Healthcare Design Thinking and Usability Need Engineering and Workflow

[Thank you to @HealthStandards and @uuability for hosting this week’s #HITsm tweetchat on Usability Gaps in Health IT and prompting this blog post!]

Usability and design thinking are currently hot topics in health IT. They should be. In fact, they should have been for a long time. However, contrarian that I am, I have a bone to pick.


But first, my bona fides. I started out as an engineering student, where I took not just traditional engineering courses, but courses in systems and engineering design. I transferred around a lot but eventually got a masters degree in Industrial Engineering, where I focused on human factors and workflow. One of my advisors wrote the first textbook on human-centered design.

The origin of design thinking is attributed to Herbert Simon’s seminal book The Sciences of the Artificial. I attended Simon’s lectures at Carnegie Mellon years ago (here is a blog post about how his ideas influenced me). I’ve talked design with Don Norman (and written about his mixed feelings toward user-centered design).

Over the years I’ve designed (and written code for) EHR software still in use today, as well as designed or “debugged” innumerable healthcare workflows relying on workflow technology.

The bone I have to pick? Design thinking and usability engineering don’t have enough engineering or workflow substance to be the success they might otherwise become. I am not alone in this assessment (Engineering as a Driving Force Behind the Design Thinking Movement).

One does not have to have an engineering degree to design usable products and systems. However, I believe, you do have to be able to do what engineers do — it is in fact intrinsic to our self identity — build stuff! I was an industrial engineer (now called systems engineering in healthcare), so I built workflows, not cool interactive robots like my mechanical and electrical engineer cousins. However, technology and society have so evolved since then that almost anyone can build stuff today, even cool interactive robots. So much so, that now, I too, build robots, using 3D printers, microprocessors, sensors, actuators, and software.

Users need to make the systems they use. In other words, users need to become creators, or Makers in popular parlance. In healthcare and health IT, this means designing, tweaking, and improving the workflow in which they are embedded.

But engineers can’t build something out of nothing using nothing. Engineers need tools with which and platforms on which to create. This is why I am a proponent of workflow technology. If you know your workflow, and you know how to use a computer, but are not yourself a programmer, then you can design your own health IT application workflow… if … health IT applications are themselves built on workflow platforms. Today these systems have various names, process-aware information systems, business process management, and case management systems. But many other IT platforms currently diffusing into healthcare and health IT also embed the most important characteristics of a process-aware information system, some sort of representation or model of work or workflow, plus some sort of engine to interpret the model. It is often called a workflow or process orchestration engine. Similar, by analogy, to how a software language interpreter interprets lines of code, a workflow engine interprets a description of workflow, to drive health IT software application behavior.

Given the above context (bona fides, plus philosophy and tutorial) here are my answers to this week’s #HITsm questions regarding health IT usability.

Topic 1: Why is usability in healthcare so important? #HITsm

Usability is important because safe, efficient, effective, satisfying workflows are important.

Topic 2: What are some common myths about usability and UX in HealthIT? #HITsm

The number one usability myth has to do with direction of causality. Systems don’t have good workflow because they are usable. They are usable because they have good workflow.

The number two usability myth is adding usability experts to workflow-oblivious software (read, “process-unaware”) can dramatically improve usability of that software. If you can’t change the workflow you can’t make it more usable (at least not dramatically so). There’s a major health IT vendor out there that proclaims their software is usable because they employ 300 usability professionals. Wow! They need 300 usability professionals… I wonder why? Again, please consult myth number one. Usability does not create workflow. Great workflow creates usability.

The number three usability myth is great workflow can be achieved without workflow technology. In other industry when there is a problem, say, pollution, you often see technology to fix or manage the problem named after the problem, as in pollution technology. Healthcare has a workflow problem. It requires workflow technology to fix or at least manage.

