Why is Health IT behind in workflow-friendly technology and process awareness? How do we fix?

Republished from Health Standards.

Why is Health IT behind in workflow-friendly technology and process awareness? How do we fix?


Thank you to Health Standards for allowing me to press my case for using workflow technology to counter healthcare’s Workflow Problem. I’ll argue that we should adopt a new metaphor. Instead of “data silos,” let’s speak of “workflow silos.” Instead of waiting until we understand healthcare workflows to automate them, let’s use workflow technology to create and leverage understanding. Let’s promote a Workflow Triple Aim in service of healthcare’s Triple Aim. Let’s educate, highlight, and recruit the best workflow minds to improve care, outcomes, and costs.

From Data Silos To Workflow Silos

Metaphors are not just flowery language used by poets. The metaphors and analogies we use, user-friendly (treating computers as people), data silo (farming, nuclear war), and data liquidity (flowing water), powerfully influence how we think. That is the point of Metaphors We Live By, an influential book in cognitive science.

I propose we stop talking about ‘data silos’; start talking about ‘workflow silos”. Data and workflow are related concepts, but very different ways of looking at healthcare. In fact, almost everywhere you see ‘data’ (especially in a headline), just replace it with ‘workflow.’ You’ll be pleasantly surprised by the innovative ideas that just seem to begin to, well, flow!

The occasion of my plea to “Think different.” is my response to a special live #HITsm tweetchat that took place Tuesday, 14, at the HIMSS15 conference in Chicago. I wasn’t present, sadly so, since a question I submitted was asked of four health IT experts before an audience of HIMSS15 attendees. I do, however, have the livetweeted #HITsm transcript. I did respond, two days late (oh, I wish I’d been there in person!). Those tweets and my dozen tweeted responses are embedded in a blog post on my Healthcare Business Process Management Blog. As usual, I’d love your comments, here, my blog, or even to the embedded tweets themselves.

Let me focus on three of those tweets.

“T5 Why does the HIT industry lag behind in terms of supporting workflow-friendly technology & process awareness? How do we fix?”
“Missing interoperable workflows, but first need the data to bust down silos, establish what those are”
“We still need interoperable workflows between providers but we don’t yet know what those workflows should be”
Let’s talk about data silos first.

I grew up on a corn and soybean farm, so I happen to know lots (well, probably more than average) about grain silos and elevators.

Let’s consider a definition of “data silo.”

“A data silo is a repository of fixed data that an organization does not regularly use in its day-to-day operation. So-called siloed data cannot exchange content with other systems in the organization. The expressions ‘data silo’ and ‘siloed data’ arise from the inherent isolation of the information. The data in a silo remains sealed off from the rest of the organization, like grain in a farm silo is closed off from the outside elements.”

If one accepts this description of a silo, then one’s thinking tends to head down some paths, but not others. Of course, “busting” silos is more of a World War III metaphor than a farming metaphor. Keep in mind the result of busting a nuclear silo is not the freeing of its content, but its destruction. So back to the farming analogy, which seems more constructive for our purposes. What if we think about silos from the perspective of how they are *actually* used in agriculture?

After the recent HIMSS15 conference in Chicago, I continued to my family farm in NW Illinois. I tweeted pictures of farm houses, antique tractors, and grain silos. I asked a well-read farmer about what he thought of the data silo analogy. He said something profound (which I tweeted at the time), “Seeds are alive & in the spring they know it’s time 2 germinate, they swell & begin 2 sprout”. This dynamic process can actually start in the silo! Further discussion confirmed he did not think of seeds or grain as inert, at all. In fact, they are alive, dynamic, tightly coiled bundles of potential energy (a “spring” metaphor, if there ever was one, and borderline pun, to boot). By the way, a really great book about seeds is The Triumph of Seeds. Seeds are metaphorical supercomputing self-assembling, micro-robots with sensors and actuators. They put today’s Internet of Things to shame.

What’s inside seeds is much more like workflow than data. Data is static, inert, and tactical. Workflow is dynamic and strategic. Workflow acts on data: transporting and transforming.

What about a pile of seeds? Take it from me; big piles of seeds are not static or inert. They are shifting and treacherous. 31 people died in grain-bin entrapments last year. Two young men died in my home county in 2010. (My mom knows the families.) I never worked in a silo. I did sneak into a corn bin once, until I was chased out and given the lecture of lifetime. After that, the couple times I peeked into a grain silo, I saw riptides and treacherous currents, not a static pile of “data.”

