BPM, FHIR, Interoperability, and the Healthcare Services Platform Consortium at HIMSS16

There’s a great fit between BPM (Business Process Management) and FHIR (Fast Healthcare Interoperability Resources) when it comes Achieving Task and Workflow Interoperability in Healthcare. FHIR provides access to EHR data. BPM orchestrates tasks and workflows across EHRs and other health IT systems, potentially in different healthcare organizations. I’m delighted to see Healthcare Services Platform Consortium (HSPC) combine these technologies and that they will be represented at HIMSS16. I still have a lot of questions about how FHIR and BPM will play nicely (see my ten questions in Health IT Workflow Integration: Whither FHIR?). But I suspect FHIR and non-FHIR EHR API initiatives will play important roles in ushering into healthcare the kind of process-aware BPM-style workflow technology it so desperate needs.

I’ve been tracking diffusion of process-aware workflow technology, such as business process management, into healthcare for decades. See I’m Looking For Healthcare Workflow & Workflow Tech Stories at #HIMSS16 for links going all the way back to HIMSS00 (2000 HIMSS conference in Dallas). Healthcare Services Platform Consortium popped on my radar in 2014 (occasioning my 2014 Healthcare Services Platform Consortium Business Process Management Marketecture). In the following tweets I highlighted elements of the proposed HSPC architecture that correspond to BPM elements (BPM, workflow, orchestration, process engines, etc.)… but click here to skip them and move directly on to more recent HSPC/BPM content…

I poked around the HSPC wiki looking for process-aware BPM-style workflow technology, and found lots. Enjoy!

The following are from Peter Haug’s Workflow Modeling for Medicine: An experience with BPMN2 at Intermountain.


From Tier-2 Functionality and Development Sandbox Initiatives (Greenes) (green oval is my emphasis)


Glance at this BPMN 2.0 model of pulmonary embolism but then read the very interesting speaker notes.


“Developed with docs.
Started with pencil and paper workflows, then functional prototypes, then workflow.
Problem with prototype was, all of the logic was not evident.
We really had to work at it to get the docs to concentrate on the workflow and think through it.
They were immediately drawn in to the prototype, like watching a story. You have to think to work through workflow.
Each square here is a subprocess. X’s are gateways. Flowcharting on steroids. Flowcharting with semantics.
3 Levels in the the BPMN process: high level design, happy path; exceptional paths; wiring up services.”

Here are some random extracts from both sets of slides. Please go through the originals! All of the above and below is very much on the path toward what I call task and workflow interoperability AKA (subset of) pragmatic interoperability.

BPMN 2.0

Business Process Model and Notation 2.0
OMG Standard
Roots are in Graphical Modeling Environments for Business Processes
Version 2.0 => Computability
Requires Services
Used for Service Orchestration
Allows Construction of Applications by Integrating Services
Provides Standard Workflow Components
Provides Integration for Custom Services


My emphasis in green…


Framework has Internal Services (services used in managing workflow engine activity)

Start Protocol
Registers patient into protocol, records protocol status.
Save Protocol
Serializes protocol to storage.
Get Protocol State
Recovers protocols and protocol states for a given patient
Alert Service
Build and store Alert Event/attach to relevant user task
Get active user tasks
Finds protocol associated active user tasks
Complete user tasks
Signals completion of user tasks/updates protocol data


BPMN-Frameworks Consume Services (provided by EHR-based environment to workflow engine-HSP)

Patient Lookup/Retrieval
Clinical Data Access
Clinical Data Storage
Order Query
Order Communications
User Communications
Client Integration
Alert Delivery


Two Examples

Pulmonary Embolism Workup
Built using BPMN 2.0 authoring
Delivered using BPMN 2.0 runtime
Used Activiti (open-source version)
Pneumonia Protocol
Originally build in Java/Drools
Conversion to BPMN 2.0
Uses Complex Event Processing Framework


My emphasis in green…


Advanced CDS Delivery Framework

Standardized CDS management tools
Multi-component inferencing environment
Broad (standardized) data access
Access to key care-oriented services (ordering, etc.)
Multiple, flexible alerting channels
Standardized, component-based client environment
Formal workflow authoring/delivery system
Broad workflow logging system


TIER-2 BPM/CDS services

Current area of focus of subgroup – for care coordination / care pathway use cases
Focus on services to:
Identify possible care pathway(s) for a patient
Evaluate status of a patient with respect to a care pathway
Determine next steps/actions or need to change to another pathway
Orchestrate subsequent actions
Record data for tracking pathway status
Analytics for dashboards, outcomes reports, etc.

@wareFLO On Periscope!


Like a Hawk I’m Looking For Healthcare Workflow & Workflow Tech Stories at #HIMSS16: What’s Yours?

