Where Will SMART, FHIR, and Healthcare BPM Be, In Five Years?

During today’s HIMSS16 pre conference symposium Interoperability and Health Information Exchange Symposium: The Road to Interoperability I had the opportunity to ask Grahame Grieve (GG) and Josh Mandel (JM) the following question (paraphrased, as is their answer).

Question: I spend part of my time in the workflow technology industry, where non-programmers have been able to create entire applications by drawing or clicking to create workflows, for decades.

Given your goals of fast and easy creation of health IT apps, based on SMART & FHIR, in five years, do you envision users (not programmers), who know their workflows best, to be able to create their own workflow apps by dragging-and-dropping SMART apps interacting with FHIR.

Answer (conflating GG & JM): We need to observe how SMART & FHIR are used, but yes that seems reasonable within a five-year time frame.

Most modern BPM (Business Process Management) platforms already have sophisticated incoming and outgoing APIs. Many have means to extend the drag-and-drop tasks they support. It will be interesting to see which of the following comes true more quickly.

  • Health IT adds process-aware application architecture, such as workflow engines and workflow editors (I’m seeing this happen), capable of assembling SMART and FHIR-based sophisticated workflow applications.
  • BPM adds hooks so its sophisticated workflow orchestration engines and graphical workflow editors can assemble SMART- and FHIR-based components and functionality into sophisticated workflow applications.
  • Both! As in interesting mashups, such as BPM platforms integrated with traditional health IT, essentially outsourcing their workflow management.

@wareFLO On Periscope!


Improving the Patient and Provider Experience (w/BPM!): The Systems Behind the Smiles

I have been a vocal proponent of using workflow technology in healthcare long before EHRs were called EHRs and Business Process Management (BPM) was called Business Process Management. Back then they were called CPRs (Computer-Based Patient Records) and Workflow Management Systems. I celebrate every milestone and signal that process-aware workflow orchestration engines are diffusing into healthcare. Every year, for the past five HIMSS conferences, I searched every exhibitor website for BPM and “Business Process Management.” Guess what. BPM isn’t just diffusing, it is flooding into healthcare, if this year’s HIMSS16 exhibitors are evidence. For example, for the first year, the billion-dollar BPM “unicorn” Appian (booth #10430) has come to HIMSS16.


Just in time for HIMSS16, Appian has the best eight-page executive summary white paper on BPM in healthcare I have ever seen. Below is the beginning. I hope you will download and read the entire document. Then, let’s chat further about the incredible potential, already being realized at a growing number of healthcare organizations adopting modern Business Process Management, to quickly build secure desktop and mobile apps with automatic, transparent, flexible and systematically improvable healthcare workflow.

Improving the Patient and
Provider Experience: The
Systems Behind the Smiles


Not too long ago, we spoke of front-office versus back-office. The front-office dealt directly with customers. The back-office played crucial but supporting roles behind the scenes. Increasingly—and especially in healthcare—these layers are merging. Back-office systems are becoming front-office systems, as customers— especially younger ones—prefer mobile apps over human interaction. These trends dictate complete transparency of any systems directly or indirectly affecting your customer’s journey.

Healthcare is full of complex systems. Your customers—members, patients, providers, and partners—increasingly call the shots. Our challenge is to design, manage, and improve our systems so we can maximize their smiles.


Healthcare payers and providers have many different challenges. However, when it comes to the systems behind the smiles, all face four key challenges:

  1. Improving collaboration
  2. Sharing data
  3. Managing risk
  4. All while improving member and provider experience


In response these challenges and requirements, health plans are increasingly turning to modern Business Process Management (BPM) to quickly and easily create powerful software applications that can tie together systems and help deliver a unified—and overwhelmingly positive—customer experience.

From the Appian white paper landing page…

Download this paper, and you’ll:

  • Gain a better understanding of the four key challenges to overcome
  • Learn how you can break free of information and workflow silos
  • Gain insight into how to address evolving patient and member expectations

@wareFLO On Periscope!


An Expert Conversation on Patient Flow With Jason Harber, VP Product Management, Teletracking


A wide-ranging, in depth discussion on the challenges and opportunities facing the industry today.

