Charles Webster, MD and Nate DiNiro discuss blockchain and workflow in healthcare

[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!]


Nate DiNiro: Good morning. This is Nate DiNiro with HealthIT.TV, and we are doing another installment today of decentralizing healthcare with support from Corepoint Health. Thanks a lot to the folks at Corepoint for supporting us in our endeavors here to understand and examine various aspects of transformations going on in health IT and trying to decentralize that infrastructure.
This morning we’re joined by Charles Webster, MD. Definitely regarded as an expert in workflow in healthcare, and we’re going to talk a little bit today about blockchain and workflow and healthcare. Over the past, I’d say about year or so, blockchain has gained a ton of traction in the health IT industry, and it’s being seen by many as sort of a panacea for solving a number of different sticky problems in health IT. That remains to be seen. It’s still relatively new in its application in this space, but we’re going to talk a little bit about how it potentially impacts workflow.
Again, I want to introduce Charles. Go ahead and say … We want to welcome you. Charles.

Charles Webster: I’m delighted to be here. Thank you very much, Nate. I bumped into you frequently at health IT conferences, lugging around all kinds of great-looking video equipment. Now here I am, so I’m delighted. Thank you for the invitation.

Nate DiNiro: Here we are chatting. Yeah, you’re very welcome. Then, of course, I think last time we saw each other at HIMSS last year in the pressroom, we had lots of discussions about blockchain and healthcare, and some of the discussions we had around workflow were really interesting. Of course, that was at a time when it was just starting to get noticed in the industry, and we’re almost a year into that.
Why don’t we start off by having you define … We all think we know what workflow is, but what is it and how does it apply to healthcare? Why is it important?

Charles Webster: Philosophically speaking, all purposeful human activity involves workflow. Anthropologists study workflows. They study rituals, sequences of events consuming resources, achieving goals, and they have notations.
My background is I’m an industrial engineer who went to medical school. One of the things that industrial engineers have done for 100 years is to draw workflows and to time things. About 20 years ago I saw, actually more than that now, more like three or four decades ago, software remediates workflow basically, increasingly. There’s two things I’d like to describe. One is workflow, and the other is workflow technology.

Nate DiNiro: Okay.

Charles Webster: I’ve looked at hundreds of definitions of workflow, including some that would span two PowerPoint slides in small font. My personal favorite, because it’s Tweetable and it’s malleable enough to apply to a lot of situations is, a sequence of steps consuming resources achieving goals. Those steps could be tasks, activities, experiences. Those resources include things like money, user attention, data from other systems. Those goals are someone enters the hospital to get their appendix out, so the goal is to safely remove that appendix.
This definition of workflow puts it in an economic context, so consuming resources, that’s costs, and achieving goals, those are benefits. So there’s a benefit/cost ratio. Every time the world changes due to changes in technology, consumer preferences, a new disease emerges from someplace, regulations change, then the set of economic ratios change, so workflows need to constantly adapt to the changing cost benefit landscape.

Nate DiNiro: Okay.

Charles Webster: What is workflow technology? My other degree is actually a masters in artificial intelligence, and besides that I’m all but dissertation [inaudible 00:05:16] in linguistics from Carnegie Mellon. I’ve never finished my thesis. A big topic in … Of course, today it’s machine learning, but if you go back to what’s called good old fashioned artificial intelligence, it’s knowledge representation. It’s representing something and then having an engine operate on that representation to do useful things. It might be frames that describe the world.
The point is what I described, which is a series of steps consuming resources achieving goals, if you represent that in the computer, if you have a workflow diagram where the workflow represented at XML or as business process model notion or whatever, if you have a model of it you’re really close to being a program, because an engine can execute it. An engine can come along and make each step happen automatically. If it doesn’t happen, it can escalate it or annotate it, timestamp it for later analysis.
Having these models of workflow in the software is an incredibly valuable thing for a wide variety of purposes. From making systems more usable, for making systems that the users can change to fit their workflows, systems in which task status is more transparent so nothing falls between the cracks.
Classically, 20 years ago you had something called a workflow management system, and a workflow management system had a workflow engine that consulted some kind of representation of workflow to make things happen.

Nate DiNiro: Right.