What about grain elevators, those collections of interconnected silos one sees throughout our Midwest?

“Grain elevators play a key role in U.S. agriculture, and fulfill three main functions: post-harvest handling and storing of cereal grains and oilseeds, conditioning and preserving of grain, and facilitating the delivery of grain to domestic feeding and processing, as well as overseas, end-use destinations. These facilities have evolved from mere storage sites to large, high-throughput, highly automated, processing plants…. grain elevators represent a key intersection in our food production chain” (Design Considerations for the Construction and Operation of Grain Elevator Facilities. Part II: Process Engineering Considerations)

Consider that phrase,”evolved from mere storage sites to large, high-throughput, highly automated, processing plants”… again, sounds more like workflow, than data, to me.

Seeds, piles of seed, silos, and collections of silos, are in constant motion, channeled by agricultural organizations and technology. There’s a giant grain-to-food conveyor belt workflow from thresher to table.

I’d rest my case, but I have two more tweets go!

From Workflow Oppressed To Workflow Owners

3. “We still need interoperable workflows between providers but we don’t yet know what those workflows should be”

To which I tweeted back:

“IMO we should NOT wait 2 understand workflows B4 using workflow tech, cuz WF can be adjusted!”
“that’s POINT of workflow tech, since workflow is liquid, can implement WRONG WF but fix later”
If you think my ‘workflow silo’ analogy is a bit, well, ouut-theere, just wait until you see my next one! Stick with me!

Throughout the history and evolution of democracy and democratic traditions, autocratic regimes sometimes agree that democracy is good, but citizens need to be taught about democracy first. Only after citizens have matured, can they be trusted to actually vote. This is how revolutions happen. The citizenry see through the ruse, won’t wait, and deposes the despot. The rejoinder to these despots is that one learns by doing. Perhaps badly or imperfectly at first, but this is the only practical route to democratic civil society.

Something similar can be said of healthcare workflow. In fact, I’ve sometimes used the Twitter hashtag #OccupyHealthcareWorkflow. Healthcare, but more specifically, health IT, has a “workflow problem”: usability, interoperability, safety, patient experience, and more… What do all of these have in common? Workflow-oblivious technology (see my five-part series on healthcare workflow tech).

Users of health IT, especially clinical staff and patients, need to own their workflow. What could I possibly mean by “own workflow”? How can we make it possible that patients, physicians, the intended beneficiaries and users of these IT systems, should own their own workflows?

The key to solving the workflow problem, and repatriating healthcare workflows to their most important stakeholders, is workflow technology. In other industries, when you have a problem X, X technology arises to help solve or manage. Think pollution/pollution technology. Think, healthcare workflow/healthcare workflow technology.

Saying we can’t automate workflow because we don’t yet understand workflow makes sense if you hardcode workflow. That is, if you use third-generation languages such as Java, C-sharp, and Mumps, to automate the series of tasks that make up a workflow. Since you can’t easily or inexpensively change workflow after the code is written, then, By God, you better get the workflow right in the first place.

The problem with this stance is that there is no single correct workflow. Workflow changes all the time. Government regulations change. Patients change. Society changes. Science changes. Medicine changes. Everything is changing, all the time.

What is the alternative, then? Low-code software development.

Use workflow technology. Draw workflows in workflow editors. The results are both executable by workflow engines and understandable by non-programmers. Some of these systems look like traditional workflow diagrams, such as produced by Visio. If you don’t think non-programming users of these systems can understand workflow diagrams (many can, in my experience), then there are systems that present simplified, but still usefully editable, workflow.

What if patients and physicians don’t want to click or touch anything during design? BPM (Business Process Management) systems can be changed, even implemented, a magnitude faster than traditional health IT system. Analysts (business and clinical) can quickly iterate through a series of workflow designs, until converging on workflow satisfactory to patients, physicians, and staff. In either case, super-users creating super workflows, or healthcare organization analysts doing the same in close coordination with users — break the workflow monopoly that has been imposed on us by workflow-oblivious legacy health IT.

In fact, I’m seeing a convergence, between patient experience and user experience. The tech that will make this practical and scalable will be workflow technology. Some of the most sophisticated uses of workflow tech have been in customer- and consumer-facing “Systems Of Engagement”, those systems at the edge of the enterprise (to contrast with “Systems of Transaction”, mission critical processes deep within the enterprise).