Chuck Webster, MD, MSIE, MSIS has degrees in Accountancy, Industrial Engineering, Intelligent Systems, and Medicine (from the University of Chicago). He’s the ex-CMIO for a three-time HIMSS Davies Award-winning EHR. Dr. Webster currently serves as CMIMO (Chief Medical Informatics Marketing Officer) for workflow technology in healthcare.

Jason Harber, TeleTracking’s Vice President of Product Management is responsible for managing the direction for TeleTracking’s suite of industry-leading solutions. Jason has more than 10 years of experience in healthcare technology, data and analytics and product management. Teletracking is a HIMSS16! (booth 7410)

Q: Chuck, you are a trailblazer in the field of healthcare workflow and workflow technology. Your work is so relevant and meaningful to an organization like TeleTracking. How did you become so passionate about the subject?

Chuck Webster: For one year, during my graduate degree in industrial engineering from the University of Illinois, Champaign-Urbana, I gathered data and wrote a computer simulation of patient flow through the U of I student health center and hospital. They had a hospital with 24 beds—and they also had patient flow problems. I used old-fashioned time-stamp machines and gave every patient a green slip of paper, with the instructions that every time they saw a time stamp machine to stick the paper in it. For one week I observed people and then created a discrete event simulation. I remember thinking, what if I simply had all this time-stamped data, in real-time, all the time. Then people could actually change their workflows, and see, again, in almost real time, what the effects of the changes in workflow did to indicators like cycle time, wait-time and resource idle time.

Q: TeleTracking began as a mobile hospital bed status tracking company, but has evolved to include a wide range of services for enabling the timely delivery of care. Jason, can you elaborate on how these events unfolded and their influence on TeleTracking’s trajectory?

Jason Harber: When TeleTracking was founded in 1991, we were looking to reduce lag times in the bed turnover process with our inaugural BedTracking® product. BedTracking was so successful and that led us to realize that technology could move beyond housekeeping and have a positive impact on other departments. So in 2002, we expanded our focus to encompass the entire hospital and eventually to the development of core components like the TeleTracking’s Capacity Management Suite that centrailizes patient placement across multiple hospitals; the Patient Flow Dashboard™ and PatientTracking Portal™ to manage real-time status of enterprise operations. We went moved on from there to developing capabilities built around; and RTLS technology to advance workflows using real time location awareness. Building on on that success were products like Orchestrate™ for outpatient patient flow throughout the perioperative and ancillary care areas. The bottom line is a synergistic relationship between access and throughput—both must be in place for success.

Q: What does workflow mean in the context of patient flow? How much of a strategic imperative do you think patient flow is today and will become tomorrow?

Chuck Webster: “Workflow” is a catch-all phrase covering a wide variety of “flows.” My favorite definition is that workflow is a series of tasks, consuming resources, accomplishing goals. The biggest difference between patient flow and all the other kinds of workflow is two-fold. First, the patient can only be in one place at one time. Second, patient flow is strategically the most important of all the workflows. All the rest are in some sense subordinate and supportive.

Healthcare is moving from a provider-centric, cost-for-service system of relatively unmanaged workflow, to a more patient-centric, value-based systematic management of workflow. Given that patient flow is the most important kind of workflow—its metrics and technologies for improving them—will inevitably become an increasingly important strategic concern for healthcare enterprises.

Q: Explain which TeleTracking products and services fit together with other hospital IT systems to drive healthcare workflow in real-time?

Jason Harber: We create systems that alert healthcare workers to changing circumstances and give them the information they need to do their jobs and deliver quality patient care. And we recognize that hospitals use a range of systems to help deliver that care, which is why we have more than 80 integrations. This type of interoperability among all health IT systems liberates an incalculable amount of caregiver time, enabling a reallocation towards more purposeful care.

By managing capacity and throughput, we are examining the admitting and discharging process, as well as the workflow at a clinical and procedural level. And we will continue to build on our capabilities, as we launch our OnCall Scheduling and Behavioral Health products. Both products provide additional data to help with managing access and throughput. Our Community Access Portal suite will eventually coordinate with electronic health records, so all the data on a patient will be in one place.

Q: Consolidation seems here to stay, at least for the foreseeable future. As health systems consolidate and sub-specialize, what role can workflow play in improving patient access? Have you seen particularly innovative and/or effective examples in this?

Chuck Webster: I saw lots of innovative examples of effectively leveraging workflow within and between healthcare organizations to improve patient access and experience at the 2015 TeleTracking Annual Client Conference.

