The Patient Experience “Stack”: From API to Experience Through Workflow

[This post is part of a series I am writing as a HIMSS17 Social Media Ambassador (four years in a row!) in the run up to HIMSS17, in Orlando, February 19-23. Stop by and meet me at the first ever HIMSS Makerspace, booth 7785 in the Innovation Zone!]


When I cross-index “patient experience” and “API” in Google, the number one ranked result is The Untapped Potential of Health Care APIs in Harvard Business Review. It was published in 2015. I’ve read it before. It was tweeted around when first published. Some of what the paper predicted has come true. It’s still a great read. And a great pivot to my favorite topic: healthcare workflow and workflow technology.

Here are some quotes (my emphases):

“Leaders of most internet-based businesses have realized the critical importance of using open application programming interfaces (APIs) to expand the reach of their organizations. If the health care industry followed suit, the impact on the quality and cost of care, the patient’s experience, and innovation could be enormous.”

APIs are programming routines or protocols that allow software applications to share data…. Ultimately, this type of innovation serves the end customer — creating better functionality and experience for the user.”

“Cultural and workflow issues within health systems must be addressed…. At Ochsner Health System, a pilot program to prevent heart failure and hypertension used an API to collect body weight and blood pressure data from over 500 individuals’ connected devices…. results from these and other pilots across the country have shown the potential of APIs to improve care and create a better experience for patients and providers alike.”

Sounds great! What’s missing? (Though it’s hinted at in that last quote…)

What is the single most important concept and technology to leverage APIs to improve patient experience? Workflow and workflow technology. Let me lay out my case.

There is a wonderful phrase from the hospitality industry: The System Behind the Smiles. It actually originated in a book about marketing, written by someone who had been extremely successful at selling automobiles. Here is the key quote.

“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.”

What do systems engineers think when they hear “system”? They think, “workflow” (or “process” in highly automated industries). The reason they think in terms of workflow, not systems, is system is a very general term. However, workflow is very specific term, concerning the order in which things happen and their inputs and outputs. Great patient experience requires great workflow. Great workflow requires great workflow inputs. One of those important inputs is data. Where will this data increasingly come from? APIs.

Lets think about patient experience in terms of a software concept, a “stack.” A stack is a set of layers, each layer depending on the layer below, and adding functionality depended upon by the next layer up. For example, there is the LAMP stack (Linux OS, Apache web server, MySQL database, PHP programming language). You may have heard of such a thing as a “full stack” developer. They are proficient at all layers and how they fit together.

If it seems odd to include experience in a software stack, I assure you it’s a great idea. Even Intel, which makes most of its money from the very bottom layer (silicon), thinks in term of stack all the way up to experience.

I’d like to return to the “The System Behind The Smiles” concept. It really means “The Workflows Behind the Smiles.” Here is a sequence of slides from a presentation I gave last year.

One of the most popular definitions of patient experience is that of the Beryl Institute.

Let’s break it apart to understand what are the smiles versus what are the workflows.

First there is what happens to the patient and how they experience it.

There there are the systemy/workflowy stuff causing things to happen the patient.

Let’s drill down into interactions and continuum of care…

That word “orchestration”? It’s workflow. Or rather it is what is done to create great workflow. For patients to have Smile experiences, all the System workflows need to be perfectly orchestrated. And great orchestration requires great interoperability, to which APIs contribute.

You may have heard of syntactic and semantic interoperability. Syntax is the shape of data and ability to move it between systems. “Shape” is important because data structures must be generated and parsed to travel. Semantics is meaning. Does data mean the same thing before and after transit? In addition to syntactic and semantic interoperability, there is a third layer of interoperability that is less mentioned. Task-workflow interoperability. (This kind of interoperability is also known as pragmatic interoperability.)

The very top of the patient experience stack is, well, patient experience (not shown above). But what’s between the bottom, data-centric syntactic and semantic layers and the top layer, patient experience? You guessed it. Workflow. I’ve written two separate five-part series about this layer, one from a engineering point of view and the other from a linguistic science point of view. Workflow determines patient experience.

If workflow determines patient experience, what technology is most relevant to patient experience? Workflow technology. What is workflow technology? Why is it important to patient experience. How to we accelerate use of workflow technology to improve patient experience?

To understand workflow technology you must understand workflow. Workflow is a series of steps, consuming resources, achieving goals. Workflow faces in two directions, towards people and towards technology. Steps may be tasks, screens, activities, or even experiences.

Similar, by analogy, to database management systems, which rely on on data models; workflow management systems rely on workflow models. These workflow models look a lot like workflows you’ve probably scribbled on a napkin as some point in your life. We draw workflows to think and communicate. The magic of workflow technology is that these diagrams become actual programs, executable by workflow engines. The best known examples of workflow technology today are business process management suites. BPMSs are examples of what researchers call Process Aware Information Systems. But many other technologies, not traditionally identified as workflow technologies, are becoming process-aware. These include customer relationship management (CRM) systems, data science and machine learning systems, chatbots and natural language processing systems, as well as traditional health IT systems, such as laboratory reporting and imaging systems. What all these disparate systems have in common is a pivot from sole focus on data to more equal emphases on data and workflow.

Workflow technology is finally being use to improve both patient and health IT user experience. Two years ago, in a five-part, 7000 word series in Healthcare IT News on task-workflow interoperability, I predicted the following:

“We will see a plethora of clinically- and patient-oriented workflow platforms. Many have already obtained considerable investment and beginning to expand their market footprints. It’s early days yet. But, within five years we’ll see as much, or more, about facilitating workflow at the point-of-care and point-of-health as the emphasis on population health and patient engagement at the recent HIMSS conference in Chicago. In fact, population health and patient engagement are playing critical roles in driving adoption of process-aware workflow technologies in healthcare. If you drill down through the layers of technology necessary to do both, efficiently, effectively, and flexibly at scale, you’ll invariably find some form of workflow orchestration engine. In some cases these will be based on third-party business process management suites. In some cases the workflow engines will be proprietary. It’s often hard to tell which is which, since many vendors do not wish to reveal they are relying on an embedded third-party product.” (Task-Workflow Interoperability)

However, adoption of process-aware workflow technology in healthcare and health IT is not happening fast enough. How to we accelerate use of workflow technology to improve patient experience? I wrote about a healthcare workflow triple aim on the Health Standards website two years ago.

  • Educate all healthcare stakeholders about workflow, workflow technology, and process-awareness. (This post, crafted in advance of the Availity tweetchat about patient experience, is an example.)
  • Highlight healthcare workflow success stories. (For example, every year since HIMSS11 I’ve searched every website of every HIMSS conference exhibitor for workflow related material. I use the #POWHIT hashtag, for People and Organizations improving Healthcare with Information Technology, to publish and organize on social media.)
  • Recruit current and potential healthcare workflow technology solution providers to create and market excellent process-aware workflow solutions. (Talking or writing or tweeting about healthcare workflow and workflow technology all day long won’t accomplish a thing, until and unless actual workflow products and services get into everyday use.)

If I have convinced, or at least, intrigued you, about how healthcare workflow and workflow technology is the missing link between APIs on the one hand and patient experience on the other, I hope you take a wee keek at any of the following posts, articles, or series.


@wareFLO On Periscope!

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