Topic 3: Has the ONC “Safety-enhanced Design” requirements helped or hurt the Usability of EHRs? #HITsm

Top-down usability certification hasn’t made much difference because it cannot make much difference, without the underlying health IT software in use become much more automatic, transparent, flexible, and improvable, in a workflow sense. Usability can’t cause these things. Usability is caused by these things. Unless and until health IT moves to more process-aware workflow platforms (which, BTW, is happening, though not fast enough), these sorts of efforts are doomed to frustrate all involved.

Topic 4: What are some additional areas (gaps) in usability of EHRs? #HITsm

Lack of use of workflow thinking and workflow technology.

Topic 5: Medical mistakes are the 3rd largest killer in the USA. What can we do to stop usability issues from killing our fellow citizens?#HITsm

Adopt more workflow technology, so the underlying software can be improved through a variety of means, including usability engineering techniques. See my post on patient safety and process-aware IT.

Thank you to both @HealthStandards and @uuability for hosting this weeks #HITsm chat, and giving me this opportunity to gnaw away at some favorite ideas!

P.S. Oh, by the way, some of the leading figures in the design thinking movement agree with me!


@wareFLO On Periscope!


2,241 Tweets from 321 Tweeps With 5,497,584 Follower Reach at Appian World 2016!

I just returned from the Appian World 2016 BPM (Business Process Management) conference in Washington DC. As usual (been to every one since 2008) it was super stupendous great. Every year there are more folks from healthcare and health IT, which is also super stupendous great. Here is a blog post I wrote about one of the healthcare presentations, Putting (Healthcare) Data to Work (using BPM) for Service, Efficiency and Compliance.

Twitter stats rose 17 percent over Appian World 2015. Here’s a bit of a drill down.

Tweets including #Appian16 OR #AppianWorld topped out in the 800s during the main two days of the Appian World 2016.


  • 2,241 Tweets
  • 321 Tweeters
  • 5,497,584 Reach (Tweeters x Followers)
  • From 152 Locations


Congratulations to Appian World’s most prolific tweeters!


Ha! Ayax, I beat you by one tweet! (what a great selfie!)

And there were tweets in at least 8 languages! I’m trying to find those Swedish and Finnish tweets…


Predicting the future is always dangerous, but I can confidently predict even more healthcare and more tweets at Appian World 2017 in Miami Beach.

@wareFLO On Periscope!


Putting (Healthcare) Data to Work (using BPM) for Service, Efficiency and Compliance

I just live-tweeted a general session at Appian World about using the Appian Business Process Management Platform in healthcare, specifically by AmeriHealth Caritas, a Medicaid managed care company in 19 states. Phillip Merrell (VP, IS Strategy & Shared Services) was so good I’ve archived my tweets as a sort of notes slash blog post. Most are self-explanatory, relying on tweeted slides. Several are a bit terse, more reminders to myself, so this is also an opportunity to unpack and provide some context.

Healthcare and health IT is extremely focused on collecting data. Business Process Management technology can make sure that data is good clean data, not bad dirty data. Then, BPM can be used to make that data actionable, so that good clean data can trigger all the right processes and workflows necessary to systematically improve population health.

Process management, making sure processes do what the healthcare organization needs and does so correctly every time, is integrated into the Appian BPM Platform. Instead of separate, disjoint, databases forcing users to switch from application to application to application, BPM knits together data from multiple sources into coherent workflows, across users, departments, and even organizations. This knowledge of workflow guides what is automatically presented to who and in what manner, so as to minimize user effort. Stuff, the right stuff, happens automatically.

Regarding that “workflow layer above data layer”, I’m referring to the capacity for BPM to make data come alive, and to knit together disparate health IT applications. In fact, I recently wrote two five-part series on exactly this idea! Check out the following to entry points to those 7,000 and 10,000 words series, respectively.

Anyway, Phillip’s presentation was a virtuoso display of the understanding and articulation of the forces of change leading toward more use of Business Process Management technology in healthcare!

P.S. By the way, Phillip referred to a conversation with me the night before about consolidation in healthcare: Thanks for the shout-out! 🙂

@wareFLO On Periscope!