During the TeleTracking conference I tweeted: “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 is immediately sent somewhere useful.
  • By “patient & task state” I mean tracking not just the location of people and objects, but also tracking patient status changes
  • 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

All three of these ingredients—events triggering workflows, tracking and influencing patient states, and doing so within and across healthcare organizations—are incredibly important to freeing and mobilizing staff to improve patient access and experience.

Q: Speaking of event-driven propagation and patient states, Jason, can you describe Orchestrate™ and if there are any plans to expand its use beyond perioperative workflows?

Jason Harber: Orchestrate is an application that provides the technical and process management tools to improve patient flow throughout perioperative and ancillary care areas, and helps ensure a hospital maximizes its most valuable resources to full capacity. It also helps staff maximize the amount of time a patient is receiving clinical care, versus dealing with administrative tasks. With Orchestrate, unique workflows are possible because we’re aware that one size doesn’t fit all. The current market is operating rooms and cancer centers, with a growing installation base in other clinical specialty areas.

Q: Continuing with the idea of Orchestrate. Two important workflow terms are Orchestration and Choreography. Orchestration implies a workflow “conductor” in analogy to the conductor of an orchestra. In contrast, choreography is about distributed workflow control. It’s like a jazz ensemble in which all the musicians have workflow rules in their heads and watch each other and react constructively to each other. The musical workflow emerges out of this synergy. Comments?

Jason Harber: With our primary applications, there is no true conductor. We are acting as choreographers across stakeholders. Our TransferCenter product – with a referral network from patient placement to nursing – works because all of the parties are engaged and on board. There are set boundaries and defined responsibilities. With Orchestrate there are multiple roles, but at the same time, people have the autonomy to make informed decisions based on the current conditions.

There is always a base process that helps establish a base workflow and measurable outcomes. However we also build in the appropriate degree of flexibility that allows people do their jobs and respond to changing situations.

Q: TeleTracking IQ™, the new cloud-patient workflow platform, debuted at the 13th Annual TeleTracking Client Conference. What is it, what does it do, and do you have any updates on its status?

Jason Harber: The introduction of TeleTracking IQ demonstrates TeleTracking’s continued focus on enabling timely and purposeful patient services across the healthcare continuum by providing a streamlined user experience. The TeleTracking IQ platform also augments the investment that hundreds of hospitals and health systems have already made in TeleTracking’s industry leading patient flow solutions. Our users are empowered to take their capabilities to the next level.

TeleTracking IQ offers significant advancements in user experience. Solutions will share common information and workflows, so users will not have to navigate among multiple products unnecessarily. For example, health systems that use TeleTracking to manage transfers, referrals and direct admits will have one comprehensive view of access management that incorporates other tools that support their workflows, such as a view of the physician on-call schedule and a Community Access™ Portal for referring physicians.

Q: How does TeleTracking real-time event-driven workflow technology improve patient experience?

Jason Harber: TeleTracking delivers an operational platform and proprietary set of capabilities backed by 25 years of expertise in patient flow. Frequently observed outcomes include a 10% – 20% increase in patient volumes while reducing length of stay, improving utilization of health system capacity & resources, and reducing wait times and call volumes. This means hospital workers can deliver the right care, from the right provider, to the right patient at the right time.

Q: The teams at TeleTracking spend a lot of time thinking about the notion of “timely and frictionless” patient and caregiver experience. And we do that, among other things, by examining the proportion of time spent on non-purposeful activities. Patient boarding, diversions, late starts, manual data search / entry, countless phone calls and poor care coordination are things we hear about. How big is that impact and what are healthcare leaders failing to take into account as we try to solve for it?

Chuck Webster: Ten years ago everyone was trying to figure out how to implement EHRs without decreasing productivity. Today, everyone is trying to figure out how to leverage EHRs to increase productivity, a subject smack dab in the middle of your question.

Value-added activities (your purposeful-activities) are typically those that someone will pay for. Hospital patient stays and encounter lengths are determined by a combination of value-added and non-value-added activities. Value-added activities include collecting data that may be used in a future decision or making a decision that affects the welfare of the patient. Non-value-added activities include navigation from screen to screen and searching for the next person to handover the next activity in the encounter. If these non-value-added activities, and the time required to accomplish them, can be eliminated, both hospital stay and encounter length can be reduced.