Charles Webster: Today you have what are called business process management systems, which are workflow engines with executable models, and they are surrounded with a whole bunch of other modules, such as analytics modules or things that generate native code so that you draw the workflow, draw a couple of forms, push a button, and now you’ve got native apps on half a dozen different devices. That workflow management system stuff has blossomed.
Yet healthcare is remarkably behind the curve in using workflow technology. In fact, on my Twitter profile right now there’s a quote, and it’s quoting me. It’s, “Workflow eats data for lunch,” kind of a riff on culture eats strategy for lunch, or something like that. Healthcare health IT has been very data centric for a very long time, and I’m just thinking we should be a little more workflow centric. In fact, I can remember 20 years ago, 30 years ago, going to the first medical artificial intelligence conferences. People were modeling workflows, but now we went for kind of a boil the ocean … We’re going to collect all that data, so we have to model that data. Data’s important, but workflow’s important, too.
Now we get to blockchain, and certainly I understand how valuable blockchain is for sharing data in a way that people can trust that data. They couldn’t get at the data before in the same manner. I’m interested in blockchain and workflow. My interest is in workflow, so I look everywhere, whether it’s computational linguistics or usability or blockchain, how can that improve the workflow.
When I looked at blockchain, I was most interested in this idea of how blockchain can facilitate workflows between organizations. I wrote a blog post, which I think I sent to you a few months ago, and that is the kind of exciting thing, and I am getting to the end of my answer here, to me is … At the recent Academic Business Process Management Conference down in Brazil, these computer scientists basically propagated workflow state. You can imagine you have a supplier and then an intermediate seller and then a customer, hence you’ve got kind of a supply chain and you have a workflow that crosses all of these people, and what they use blockchain to do was to make sure that everybody knew what steps had been executed in the other organizations, and to ensure that those steps really had been accomplished, which is an enormously valuable thing in terms of coordinating the behavior.
The data is not the actual data of the thing that you’re buying, or patient record. The data is simply about, “Yes, this step has been accomplished. This information has been gathered,” for example.

Nate DiNiro: We might call that a state machine.

Charles Webster: It’s exactly what it is. It’s a state machine, yeah. State machines are … Yeah, I took formal languages in Automata years ago. However, if you implement formal state machines, the world is a messy place.

Nate DiNiro: Yeah.

Charles Webster: It’s difficult to represent everything that needs to be represented-

Nate DiNiro: Sure.

Charles Webster: In a state machine formalism, but under the hood the most scientific theoretical representation, to go back to what I was talking about, is a state machine transition network representation.

Nate DiNiro: Which lends itself to the last conversation you had in the last hour around RESTful interfaces and micro services. It’s kind of interesting. It seems like, in terms of maybe how it applies to the questions at hand here, there is probably a lack of determinism in the healthcare industry. It is a very fuzzy type animal, right? It’s not something that is easy to define a model for holistically, because there’s so many moving parts and so much variability. Maybe achieving these technical goals becomes that much harder. Do you see that as something that blockchain is really able to help with?

Charles Webster: I’m not an expert on blockchain.

Nate DiNiro: Sure.

Charles Webster: Like I said, I was struck by this idea of … My impression, when people talk about, for example, interoperability in healthcare, and then they look at blockchain, they’re thinking about, “Oh. Here’s the patient record here and it’s duplicated over here and it’s the same, so therefore we’ve solved interoperability.” Well, no we haven’t, because you still have to … What’s shared has to be interpreted, those interpretations the meaning has to be the same.

Nate DiNiro: Context.

Charles Webster: Yeah, well. You’re talking to a linguist. Context is actually pragmatics.

Nate DiNiro: Okay.

Charles Webster: You have syntax, semantics, and pragmatics.

Nate DiNiro: Sure.

Charles Webster: Syntax is sort of the shape of the data so that you can ship it from system to system. Semantics is does it mean the same thing in the two systems. Pragmatics is basically the context, and usually the context is about goals that are achieved. When I send you a message, I send that message to you with the intention of achieving a goal. In pragmatics in linguistics, when I say something, when I say, “Do you have the time,” my goal is for you to tell me the time.

Nate DiNiro: Right.

Charles Webster: The understanding of the conventions and the goals and purposes of these rational intelligent agents as they are coordinating and communicating is the context.

