[Also see my interview with David Freeman, of Quest Diagnostics!]
I was delighted to be asked by Quest Diagnostics to moderate this excellent Lunch & Learn panel on healthcare data and workflow. I was also asked to deliver a few words of industry perspective. By ‘industry’ I’m sure we all know that that means, the healthcare industry in which we work every day. But what is a perspective? It’s an attitude. A point-of-view. A standpoint. A slant or approach. An interpretation. A stand.
— Charles Webster MD🤖 (@wareFLO) February 20, 2017
My perspective is that of an industrial engineer who went to medical school, and also got a degree in artificial intelligence along the way. You can think of industrial engineering, now sometimes called systems engineering, as an academic degree in workflow. We describe workflows. We model workflows. Increasingly workflow engines execute these models of workflow, just as computers execute computer program, albeit at a higher, more understandable level of abstraction.
The four most important qualities of a data-driven workflow are actionability, transparency, flexibility, and improvability. So, when I look at workflow and workflow technology in healthcare, I look for these four things.
I’ll focus on actionability, since that is in the title of today’s Lunch & Learn. The dictionary defines actionable as having practical value. How appropriate! Healthcare abounds in data. Data, data everywhere, but often not actionable, I think.
In fact, if you think about it, data should trigger workflow, if it is to have practical value. Data that does not do this may have potential value. But it is merely a potential. Practical value does not come into existence until data actually triggers action. As an industrial engineer, I prefer to think of actions as workflows, for a variety of reasons, but the most important reason is that descriptions of workflow can be used to communicate about actions, measure resource consumption, and achieve goals. In our case, the goals are improved outcomes, reduced costs, and more satisfied patients and clinicians.
For the last four years I have been what is called a HIMSS Social Media Ambassador. It basically means I tweet a lot (from @wareFLO). Especially I tweet about workflow. I think the reason I became an ambassador is because every year since 2011, I have searched every website of every HIMSS exhibitor for workflow-related material. Then tweeted about it! In fact, I use the hashtag on my tie: #HIMSSworkflow.
I searched exhibitor websites to understand the state of the healthcare industry regarding healthcare workflow and workflow technology. In 2011 there was very little about workflow on any HIMSS exhibitor website. Today, almost half of HIMSS exhibitor websites have some sort of substantial workflow “story.” We improve your workflow. We fit into your workflow… “seamless” and “seamlessly” are favorite words. Some exhibitors even mention various kinds of workflow technology, such as workflow engines, sometimes called process or orchestration engines.
All of this is great. However, what is it that triggers workflow? Data. But not just any data. It has to be actionable data. It has to be just the right data, which comes into to existence at just the right time, and within view of some agent, human or automated, which can take an initiative, and trigger a workflow.
This is the relationship between actionable data and workflow. But what about integrated workflows? When workflow occurs in my organization, but which depends on activities occurring outside of my organization, perhaps in or around the patient, or perhaps down the road at the clinical laboratory, how are my and your workflows to be knitted together into a seamless whole?
Here, let me describe a different, but related perspective. Besides my many degrees, already mentioned, I’m ABD in what is called computational linguistics. ABD means All-But-Dissertation. I did not complete my Ph.D. But I did take 20 courses in linguistics and computer science.
Why do I bring up linguistics? The two most important healthcare data interoperability concepts are syntax and semantics, both of which are drawn from linguistics, the theoretical study of human language and communication. If you work in healthcare interoperability, you’ll often hear the phrases syntactic interoperability and semantic interoperability.
Syntax concerns the hierarchical shape of works and sentences. Think back to sentence diagraming in high school English class, if they do that any more. Syntactic interoperability concerns to hierarchical shape of messages containing healthcare data. These shapes have to be the same across systems, if my message generator is to be capable of sending a message to your message parser.
Semantics concerns the meaning of words and sentences. Do they mean approximately the same thing in your and my brains? Semantic interoperability requires that the codes exchanged between health IT systems refer mean the same thing in both systems. Code 123 must refer to disease XYZ in both the sending and receiving systems.
However, there is a third, but largely ignored area of linguistics, at least within healthcare interoperability. This area of linguistics is called “pragmatics”. How do you and I use language to accomplish common goals. Correspondingly, there is “pragmatic interoperability,” the ability of two IT systems to work together to achieve common goals. I am NOT coining phrases. Please, Google “pragmatic interoperability.”
Syntactic, semantic, and pragmatic interoperability are like the legs on a three-legged stool. Much of healthcare interoperability is missing the third leg, this so-called pragmatic interoperability.
Which brings me back to “actionable data”. To me, in my view, that is, my perspective on workflow and data in the healthcare industry, actionable data is about adding the third leg to complete this three-legged stool. Actionable data is the data that kicks off the workflows that make our investment in the data worthwhile.
Just as I am using language in an attempt to achieve our commons goals of participating in a successful Lunch & Learn, healthcare organizations use actionable data to participate in common goals of achieving great clinical outcomes, at reduced costs, while satisfying patients, clinicians, and supporting personnel.
Thank you for indulging my foray into linguistics theory, I’d like to think those several years might yet pay off!
More specifically, I think there are several key points to be made and acknowledged.
Like it or not, the EHR is the key point of data convergence, contact, and command. I was a Navy brat. My dad served on a sub. When I was a CMIO for an EHR vendor, I thought of the EHR as like the aircraft carrier in a carrier group of hundreds of other ships, planes, and submarines. Data and workflow are spread across a complex and sophisticated command-and-control systems. However, the carrier, i.e. the EHR, remains pre-eminent.
Nonetheless, physicians are getting tired of EHRs. They are tired of burdensome administrative and reporting requirements. They are tired clicking, clicking, and clicking. They even have a name for this disease: “clickorrhea” (after “diarrhea”). They’d rather spend their time actually talking to actual patients.
What is the solution? Actionable data and integrated workflow is an important part of any solution to clickorrhea. Don’t show me the data unless it is relevant to my next important clinical action. In order for this to become true, the right data has to flow to the right place and person and be presented in the right way. In order for THIS to be true, we need more than mere data interoperability, we need true workflow interoperability.
THIS is actionable data. It should make life easier, not harder, for physicians.
I enjoyed several phone conversations with our panelists, Lidia Fonseca, SVP & CIO for Quest Diagnostics, and Ken Mandl, from Harvard Medical School and Boston Children’s Hospital. Now I look forward to their presentations and subsequent audience discussion.