I think almost everyone, including myself, suspects the impact of these non-purposeful, non-value added activities is enormous. The crucial ingredient has always been, and will continue to be, time-stamped clinical and administrative workflow data, such as what TeleTracking collects and leverages, since this is the data from which cost of labor and tied up physical resources can be most accurately estimated.

Better Patient Experience Through Structured Messaging and Workflow Technology

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Hello. My name is Chuck Webster. Welcome to my webinar, Wellness Through Workflow: Structured Messaging Contributes to Better Patient Experience. An alternative title could be Structured Workflow Contributes to Better Patient Experience, but I will be using the specific example of structured messaging.

Here is the outline. A little bit about who I am. Then this idea called the system behind the smiles, the relationship between patient experience and healthcare workflow, what I call healthcare’s “workflow wall”. Finally, how can structured messaging help?

I’m an odd duck, I have a lot of degrees. My mother says I’m killing myself by degree. Medical degree, I also have a Master’s in Industrial Engineering, where I focused on workflow usability productivity. My Medical Informatics degree was in Intelligent Systems, and I’m the only premed Accountancy major I ever met, or I majored in Cost Management Systems and MIS. I did design the first undergraduate degree in Medical Informatics, and I was Chief Medical Informatics Officer for an EHR vendor for over a decade, where I helped the three medical practices win the first three consecutive HIMSS Davies Awards.

I’m extremely active on Twitter, and there’s a kind of a virtual drinking game, where if someone’s at a conference, or they read something, and it’s about workflow or healthcare workflow, or healthcare workflow technology, they tweet about it and they mention me, @wareFLO.

What we have here is a hashtag, which I have been using for about four years, and I also have various social badges. #POWHIT, People and Organizations Fixing Workflow with Heath IT. That’s kind of a reference to the old Batman show, pow, hit. If you tweet about this webinar, or during the blab, I hope you’ll use #POWHIT. I’ve got about half a dozen folks, now, who are starting to use it, and it’s all about the folks in the white hats that are rushing to fix workflow in healthcare.

At the top of the hour, join a blab. It’s kind of like Google Hangouts and Twitter had a beautiful baby. It’s a lot of fun. All of this, the @wareFLO, blab workflow, HIT #POWHIT will be in all of the slides, works best in Chrome. That’s that middle URL, and I hope to see you there, because you can actually take a seat and tell us a little bit about yourself. The subject, this just an example, but the subject is any aspect of healthcare workflow and patient experience.

Take me to the next post in this series: The Systems Behind The Smiles: Patient Experience.

The Systems Behind The Smiles: Patient Experience

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There is this idea, in the hospitality industry, in the hotel industry, luxury hotel industry where my wife works, and it’s called The System Behind the Smiles. When you arrive at that hotel, you walk in, the bellman greets you by name. You walk to the front desk, you’re in you’re room in ten minutes, everything works perfectly. All of the staff is well-trained, radar on, antenna up, they can see anything that you need and it’s right there. Well, guess what? There’s an incredibly system behind the scenes of databases and workflows that make this all possible, and that’s The System Behind the Smiles.

The System Behind the Smiles comes from a book, in 1990, called Customers for Life: How to Turn that One-Time Buyer into a Lifetime Customer, by Carl Sewell. This is the only thing I’m going to read word-for-word, quote-wise. “What’s needed in restaurants, car dealerships, department stores, and every place else is systems–not just smiles–that guarantee good service. Every business is composed of systems. These systems must work together to create a process that is efficient and responsive to a customer’s wants.”

About fifty percent, roughly forty to sixty percent, of customer experience, patient experience, is due to the actual, face-to-face or on the phone, interaction with some staff member or customer service member.

That means that the other fifty percent, forty to sixty percent, is due to things that are not under the control of that front-line staff person. These are the workflows and the systems that are behind the smiles. These are the backroom enterprise transaction systems. When you make a reservation at the hotel, you make a reservation online for the airline. You go there, the reservation is in place, you get your seat, you get your room. All of that has to work, that is absolutely critical to making sure that the folks on the front of the line can deliver, are free to basically live the visions and ideals of their organizations. They can count on these workflows working every time.

Take me to the next post is this series: The Workflow Behind The Smiles: Patient Experience.