Nate DiNiro: Okay.

Charles Webster: That’s where these models of workflow are important. If you share the models of workflow across organizations, you are sharing the necessary context within which to better interpret the shared data.

Nate DiNiro: Mm-hmm (affirmative). Okay, and you see the potential for blockchain to assist with that? Is that I’m getting [crosstalk 00:13:56], facilitate that?

Charles Webster: Okay, here’s a couple of terms. Orchestration and choreography are terms frequently used in workflow, and currently you see them more, for example, in DevOps and managing other kinds of software. Orchestration is kind of what a workflow engine does. You’ve got a workflow that goes A, B, C, D, E, and C and D are done by someone else. In order for that workflow to execute, you’ve got steps that happen in the hospital, steps that happen in the radiology clinic, and steps that happen in the ambulatory care, so your workflow, your logic, or your continuum of care workflow, really is stretched across all of these symptoms.

My interest in blockchain is there’s a peer-to-peer aspect that blockchain potentially enables relative to the workflows. In order to coordinate that workflow that I just described across three entities, you need to have some kind of dominant orchestrating engine out there someplace. Either one of those entities has to be in control of things or-

Nate DiNiro: In today’s technology model.

Charles Webster: Right, right. Exactly. Okay. But if you have workflow engines in all three of these organizations, the hospital, the radiology clinic, and the ambulatory setting, and they share a model, they all agree, it’s like a contract. We get together and this is our workflow. This is our shared workflow vision of how we’re all going to work together. Now blockchain potentially can check off the steps in the workflow so that they know that the ball is in your court. “Well, no. The ball is not in my court. It’s in your court and I can prove it.”
I’m interested in blockchain from the point of view of representing workflow state, sharing provably correct workflow state so that these more distributed workflow orchestration engines can move from the necessary, having some sort of super-administrator workflow engine out there making sure everything happens, to a much more cooperative organic peer-to-peer workflow execution across entities. I didn’t do a great job on that, but maybe you can restate it.

Nate DiNiro: Yeah, I mean, I get it. Less cybernetic commanding control and more decentralized even, not even distributed necessarily, but decentralized, I think, is what it’s gotten down to.

Charles Webster: You said something interesting earlier about determinism and state machines. One of the great things about workflow technology is it’s easy to change the workflows. Which means that you can get the workflow approximately correct, and then gradually improve it until it’s really good. Traditional health IT systems in which the applications are third generation, all your workflow is implicit in all the case statements and the end statements and so forth. It costs so much to create these systems, and then it is so impossible to change them that you sometimes see analysis paralysis. “We have to get this right in terms of our user requirements,” and so forth.
The great thing about workflow systems is you can get it approximately right, and after you have deployed it, after you have gone live, you can go back and change the code, because you’re not really recompiling code, you’re just changing the workflows, you can fix the workflows.
Nate DiNiro: Right. You see that as something, or that’s an approach you would feel is acceptable in the healthcare industry?

Charles Webster: Yes, because it’s kind of like when I was on a forms committee in a community hospital, so people would get around and we’d look at all the forms that the hospital used, and we would argue about what should be on the form and where it should be on the form and how it should be described and so forth. In fact, I know there are workflow committees now, particularly as you’re starting to see workflow technology come into healthcare, where people will get together and just like they used to hammer out these forms, which in a way those forms were workflow.

Nate DiNiro: Sure.

Charles Webster: Different people filled out different sections of the forms. You really were defining workflow using these forms, which was a really bad way of doing it. That example I gave of the hospital and the radiology clinic and the ambulatory venue getting together periodically to review their workflows and how they interact with each other, and to address any exceptions that have been documented and so forth to improve them, they can do that because of the low code, less code nature of workflow technology. To me, everything is a nail, because, you know, hammer. Workflow technology … I look at these things, like natural language across this thing, and mobile, and social, and blockchain, as how does that fit into this larger, my workflow model. Healthcare needs to become more process aware. It needs to be able to … The machines need to have representations of processes and they need to build a reason across those processes.
A lot of the workflow technologies coming into healthcare is coming in under the guise of other things. Social, mobile, analytics, and cloud, a lot of those systems, which are getting a lot of share of mind, they have in them workflow engines. They have environments that allow you to create the applications in a relatively less code or low code way. They’re essentially rudimentary workflow management systems with all kinds of APIs to Twitter for the social or to the BI platform for the analytics. They’re vectors like in an epidemiological sense. These technologies are coming into healthcare, and they’re bringing and they’re facilitating the workflow technology, whether you call it that or not. Automatically, new technology comes along, whether it’s Google Glass or Watch, and I say, “How does this fit into bringing process awareness into healthcare,” and the example I gave is kind of like the best example that I could come up with.