Every year, at the HIMSS conference, I’m a sharp-eyed HIMSS Social Media Ambassador hawk, scanning the exhibit floor for tasty morsels of workflow and workflow technology… I think that’s about as far as I’ll take this particular metaphor… 🙂

For over two decades I’ve been tracking diffusion of process-aware information systems, such as workflow management systems and business process management, into healthcare and health IT. At the 2000 HIMSS conference in Dallas I gave the first presentation about a workflow management system-based EHR. In 2010 I presented Process-aware EHR BPM Systems: Two Prototypes and a Conceptual Framework. Most recently I published three (3!) five-part series: BPM-based Population Health Management & Care Coordination: Workflow, Usability, Safety & Interoperability, Achieving Task and Workflow Interoperability in Healthcare, and Pragmatic interoperability: Interoperability’s Missing Workflow Layer.

Every year, as a HIMSS SMA, I tweet incessantly about healthcare workflow and workflow technology. Starting in 2011, I searched for workflow and workflow technology on every HIMSS conference exhibitor website. Beginning at a pitiful two percent, but then doubling every year to last years impressive 33 percent plus, I’m finally seeing the surge I’ve been predicting for many years. I can’t wait to find and tell great healthcare workflow and workflow technology stories.

What’s yours?

@wareFLO On Periscope!


Why I Love Being A #HIMSS16 Social Media Ambassador: Thinking Out Loud

I love being a HIMSS16 annual conference Social Media Ambassador (SMA). I’ve been three times, starting at HIMSS14. There are many reasons, perhaps as many as there are SMAs (20!). But if I had to pick a single reason, it’s the opportunity to learn about new health IT products and services, and then, basically, think out loud about them on social media.

I read somewhere, a long time ago, that the really great, memorable, conversations start from a simple but profound premise. Someone has a conversation with themselves, in their head, about something that interests them greatly. At some point, somehow, what’s happening inside their head and what’s happening outside their head intersects. In effect, they talk out loud, someone hears them, and takes a seat at the conversation table. That internal conversation may have been going on, gangbusters, for years. All of a sudden, it’s out there, perhaps fueled by someone else, who may also been having a similar conversation in their heads, gangbusters, for years.

If I look back what I’ve talked to myself about over the years — archeology (high school), artificial intelligence (college), cognitive science (grad school), health IT and workflow (now) — the really memorable conversations I’ve had, the ones I replay and savor, seem to come from this place. The problem was, they happened rarely. Maybe a couple times a year, max.

Today, though, due to Twitter (and increasingly Blab), and ESPECIALLY during #HIMSS14-#HIMSS16, sometimes I’ve had as many as six impossibly good Twitter conversations about healthcare workflow before lunch! Let’s see, at twice a year before, but 365 times 6 now, that’s over a gazillion percent improvement!

See you, online or in person, at #HIMSS16!

@wareFLO On Periscope!


Task Workflow Pragmatic Interoperability: The Coming “Workflow-ization” of Health IT

The following post was inspired by the topic of this week’s #HITsm tweetchat. It generated a robust conversation about healthcare interoperability and workflow. See select embedded tweets below.

What does interoperability mean to me?

Several years ago I wrote about the concept of Pragmatic Interoperability. Pragmatics is a subfield with in linguistics. You may have already heard of syntactic (message structure) and semantic (literal message meaning) interoperability. Both terms are borrowed from linguistics. Pragmatics is about non-literal meaning. It’s what we intend, even if we to not explicitly state that intention. The most famous example of this is, “Can you pass the salt?” The literal interpretation is that this is a question. The non-literal interpretation is that this is a request. EHRs and health IT systems are overly literal. Instead, they need to understand and facilitate. The area of linguistics dealing with understanding and facilitating is pragmatics. Pragmatic interoperability is compatibility between intended and actual effects of message. When I say something, or when I send you a message, I intend something to happen, for the world to change in some way, for some goal to be accomplished. If all of this happens, then my intentions are realized.

Pragmatic Interoperability is the missing third leg of the healthcare interoperability stool, currently teetering on the two necessary but insufficient legs of syntactic and semantic interoperability. The output of syntax is an input to semantics. The output to semantics is the input to … well, not much yet in healthcare and health IT. This is why we need to move beyond mere syntactic and semantic interoperability to complete interoperability, by including pragmatic interoperability. What is the most appropriate technology to implement pragmatic interoperability? Workflow technology: workflow engines, business process management (my five-part tutorial), and related process-aware information systems.

Who are interoperability’s stakeholders?