The Workflow Behind The Smiles: Patient Experience

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Today, industrial engineers, and I have a Master’s in Industrial Engineering, they’re changing their name to Systems Engineering. When you’re a systems engineer, and you start talking about improving systems, basically, what systems engineers do, is they replace every word that is “systems” with the word “workflow”, because as soon as you start talking about workflow, you’re starting to talk about actual sequences of things. There’s all kinds of tools to help you improve those workflows.

What’s the relationship to patient experience? Folks are developing mobile apps for patients to interact with, and folks are coming in and doing, kind of, sophisticated “Charm Schools” for the folks that are interacting with the patients. I’m going to talk about this back-end stuff, but let’s start with probably the most famous, and prevalent, and popular definition of patient experience, from the Beryl Institute. “The sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care.” If you drill down on each of these four areas, Beryl also defines those.

Let’s take a look at the stuff in the middle here, the organization’s culture to influences patient perceptions. That culture is made up of vision and values, with then inform the attitudes, and demeanor, and training, and behavior of that front-line staff, interacting with the customer or the patient. The perceptions, that’s the other half, that’s the patient reacting, saying, “I recognize this, I understand this, I remember that.” Those are the smiles.

The systems is the rest of that definition. The sum of all the interactions across the continuum of care. If you drill down and grab the description of interactions, and the description of continuum of care, from the Beryl Institute, put them together, you get this. The orchestrated touch-points of people, processes, policies, communications, actions, and environment, before, during and after the delivery of care. The key word here is “orchestrated.” Orchestration is a very important word, it is a important part of the terminology of the workflow, and the workflow technology industry.

One way to understand orchestration is to contrast it with choreography. Orchestration implies some sort of central workflow conductor. You’ve got the conductor up there, they’re waving their want, and everybody is kind of doing what they’re told to do. In software, that’s often a workflow engine, which we’ll talk about in a little bit, but they can also be a human, a human care coordinator, who is facilitating these workflows. Choreography is about distributed workflow control, so there is no conductor, it’s like a jazz ensemble, and everybody has a set of, kind of, workflow rules in their heads, and they’re watching each other, and they’re doing a kind of a dance.

Modern workflow systems tend to be hybrids of orchestration and choreography. Some are very much toward orchestration, but they still have some choreography. Some are very much about peer-to-peer choreography of workflows.

Take me to the next post in this series: Health Information Technology’s “Workflow Wall”: Patient Experience.

Health Information Technology’s “Workflow Wall”: Patient Experience

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We have invested tens of billions of dollars in health information technology and electronic health records over the last several decades. I believe that we have hit what I call the workflow “wall”. The workflow wall is the invisible workflows, that is, you can’t see task status, you don’t know what’s going on, all these black boxes around us.

The inflexible workflows, you can’t change them, because they’re hard coded into the software. They’re ineffective, they’re not achieving the goals we need them to achieve. They are inefficient workflows, that is, they consume too many resources when they are executed.

This has created what I call workflow discontents. If you go to a healthcare industry, or particularly a health IT industry conference, you may see people talking about workflow, it may be in some abstracts. For sure, when you walk down the hall, you will hear the word workflow, it’s like a cocktail party effect, where you hear someone mention your name across the room. You walk down the hall, and every thirty seconds you’ll hear “Workflow, workflow, workflow.”

Let’s say you have a problem, pollution, you have a pollution problem. Guess what, then you have pollution technology. Well, healthcare has a workflow problem, so we need to use workflow technology. In the academic research realm, the folks who study workflow technology, call these “process-aware information systems”. Process aware means that there’s some kind of model of the process or workflow, and aware basically means, not that the software has consciousness, but that it can inspect that model, and it can refer to that model, and it can reason with that model in order to facilitate, and make these invisible workflows visible, flexible, effective and efficient. Structured messaging is an example of workflow technology and process aware information systems.

This is the only slide that’s full of statistics, and it’s really to drive home the point, that this is an important problem, and there’s a way to characterize it.

First of all, fifty percent of all healthcare errors are due to slips and lapses, such as not executing some intended or an interrupted action. This is called perspective memory. Perspective memory is when you say, “I need to do something next, or eventually, and you intend to do it. Then later, you remember that you intend to do it, and then you do it. Obviously, if you forget to do it, that can be a problem.