Ben Moore, CEO, TelmedIQ, on Why Secure Text Messaging Apps Aren’t Enough

Every year, for the past 6 years, I systematically (some say obsessively) search for examples of workflow technology at the annual HIMSS conference. Six years ago, not much. This year, lots! For example, Ben Moore (CEO, TelmedIQ) spoke about, Why Secure Text Messaging Apps Aren’t Enough, in the Mobile Health pavilion. It was a fascinating mix of information technology, human communication, and classic process improvement themes. In fact, HIMSS tagged it Process Improvement, Workflow, Change Management. The first thing that caught my eye was this quote from its description:

“Many organizations, however, are finding that secure text messaging apps fail in healthcare environments because of their inability to recognize complex communication workflow underpinning patient care coordination” (my emphasis)

Next, there’s this slide:


I’m not going to go through TelmedIQ’s messaging architecture box-by-box, except to point out two things. First, the box in the lower right (workflow engine sighting!). And second, it bespeaks an extremely sophisticated software architecture, with lots of hooks to legacy and other health IT systems. I’d love to have a conversation with Ben someday, in which we visit each layer and component. I suspect it would illustrate just how much secure structured messaging is becoming a multi-functional platform. TelmedIQ certainly meets my definition of a Care Workflow Platform.

Here are my notes from Ben’s talk, high-lighting workflow themes:

  • HIPAA compliant communication platform that focusses on workflow and care improvement through care coordination
  • 300 customers, 80,000 end users
  • Ben’s personal story daughter born prematurely, HC communications “shocking & stunning” (pager, requesting call backs, simple tasks took astronomically longer than they should have had to)
  • Before Secure Texting, sending insecure SMS messages
  • 5 years ago industry born, mobile apps securing emulating SMS (added value, retention policy, self destruct…)
  • 600 bed hospital saved 40 nursing FTE per shift (hour and a half a day in time savings)
  • 500 percent improvement communications workflow efficiency
  • Reliability, adoption, user inclusion, structure & policy, integration
  • put policy on message, escalation, if can’t reach user, try alternatives, calling, escalation policy
  • Adoption issues, page is already embedded in workflow with 20 clinical systems
  • patient-centric workflow, EMR can share with care team
  • inclusion issue, system focusing on physicians vs nurses, must include all workflow stakeholders
  • integrate with nurse call
  • connect to all devices,
  • put structure into the messaging, requiring certain fields based on message type enhances workflow (avoid back and forth workflow, more streamlined)
  • policy, integrate with all on call platforms
  • policy more than just schedule, reroute to different physician (routing engine)
  • orchestration key to delivering useful information & be compliant with Joint Commission (re doc texting order to nurse)
  • connecting all system is key part of our strategy as a company and we’ve done over 30 different vendor integrations with out platform

Back to that workflow engine sighting…

I’ve been tracking diffusion of workflow technology into health IT for two decades. Workflow engines are the single most important component of workflow technology. It is the workflow engine that executes, or consults, a model, or representation of work or workflow, to support workflow system users in their work. That TelmedIQ relies on a workflow engine is, to my mind, evidence the TelmedIQ messaging platform can do the four things for which I tout workflow technology in healthcare:

  • Automaticity: workflows, sequences of tasks, fire automatically and save humans work
  • Transparency: the state of current and past workflow is readily visible and apparent
  • Flexibility: what triggers what tasks in what order can be changed by non-programmers
  • Improvability: transparency and flexibility leads to improvability, workflow can be systematically improved

Ben gave an excellent talk on the importance to move beyond mere “secure messaging” to structured messaging and workflows. I’m delighted to see an underpinning of workflow technology within the TelmedIQ system architecture. And I look forward to observing TelmedIQ’s future evolution toward even more automatic, transparent, flexible, and systematically improbable workflows.

P.S. Here is a video of Ben’s HIMSS16 talk. I originally live streamed it on the #HIMSS16 hashtag using Periscope and then archived it to Where is was viewed over a hundred times…. but then Katch shut down. But not before I saved and uploaded to Youtube!

@wareFLO On Periscope!