At a recent BPM conference I attended, “empathic” workflow was a hot topic of conversation, which was aligning the customer journey of a daughter and her mother regarding a home emergency medical bracelet. Backend and customer-facing workflows and touch points must be redesigned, to respond to their customers’ journey, through experiences of worry and feeling overwhelmed, relieved, anxious and frustrated… It is the ability to change workflows and processes quickly, to quickly improve to workflows serving this mother and daughter, which make this critical alignment possible. Workflow technology will be an essential tool and platform for co-designing healthcare workflows.

Don’t wait to implement healthcare workflow technology until we completely understand healthcare workflow. In contrast to traditional health IT workflow-oblivious tech, it is the implementing of workflow tech that creates understanding of workflow. Instead of blue ribbon commissions and dusty academic research telling citizenry “correct” healthcare workflows, use workflow tech to quickly get to satisfying, shared, co-owned patient and provider workflow. Pave the cowpaths. Then straighten and widen into eight-lane super highways. Health IT that is easily molded to patient and physician workflows, which can then be systematically improved while respecting normal human tolerance for change, is the key to health IT adoption.

Of course, healthcare needs also needs interoperability to achieve this vision. However, focusing exclusively on message transport and translation has had untoward consequences. The lowest level of interoperability, syntactic interoperability, gets messages from machine to machine. The next level up, semantic interoperability, makes sure the content of these messages means the same on both machines.

But workflow interoperability (also task or pragmatic interoperability) isn’t just the end game. It is the begin game too. Do exchanged messages accomplish the goals they are intended to accomplish? Each level helps the other levels. In other words, workflow tech can greatly facilitate lower level message exchange. Modern workflow platforms support a plethora of adaptors and connectors for gluing disparate technologies together. In fact, healthcare interface and integration engines are an important area of diffusion of workflow engines, editors, and analytics into healthcare. A C-level health IT executive just told me he’s getting a BPM systems because it will work so will his regional HIE’s BPM-based infrastructure.

Communication among EHRs and other health IT systems must become more “conversational,” if they are to become more resistant to errorful interpretation. And workflow tech is the best and most natural means to enable these conversations.

Workflow Triple Aim In Service Of Healthcare’s Triple Aim

Finally, the “How do we fix?” tweet:

1. “T5 Why does the HIT industry lag behind in terms of supporting workflow-friendly technology & process awareness? How do we fix?”

There are many different stakeholders and many different skill portfolios, when it comes to the healthcare workflow problem.

You may have heard of the Triple Aim, to improve care, health, and cost. My means to contribute is a Healthcare Workflow Triple Aim, to educate, highlight, and recruit the best workflow minds.

Hence my tweeted response:

Need education
Hilite success stories
Recruit workflow tech
Educate users and buyers of EHRs and health IT about workflow and workflow tech. Find and highlight success stories to promulgate best practices. Bring into healthcare the modern social, mobile, analytics, cloud-based workflow technology called BPM, for Business Process Management. Just as health IT is a large and varied continent (hey, metaphor sighting!), BPM is too. There are different kinds of BPM. So this also means sorting through and adapting workflow technology to healthcare’s unique needs and purposes.

Every year I search every HIMSS conference exhibitor website for content about workflow, workflow technology, workflow editors, customizable workflow, workflow analytics, and business process management and related case management software. I do this to find informational and encouraging healthcare workflow tech stories to share via social media during each HIMSS conference. Five years ago, at HIMSS11, I didn’t even get to the two percent threshold. Every year since, the percentage has doubled — 2%, 4%, 8%, 16% — until this year’s HIMSS15 25 percent plus. The percentage may have actually doubled, but there was so much good and relevant workflow material I literally ran out of time (somewhere in the Qs). I’m seeing a surge of new and embedded workflow tech across almost every category of product and service. Five percent of HIMSS15 exhibitor websites actually mention “workflow engine” (the engine that executes workflow definitions).

As I put it in my HIMSS15 Social Media Ambassador blog post about thirty submitted posts about the Future of Connected Health (in which I highlighted, wait for it, healthcare workflow!)…

“The future is so bright, I gotta wear shades!”

Get ready for the bright sunshine of a healthcare workflow technology spring, and the sprouting of a million workflow blossoms. How’s that for flowery metaphor?

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Charles Webster, MD
Charles Webster, MD, MSIE, MSIS, evangelist for great health IT workflow, is the self-anointed King Of All Workflow In Healthcare (AKA The “Workflow Bear” per @OchoTex!)

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