Almost fifty percent of interruptions affect direct care tasks. About fifty percent of pages to physicians interrupt direct patient care, and almost fifty percent of pages are non-urgent. You’ve got almost fifty percent of pages, non-urgent, and they are causing interruptions, which can lead to healthcare errors. These errors may be serious, in terms of outcomes, but they also have dramatic impact on patient experience. “They forgot me,” or, “They forgot about this,” or, “This took too long.” Those affect patient experience, and that’s the system behind the smiles.

Take me to the next post in this series: The Workflow Technology Prescription: Patient Experience.

The Workflow Technology Prescription: Patient Experience

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Over the last couple of decades, I’ve noticed that whenever there’s a big, sort of, societal problem, someone will eventually get around … The problem is called “X”, and someone will write a book called The “X” Prescription, how are we going to solve the problem. I often tweet this picture of The Workflow Prescription. What is the workflow prescription?

Let’s start with what is workflow. I have seen literally hundreds of definitions of workflows, over the two or three decades that I’ve been interested in the topic. I have seen definitions that would span two PowerPoint slides and used tiny font. The very simplest is simply, a series of steps. I like this definition, it’s mine, and it is workflow is a series of steps, consuming resources, that’s cost, and achieving a goal, that’s benefit.

Let’s break it down. Series of steps, tasks, activities, so they’re called different things. If you’re an anthropologist, and you go into someone’s home, and you are diagramming their life flows, and they create process maps when they’re trying to understand how folks, for example, are using various products. They may not call them tasks, they may call them activities.

Consuming resources, or costs. These costs are not just the healthcare system’s cost, but these are the patient’s money, attention, and time costs.

Then you’ve got goals, these are the benefits, costs and benefits. Workflows exist in an economic environment. When that economic environment changes, the workflows need to change. However, there are many reasons why it’s difficult to change healthcare workflows, in the ways that would maximize the ROI, maximize the benefit/cost ratio.

By the way, process and workflow are often used synonymously, not always, and the meaning is usually clear, from context.

That was workflow, what is workflow technology? Generally, informally speaking, any technology that intentionally facilitates workflow is workflow technology, but narrowly, technically, if you’re a workflow professional, a workflow technology person, workflow technology involves models of work. These models of work are executable, meaning a computer program can look at that model and execute it just like some computer code, just like an if/then or case statement. The models can be of work or workflow, workflow tends to be sequences of things, work tends to be hierarchies of goals. Consultable means these models can be understood and consulted by a human, so that you can look at it, and inspect it, and say, “Oh, I see what the status of this task is,” or, “I see what needs to change in the design of the work or the workflow.” Consultable also means by the computer, because even if it’s not executing the model, the computer may use some model of work to interpret, for example, analytics.

These models can usually be visually represented. In the business process management industry, you have lots of systems that allow you to draw workflow diagrams, and you turn a crank, and an application comes out. Instead of writing Java, C# and MUMPS code, you draw the workflows. Workflow technology also includes calendar systems, where non-programmers are creating rules, that are running against the calendars, to route messages and escalate, and also dynamic checklists. Checklists are big in healthcare, but if you implement those checklists in such a way that all of the items are smart, and they can detect which things have to occur in a different order, that’s an example of workflow technology, too.

What’s the difference between workflow technology and information technology? Information technology certainly influences workflow, every piece of software has “workflow”. My mother, who was an English teacher, drilled into the difference between affect and effect. Affect means to influence something, maybe positively, maybe negatively. Some software makes workflow better, in healthcare, some software does not. Workflow tech is intentionally designed to effect workflow, that is, it drives workflow, it pushes tasks to the right person, checks to make sure that they’re done, and so forth. It’s kind of like Jean-Luc Picard, in Star Trek, saying, “Make it so.” That’s workflow technology.

Here’s another difference. Information technology in health IT often hardcodes workflow. What does that mean for workflow to be hardcoded? It means that, after you compile the program, in the software factory, back at the vendor, and then you send it out, and it starts to execute. All of it’s behaviors are already inside the program, they’re already compiled down. It doesn’t consult much in its environment when it executes.