Nate DiNiro: Okay. Speaking of examples, are you aware of any examples where blockchain, either at a proof of concept level or production or any level really, is being used to solve any of these problems today? Or even experiment with solving these problems?

Charles Webster: Only the experiment. There are other ways to improve workflow besides representing workflow and executing that representation. Giving everybody smartphones so they can, you know. Workload gets improved because they can be anywhere and they can still look up the information.

Nate DiNiro: Sure.

Charles Webster: When I look at the intersection between classic what are called process-aware information systems, PAIS, there are books out there written by academics on it, and the blockchain world is exactly the one I just gave you of a proof of concept prototype that wasn’t in healthcare that was a supply chain workflow in which they were using blockchain to share the workflow state. That’s the only one I know of.

Nate DiNiro: Right, amongst the partners.

Charles Webster: I think it was a Brazilian computer science group that did that. Other than that, if you’re asking me examples of a blockchain out there, I’ve seen headlines that say 18 percent of healthcare organizations are planning on doing something or whatever. I don’t have any personal knowledge. I look to you and to Leonard Kish and Jeff Brandt and so forth for my knowledge of what’s happening in the blockchain world.

Nate DiNiro: Sure.

Charles Webster: In terms of intersection with workflow, all I’m seeing is I’ve seen probably a half dozen kind of cool blog posts where people said, “Wow, you know …” The people from the business process management industry are looking at blockchain and saying, “You know, how could we use blockchain,” or “What’s the fit between business process management and blockchain,” and they’re writing speculative posts. I only really know of that one proof of concept, which I keep going back to because it was just so elegant.

Nate DiNiro: Sure.

Charles Webster: There’s actually a YouTube video out there where I think you’ve got four windows. In one window you have the system executing, and in the other windows you have the console for the three supply chain partners as the workflow is executing and the blockchain is being synchronized or whatever the terminology is, you’re seeing things happen automatically according to the representation of workflow that is shared, and the shared state as that changes in real time.

Nate DiNiro: Right.

Charles Webster: And that’s pretty cool.

Nate DiNiro: Yeah. I can think of another application where there is some experimentation going on in the research context, where you’ve got a number of research partners and they’re sharing data normally across silos and having to synchronize that data, whereas in this other model that they’re going to be testing out, they will essentially put a blockchain solution at the center and allow all those research partners to share the same data, manage consent end to end, and get results in more real time as opposed to waiting for the next time they go through a synchronization process and synchronize data across all the silos. I feel like there’s all kinds of applications, certainly, that haven’t been explored yet, but I think workflow is probably one of the areas where we’ve got one of the stronger applications certainly, and that’s why I wanted to sit down and talk to you today and see what you’re seeing out there.
You’d mentioned that you’re looking to others for your information, but I don’t know anyone who’s as deeply enmeshed in the workflow area, and certainly our discussions about blockchain have created some very interesting food for thought. With all that, do you have any predictions or thoughts? Do you see where the puck is going maybe in the next year around how blockchain might be used, at least in your area of interest? Do you have any plans to do any experimentation.
Charles Webster: No. My plan is basically everything that will further workflow technology into healthcare I pay attention to.

Nate DiNiro: Yeah.

Charles Webster: For example, every year for the last five or six years, I search every single website of every single HIMSS exhibitor for workflow, workflow engine, orchestration, business process management. Now it’s semi-automated.

Nate DiNiro: You have a workflow for that now?

