTracking is applying in not just large hospitals but across entire health systems with multiple hospitals (with associated opportunities to address interhospital transfer problems and opportunities).

Let’s turn from productivity improvement to patient experience improvement. There is a direct causal arrow from efficiency to improved patient experience.

Imagine you are waiting for a bed or waiting to go home. Imagine waiting an hour for the bed and nine hours to go home. Now imagine waiting 15 minutes for a bed and less than two hours to go home.

Here’s another example, one involving a TeleTracking core competency, “tracking” people, objects, task, and workflows. Moment by moment, TeleTracking tracking tracks patient location. Apparently there is an app allowing families to see whether their family member is in their room or not. This prevents, for example, a college student from taking a bus crosstown to the hospital to visit his mom, only to find her room empty.

TeleTracking tracks more than just people and objects, but tasks and workflows as well. In this, TeleTracking is in what academics called “process-aware” territory. Process-aware information systems have some kind of model of process, or workflow, and use this model to improve all kinds of useful statistics, from cycle time to throughput, to task visibility and safety, to visualizing workflow state, in real-time, as in, “the patient’s wound was just closed”, represented using a suture symbol.

Real-time workflow and task status is useful to lots of people, from those who clean the operating room to nurses waiting for the patient up on the floor. This same information, which can be so valuable for creating more efficient and safe patient workflows, is also extraordinarily appreciated by families waiting for news of their family member’s progress. They can watch their loved one’s journey, step-by-step, through each major stage of operating room and surgical workflow, via a real-time dashboard.

There is a pattern here. The same real-time data, about healthcare events happening and status changing, is essential for both greatly improving healthcare workflow efficiency AND patient experience. To me, this was the most exciting potential that TeleTracking made me think of: Can we make our healthcare system much more efficient while at the same time greatly improving patient experience? Yes, but it takes a combination of real-time visibility into all relevant healthcare workflows and using that information to drive other real-time workflows to improve efficiency and experience.

I enjoyed TeleTracking 2015 Client Conference, for reasons already stated, and the Pittsburgh connection. TeleTracking is based where I lived for twelve years. Every time I met a TeleTracking staff member, I asked them where they lived and hung out. From Cappy’s on Walnut in Shadyside to the 54C between the Southside and Oakland, we had great fun comparing professional and personal workflows and life-flows of another kind!

In particular, I finally met Pittsburgh’s Bill Strickland, who keynoted the conference. His life story of creating successful communities by believing in the best, not the worst, in people resulted in multiple standing ovations.

I tweeted the following, toward the end of the conference. I was trying to distill down to a single tweet what I found most interesting about TeleTracking. It’s pretty dense, and really intended for fellow healthcare workflow tech geeks. But it might be useful to unpack and explain as a summary and conclusion to this post.

“Remarkable scale of event-driven propagation of patient & task state across HC enterprises 2 apps & users”

By “event-driven propagation” I mean when something happens, information that something just happened is immediately sent somewhere useful. Why is this important? Because in healthcare lots of things can’t happen until some prerequisite thing has happened but most current healthcare organizations and health IT systems aren’t very good at this, so stuff that should get done, instead languishes. The results are delays, longer cycle times (time from beginning to end of workflows), and reduced throughout and capacity.

By “patient & task state” I mean tracking not just the location of things objects and people, but also tracking status changes, such as from not-ready-to-be-discharged to ready-to-be-discharged, or starting-surgery versus finishing-surgery. This kind of information, instantly propagated to the right person and the right can dramatically improve hospital workflow, especially patient flow.

By “across HC enterprises 2 apps & users” I mean workflows inside of one healthcare organization, such as a hospital, can be enormously important to workflows inside another healthcare organization, such as a hospital receiving a transferred patient. (In fact, I recently wrote about this topic during a 7000-word, five-part series on workflow interoperability).

Finally, by “Remarkable scale” I mean I haven’t previously seen such quantity of tracked data, and also sophisticated combination of different kinds of tracked data, display of that data, and triggering of complex healthcare workflows using that data. Much of the health IT world is about patient data in databases put there by a variety of means, but recently especially electronic health records. This kind of data is important, for patient care and understanding outcomes, but we need more. We need data about when important healthcare events occur and then means to drive other healthcare events. To me, this is the important secret sauce TeleTracking brings to the healthcare and health IT table.

All in all, great conference! Learned a lot. Confirmed a lot (about things I believe about healthcare workflow and workflow technology). And enjoyed a lot.

@wareFLO On Periscope!


P.S. Below are some of my tweets during the TeleTracking conference. There were some great slides, both from customers and from employees.

  • Community Access Portal (provider facing)
  • Command Center
  • On-Call Schedule