Softcoded software, such as workflow technology, softcodes workflow, so as the program executes, instead of just consulting some value that’s hardcoded into the program, it reaches out into a database, or reaches out into the environment, and at run time, this changes the order of things, this changes the business logic. People who aren’t programmers, people who aren’t Java, C# folks, can change the workflow behavior after you implement the system. It’s important to get the folks in the workflow, the clinicians and so forth, involved in the design at all aspects, not just before you implement, but even after to implement it. In order for that to be true, the software has to softcode workflow, so that those changes can be tweaked after the implementation.

Take me to the next post in this series: Four Benefits Of Structured Workflow and Messaging: Patient Experience.

Four Benefits Of Structured Workflow and Messaging: Patient Experience

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What is structured messaging, which is an example of workflow technology? You pre-build these message structures, and you can think of these message structures as kind of like simplified forms, that folks are very familiar with in healthcare. You send that securely over the internet, and these messages can occur in strings, back and forth, conversations. These are the workflows, these are the steps, tasks, activities.

Because you are using the same set of structures over and over again, same message types, over and over again, folks become familiar with them. When it arrives, they know exactly where to look to find the information they need, if the workflows and the forms are designed correctly. They can be, because you can change them, even after you’ve implemented.

All of this familiarity leads to both speed and accuracy. Speed is important because the faster you interact, the more throughput you can get. For example, if it takes, instead of four hours, from beginning to end of a workflow, from beginning to end of a case, if you move that to two hours, you’ve effectively doubled your capacity. Accuracy, it’s more consistent, and because you can track the task status, you can make sure that nothing languishes, or fails to be done. This combination of structured data and structured workflow facilitates automation through workflow technology.

The three major components, pieces, of structured messaging, in a calendar model, are forms, these are the forms that I just talked about. You’re sending these out, and instead of people having to type a lot of text, and then to remember what it is they need to type, and then they have to look at it and they have to interpret it, because it is structured, you have what’s called recognition memory instead of retrieval memory. Retrieval memory, you have to remember what to create. In recognition memory, you have an enumerated list of possibilities, and you choose whichever one you recognize to be correct, it might be yes, no, please ask me again when I get back to the office, that sort of thing.

Then you have the calendar. Shared mental models are so important for team behavior. If you’ve ever talked to someone about your calendar, even though there’s no calendar in front of them and there’s no calendar in front of you, there’s calendars in both of your heads, they’re like virtual calendars, and you’re using it as a shared mental model, to talk about whether you can meet up or not. Shared mental models need to be shared, not just among the humans, they also need to be shared with the software. It needs to be at high enough level that the humans can understand it, but low enough level that the workflow engine can consult it, and a calendar is an ideal model for that.

Then you’re got the rules. The rules are proactively watching for certain conditions to happen. Someone needs some care, and you check in the calendar, you see who’s available, if they’re not available, you use a rule to route it to the back-up, and then you check later to see if they answered, and if not, you escalate, those are the rules. Forms, calendars and rules.

This is kind of a pictorial representation of that. On the left we’ve got the calendar. This is the shared mental machine model. On the right we have these forms, and these forms aren’t just about text, they can also contain images, audio. These rules and these forms, the user interface and the workflow, is softcoded, so that means that once you implement it, folks who aren’t programmers can change the workflow behaviors.

What are the major benefits of structured workflow? Number one, automaticity. Because you have a workflow engine, and it’s in the software, instead of a human workflow engine, it’s a software workflow engine. It can recognize and be triggered, and do things without manual human intervention, although this can be overwritten. If the workflow engine consults a rule and sends you something, and maybe someone didn’t code something right, you can always say, “Well, no, that doesn’t apply to me.” If you don’t, then there are fallback rules in this logic.

Then you have transparency. Because every task goes through the workflow engine, that means the task is both time-stamped, and the workflow engine keeps track of the status. “Is it pending? Is it in process? Has it been completed? Is it languishing? Has it been forwarded to someone else? Has it errored out? Has it been cancelled?” All this information is available, and it can be viewed by the members of the team, that can see, “Okay, I see this task in our group, and Joe, who usually does it, didn’t do it, so I guess I’ll have to do it.” The workflow status can be viewed in reports by the supervisor, so they can say, “Show me all the outstanding tasks that have languished more than five minutes,” and they can be seen by the administrators, who are keeping the system running well.

It is this task transparency that allows you to compensate for interruptions. Instead of a human saying, “Oh, I need to do this later,” and they forget, the workflow engine knows that you haven’t done it, and it can remind you.