Charles Webster: Anyway, six years ago, basically nobody mentioned workflow anywhere on their website. Now between one third and one half of websites have some workflow story. We fit into your workflow, we make it work. Last year at HIMSS16, 15 percent of 1500 exhibitors mentioned workflow engine or business process management somewhere on there. I may cross index that with blockchain. If I cross index it with blockchain, you’re probably going to get close to a mil, but I may actually just do a search on those 1500 websites just for blockchain, just to see. That’s kind of interesting, because then the half dozen hits you would get, you go to HIMSS and you come by and you talk to the rocket scientist and find out more.

Nate DiNiro: That sounds like it would put those players on the bleeding edge. We haven’t really reached the tipping point yet in terms of blockchain and workflow, but certainly from the work that we’ve done, Leonard and I have done, and others on the UBASE team, of course, which is a blockchain software company that I’m involved with. It really looks promising and it’s pretty exciting. To be able to take that … To literally decentralize, take away that commanding control structure and, like you said, allow things to operate more organically.

Charles Webster: Certainly sharing data across the silos has great potential to improve workflow, but you still need models of workflow being executed or consulted semi-automatically by machinery that is acting to achieve various workflow goals. That area, healthcare is way behind other industries, and my hope is that as blockchain helps share data, it will help share workflow as well.
Nate DiNiro: Sure. We’ve kind of reached the end of your time here. We’ll keep it short today on this pre-Christmas or pre-holiday here. Do you have any parting thoughts? Anything you’d like to share with us? Anything you’re doing that you’d like the audience to know about?

Charles Webster: Yes. Okay. I’m always looking for intersections. If you could the all-but-dissertation, I have five degrees. So I’m always looking for intersections between things. I am running the first ever HIMSS makerspace.

Nate DiNiro: Oh, wow. Cool.

Charles Webster: I forget the booth number, but it’s in the-

Nate DiNiro: Finally.

Charles Webster: Yeah, finally. I’ve actually been working on that for three years to do this. I wish I had the number. It’s 7000 something. It’s in the innovations zone. Basically, it’s my makerspace in which I’m putting in my car and taking it to Orlando.

Nate DiNiro: Okay.

Charles Webster: Then they gave me a booth and I take … We’re talking 3D printer, CNC equipment, laser cutter, and I got a zillion boards. We’re talking like all kinds of … Obviously, I’ve got Arduino and Raspberry Pi, but I’ve got a bunch of other cool … One area I have been looking at, watching on the Internet is [inaudible 00:29:19].

Nate DiNiro: Okay.

Charles Webster: I don’t know enough about it, but it would be really cool if someone would come by the makerspace booth and poke around in my box full of internet of things, boards, and processes, and so forth. My goal, and I don’t know if this will happen, is that someone will come by at the beginning of HIMSS, they’ll keep coming by, and by the end of HIMSS they’ll have actually prototyped a product.

Nate DiNiro: That’s pretty awesome.

Charles Webster: It would be cool. Really cool. It would be really cool if someone who knew more about the blockchain internet of things would come by and say, “Oh, you know what? We’re going to implement a little toy blockchain Raspberry Pi based art installation.” I don’t know. Anything that we can then put out on social media, that would be really cool.

Nate DiNiro: That sounds interesting. I have not yet made my, believe it or not, made my HIMSS plans yet. I always wait until the last minute, but, like I said, we’ve got the UBASE stuff and it would fit in there, so maybe we could give you some …

Charles Webster: Can you think about wearables, internet things, personalization, getting close to the patient, micro-payments, interactions between these IOT systems.

Nate DiNiro: Well, sure, yeah.

Charles Webster: Could UBASE fit into that?

Nate DiNiro: Yeah. The UBASE system is literally a wallet for storing health information. As a matter of fact, some of the things we’ve talked about today could be done on UBASE. Certainly, if you’re looking at IOT and the type of devices and technology you might have that could be gathering data about a patient. Those devices about their behavior.

Charles Webster: Can I step away from the camera for about 30 seconds and come right back and show you something. I’ll be right back.

Nate DiNiro: Yeah. I’ll do my dog and pony. I was just explaining to Charles when he mentioned that he’s going to have a booth, a makerspace booth at HIMSS this year, and thought that it might be interesting to contribute some of the UBASE technology or other blockchain based technologies out there for his experiment, in hoping that he’ll get some people to prototype and/or build a working prototype application during the course of HIMSS this year at his makerspace.