Interoperability’s stakeholders are health IT system users, most obviously patients and clinical care team members. Users don’t care about intricate details of healthcare message structure. They don’t care about intricate details of coding systems. But they do care, passionately, about making sure each and every step in their workflows are successful and whether their intended goals are accomplished. Sometimes those workflows must be facilitated or accomplished by other people in other organizations. This is why I wrote my 7000-word, five-part series last year on Achieving Task and Workflow Interoperability. Pragmatic Interoperability is the science behind that engineering piece. Pragmatic interoperability is simple enough for health IT system users to understand (do what I mean, not what I say), but powerful enough to guide creation of systems that do what we want, not just what we program them to do.

What is the role of regulators and interoperability?

A generally accepted view, with which I disagree, is that regulators create the standards necessary to achieve interoperability. Where standards are necessary, they should arrive from voluntary participation in industry IT associations. Government should fund standards research, pilots, test beds, and education. Creating standards should be left to developers who will use them. In particular, government mandate of standards, which may appear to be a shortcut to interoperability, usually just cements into place standards that would not otherwise survive.

How can interoperability benefit both patients and clinicians?

Both clinicians and patient have a job to do. The patient’s job is to get and stay well. The clinician’s job is to help the patient do their job. Interoperability helps patients and clinicians do their jobs. And what is the best way to help someone do their job? Understand their workflow and facilitate that.

Why has health interoperability been problematic?

In my view (definitely a minority opinion) several decades ago medical informatics and health IT came to a fork in the health IT road: whether to focus on data or to focus on workflow. Academia and industry has double-downed on data every since. As a result, health IT systems are essentially elaborate database systems with user interfaces created as an afterthought. The problem is that healthcare interoperability is really about workflow, not data. This is why I include “The Coming ‘Workflow-ization’ of Health IT” in the title of this post.

For the next five years, most health IT effort will be around building a layer of workflow management on top of existing EHR and related systems. Initiatives such as FHIR will play a role in making data available to this process-aware workflow layer. But many other APIs will participate too. In my opinion, FHIR’s significance is not that it is a standard but that it is an API. I am convinced that if the late, not so great, Meaningful Use program had never existed, we’d have fewer, but much more usable EHRs already with decent APIs. The best of these would have eventually taken over the market, instead of the current, problematic, less usable and open EHRs we have in place now.

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Some tweets from the tweetchat:

“The Whole Ethos of Workflow Is Power and Simplicity”: Mosquito In a Nudist Colony

This week’s #HITsm tweetchat about Simplifying Healthcare prompted this post about workflow, power, and simplicity.

From a user’s perspective, the simplest workflow or workflow system is one she or he does not have to initiate or engage, have knowledge of, or worry about task failure coming back to haunt her or him. The most powerful workflow system is one that provides the tools accomplish whatever the user needs accomplish.

The trick is to make the simple easy and the hard possible. This is what is missing in most current health IT systems today, especially EHRs. Workflow systems, AKA workflow management and Business Process Management (BPM) systems (and related process-aware technologies) provide both power and simplicity. Users can design workflows to do whatever they need accomplished (without having to themselves be programmers). And then these user-created workflows can be triggered automatically, without user input or knowledge or operation, with the confidence that if some workflow task fails, it will be escalated and dealt with.

By the way, the title of this post comes from Workflows for e-Science: Scientific Workflow for Grids. Here is the complete quote.

“The whole ethos of workflows is power and simplicity. Workflow systems must be capable of performing all the functions a user requires: otherwise users just won’t use them. But the same system should be simple to use, hiding complexity where appropriate.”

When it comes to simplifying healthcare workflow, we workflowistas are, as a colleague used to colorfully say, like mosquitos at a nudist colony, in a target-rich environment. Over the past five years, workflow technology has increasingly diffused into healthcare. But one particularly resistant area has been the EHR. Most EHR functionality and workflow was dictated and then pinned by Meaningful Use. The pent-up need for the sterling qualities of workflow tech — automaticity, transparency, flexibility, and improbability — may be met through the “API-ization” of EHR data, possibly through FHIR (Fast Healthcare Interoperability Resources). See my post suggesting FHIR tackle clinical task status.

Responsibility for managing workflow will be removed from EHRs. Healthcare tasks and workflows will be managed by external process-aware technology, as I predicted last year in my 7000-word, five-part series, Achieving Task and Workflow Interoperability in Healthcare.

Here are this week’s #HITsm topics (see you there!):

  • Topic 1: What areas of healthcare are ripe for simplification? #HITsm
  • Topic 2: How can we shift thinking to deliver simpler solutions for prevention, screening & treatment? #HITsm
  • Topic 3: How can we improve communication channels with patients? #HITsm
  • Topic 4: How do we engage #payers in the value of preventive care? #HITsm
  • Topic 5: What is one thing you can do to simplify care for yourself or your family members? #HITsm

@wareFLO On Periscope!