Flexible. Workflow engines don’t just do what workflow engines do, they consult these workflow rules. These workflow rules are out there in the environment. They can be changed by the administrators and the supervisors. They tell the workflow engine what to do, they are softcoded. Therefore, when you change them, the workflows change.

When you put together transparency and flexibility, you arrive at improvability, because you’ve got this time-stamped task data out there, you can use it, using a variety of tools, to find and eliminate bottlenecks, rework or redundancies, doing things over and over again. This can be used both to improve cycle time, reduce the workflow from four hours to two hours and double your capacity, and increase consistency, that is vastly increase the likelihood that the task will eventually be accomplished within a certain window of time.

Those are kind of essential aspects of architecture, but you also have to be concerned about these sort of value added ons. It’s not just text in the form, you also have voice, images, radiology images, for example. Then you need to able to convert, so if you try one channel, by voice, and they don’t respond, well, maybe you need to text them.

As is the case with many add-ons today, you’ve got to integrate with EHR, that’s happening. Particularly, tasks that happen in the EHR may need to cause things to propagate up through the structured messaging system.

Of course you need HIPAA compliance. Then, there’s cross-platform. Because these systems are sending data to either Android, or iOS, or to the desktop, you have the option to use your own device, that’s the bring your own device phenomenon.

Finally, this may seem redundant, so why am I mentioned intelligent message routing and escalation again? Well, you want content. Just like picklists of drugs and codes are content, workflows are content, too. When you get that structured messaging system, you want to have a set of routing and escalation workflows already, sort of … Other people have been using them, and they work great, and then they work great for you, you don’t have to create them from scratch, and you can tweak them further.

Take me to the next post in this series: What If We Had Automated Workflow Before Data? Patient Experience.

What If We Had Automated Workflow Before Data? Patient Experience

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Here’s a thought experiment, I think what Einstein called a “gedankenexperiment”, and that is, what if … Take a time machine back ten years ago. What if we had started automating workflow instead of data? What an absurd idea. I mean, how is that possible? Don’t we have to have all this data? Well, in fact, I’ve done some consulting internationally, and there are a lot of companies that have watched what has happened in the United States over the last couple of decades, and they’ve kind of, just like in the model of you skip the telephone poles, and go directly to satellite phones? Some of them are saying, “You know what? What we need to do is understand the workflows first, and then only gather the data we need to accomplish the workflows.”

Today, we have all of this data and all of these databases, basically, EHRs are kind of databases with UIs slapped on them. We have this data, and people are saying, “I don’t want all this data, I want actionable data.” Whenever you hear the word actionable data, think workflow technology.

This is consistent with the famous advice from Covey, 1989, “Begin with the end in mind.” This is exactly the way industrial engineers are trained. You go into the factory, you figure out, “Here is the product, in the box, that’s being sent to someone. Now we work backwards.”

Down at the bottom here we have data, which is a very important resource. It costs money to obtain it, it costs money to stick it into the workflow. On the right, here, we have goals and benefits. That’s the end in mind. We’re trying to lay down, across all of this data, a whole bunch of workflows, to take advantage of it.

If we had done it differently, we would have done it this way. We would have started with the end in mind, we would have said, “What is the penultimate step, before the end, and what is the data that we need?” Then you say, “What is the step before that, and what is the data we need?” Then you finally get to where you are, or where you typically would be.

Instead, what we have is this situation. We’ve got all of these databases out there, we’re collecting all of this data at the point of care, and we’re trying to lay down on top of it a set of workflows to take advantage of it. It’s a lot harder to lay down all this patchwork workflow, kind of whole cloth, without following that end to start model.

What order makes sense? I’d argue adding data to workflow, but we’re kind of stuck, right now, with adding workflow to data. That means we need extremely flexible workflow technology to adapt, to lay down, to compensate for and take advantage of all of this existing data investment. This is an excellent argument for structured messaging, for example as a platform. A platform is a set of constraints and resources that you can just count on, when you’re building some other system on top, and that is the workflow platform that, I believe, in the next five years, we’re going to see dramatic investments in a variety of workflow platforms, kind of laid down on top of the data systems we have in place, and structured messaging is one of them.

Take me to the next post in this series: Workflow Engineering Patient Experience & Engagement.