Charles Webster: I’m giving this away. I have my own version of it. It’s in a shoebox someplace, or otherwise I’d bring it out. Let’s see if I can show … We’re getting closer here. This is a phone strap for the wrist.

Nate DiNiro: Okay.

Charles Webster: This is a little device, it’s got a little micro USB and it’s got a little LCD screen, and there’s also on the back there’s a plugin, and this is kind of a platform for adding modules to it and so forth. Anyway, this is a completely open source hardware smartphone. It’s got …

Nate DiNiro: Is it Arduino based?

Charles Webster: No. It’s not Arduino based, which is the wiring programming language. It’s a kind of a C-based language for interacting with the phone itself for loading the software on the phone itself, but the interactions with it, the APIs are … There’s a wide variety of … You can write whatever you want. It’s not so much that this is a smart computer, although it is, and you can change its firmware and so forth, it’s that it’s more like a sensor tag. So temperature, humidity, magnetometer, accelerometer, [inaudible 00:33:49], a couple of other things, all that gets automatically synchronized to the cloud. Then you can write programs against it. It’s hackable. It’s eminently hackable.

Nate DiNiro: Right. There’s a transceiver in it so you can get service for it on … ?

Charles Webster: This connects by Bluetooth to your phone.

Nate DiNiro: Oh, okay.

Charles Webster: And you’re automatically up. So basically it streams all of that data to your phone.

Nate DiNiro: Okay.

Charles Webster: As well as up to the cloud.

Nate DiNiro: What’s that called?

Charles Webster: It’s called Hexiware. I’ve got two. One I’m messing with, the other one I haven’t opened.

Nate DiNiro: Sure.

Charles Webster: That’s going to be sitting there. I don’t know if I’m going to collect business cards, or if someone comes along and has a good idea for a prototype they want to build, then you win it, you know, whatever.

Nate DiNiro: Right.

Charles Webster: Because I’m trying to get people involved. Hexiware, they’re out of Europe, and in Europe at a series of wearable and IOT and other conferences, they’ve won like product of the year like four times.
Nate DiNiro: Oh, wow. How much do they go for?

Charles Webster: This was a hundred bucks. I think on the internet this is the power user pack. The reason … I’m not even sure how all this works, but this right here, you plug the phone into this, and then these are all places where you can put modules.

Nate DiNiro: Right.

Charles Webster: I’m not sure [crosstalk 00:35:23].

Nate DiNiro: Kinda like Arduino World, where you have shields. You can add functionality onto the base.

Charles Webster: Yeah, exactly like that. I haven’t figured out exactly what the point of that is. It’s like 120, 130 bucks.

Nate DiNiro: Well, you might want to embed that device-

Charles Webster: I got it for a bit less than that.

Nate DiNiro: You might build out something and want to use that as the embedded brain of the device or embedded sensors in something and extend it.

Charles Webster: Right. I’m always looking for intersections. Open source, eminently hackable, smartphone, multi, multi, multi sensors, cloud, blockchain, UBASE, you know, discuss.

Nate DiNiro: Awesome. Awesome. Well, we’ve got to wrap it up here. I appreciate your time and your insights, and hopefully we’ll be able to get together here again down the road as things materialize around distributed systems in healthcare and blockchain and workflow certainly. Good luck at HIMSS. Hopefully, we’ll see you there and maybe we’ll get to talk about who run your developer or your prototyping challenge next time we chat.

Charles Webster: Nate, I may have planted a seed. If you want to come by the booth and hack for a couple of days and build a prototype, then you’re the winner.

Nate DiNiro: Yeah, well you know. I would love to find someone to tow the camera around and have fun at HIMSS.

Charles Webster: Oh well. Hey, bring the camera by the booth. The maker booth.

Nate DiNiro: Yeah, of course. If we make it to Orlando, I definitely will.

Charles Webster: I’ve got robots.

Nate DiNiro: Cool. All right. This ends another installment here of Decentralizing Healthcare with myself, Nate DiNiro and Charles Webster. Go ahead and give them a goodbye there, Charles.

Charles Webster: Thank you, folks. Love talking about workflow, love the whole maker movement, love blockchain. Maybe we can figure out how to put it all together.

Nate DiNiro: All right. Sounds good. Thanks again, and we’ll see you next time.

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