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:

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