What’s The Fix For Healthcare? How About A Workflow Magic Wand?

[This post is written in preparation for the What’s The Fix? A Free Health Care Conference for Everyone!]

What if I claimed to you that the most important thing to fix in healthcare is workflow? Think about it! Think about all the usual culprits: experience, usability, cost, interoperability, and on-and-on. What do they all have in common? Workflow!

Now, what if I further claimed that I had a magic workflow wand, which, if I waved it, and said the proper incantation, would magically fix healthcare workflows? If successful, if workflows everywhere in healthcare were fixed, then all and more of the following would be greatly improved: experience, usability, cost, and interoperability (and on-and-on!).

Now, what if I went even further and claimed this magic wand actually exists? I imagine you’d say, Chuck, Chuck, stop this game! I humored you. I put up with you. But, no, THERE IS NO WAND TO FIX HEALTHCARE WORKFLOW!

You’d be right. There is no magic wand. Magic wands exist only in bedtime stories and Harry Potter books. But there is the next best thing: workflow technology.

What? Isn’t healthcare already using workflow technology? Well, I admit it is starting to… I’ve been tracking the flow of workflow engines and editors and analytics into health IT and healthcare for almost three decades. The obsession comes from getting a degree in Industrial Engineering on the way to a degree in Medicine. You see, an IE degree is essentially a degree in workflow. For most of those decades workflow technology simply didn’t exist in healthcare, except for an occasional, tiny, non-consequential pocket here-or-there. However, seven years ago I started searching every HIMSS exhibitor website for workflow-related material. (I’ve also done so for the AHIP conference for the last three years.) The uptick in workflow thinking, and, to a smaller degree, actual workflow technology, is gratifying. But this trend needs to happen much faster, to have to kind of system-wide qualitative and quantitative impact we need in the areas of experience, usability, cost, and interoperability (and more!)

Popular (or should I say, unpopular) aspects of healthcare are frequently blamed for broken healthcare include:

  • Cost
  • Experience & Usability
  • Interoperability
  • Incentives

Let’s start with healthcare cost.

The single largest healthcare cost is expensive, professional, manual human labor. If you look as “service lines”, such as an annual physical or having your appendix out, I’ve seen estimates of cost between 60 and 80 percent being labor. Besides that Industrial Engineering degree I mentioned earlier, I should also mention my premed undergraduate degree. It was a BSA in Accountancy, from the University of Illinois, which is frequently ranked number one in Accounting. What did I emphasize during my course electives, besides biology, chemistry, and physics, to get into medical school (yes, they thought I was an odd duck too!)? Management Information Systems (MIS) and cost accounting. Guess what? That educational background (plus three decades of toiling in the health IT groves) has convinced me…

We won’t control healthcare costs until we measure healthcare costs at the level of individual healthcare tasks and workflows. (I could go into a great deal of tedious detail about why I believe this, and, indeed, I will be happy to do so, however, in the interest of brevity, I thought I’d just argue from authority!)

Now let’s tackle experience!

I frequently define workflow as a series of steps, consuming resources (costs!), achieving goals. All purposeful human activity relies on workflow. Which is exactly why fixing workflow can fix so much about healthcare. I also sometimes point out that “steps” can range from tasks, computer screens, activities, other workflows, and even experiences. From a strictly (and perhaps simplistic, but intentionally so) systems engineering view, patient experience is what happens to the patient and patient engagement is what the patient does back.

Increasingly, what happens to patient is facilitated by information technology. This is not to say that experiences are necessarily devolving into digital touchpoints. Rather, sometimes the IT happens in the background and frees healthcare staff to spend more, and better, time with patients, thereby creating more, and better, patient experience.

The problem with current health IT is this. It has no model, representation, means, or way to actually reason about patient experience, because it has no way to reason about the workflows at least partially determining patient experience. Current health IT is relatively workflow-oblivious. In contrast, modern workflow technology (including business process management, the exemplar of workflow tech), actually has models of workflow. These models are interpreted and executive by workflow engines. Just like the engine in your car, workflow engines do work. And, by doing work, they save drivers, users, and patients, from having to do the work themselves.

In effect, because healthcare lacks the kind of intelligent workflow engines that are more prevalent in other industries, patients have to become their own workflow engines. They puzzle over care plans and medication lists and attempt to compensate for a healthcare system that lacks the basic workflow thinking, tools, and infrastructure, to imagine, create, and maintain otherwise.

Yes, we need to be nicer to patients. However, only forty to sixty percent of patient experience is due to face-to-face interactions with staff. The other forty-to-sixty percent are due to “The Systems Behind The Smiles.” And these system currently disserve their users, whether they be patients interacting with healthcare staff, or physicians interacting with Meaningful Use mandated EHRs.

What about interoperability?

Isn’t interoperability really the issue? Even if we had instant data interoperability, which is 99% of health IT interoperability today, costs and experience would still suck. Health IT is almost completely missing the notion of “workflow interoperability” (technically “pragmatic interoperability”).

Data interoperability is about what linguists call syntax and semantics. (Oh, by the way, did I mention I’m also ABD, or All-But-Dissertation in Computational Linguistics? :)) Syntax moves the data. Semantics makes sure it means the same. But linguistics has one more area of research: pragmatics. Pragmatics is about how humans use language to achieve goals. Goals! Wasn’t that part of my definition of workflow? Why, yes it was!

Health IT is not currently serving patient or healthcare workers goals well. To the degree that healthcare and health IT moves beyond mere data interoperability (which we are not doing well anyway), toward true workflow interoperability (AKA pragmatic interoperability), health IT will begin to, imagine, create, and maintain systems that more directly and intentionally serve our collective healthcare goals.

Finally, incentives….

There are those who claim that one hundred percent of fixing the “healthcare system is broken” solution is changing the incentives that reward and penalize behavior (at all levels, from patient to EHR vendor to CEO). Perhaps in the very long run this is true. But in the short run, it is false.

Even if we could wave a magical healthcare incentives wand, and “fix” all healthcare incentives everywhere (which, by the way, I have to interject, is a nonsensical notion, there is no perfect system of healthcare incentives), the current system of healthcare workflows is so entrenched, so frozen, so … immutable in the short term, we’d have a classic case of an irresistible force (incentives) meeting an immovable object (current healthcare workflows).

Only by unfreezing healthcare workflows, making them malleable, and then applying incentives, can we change the healthcare system workflows determining patient experience. And what kind of technology is exactly the kind of technology you need to create transparent and flexible workflows? You got it! Workflow technology!

Anyway, thank you for letting me rant on-and-on about healthcare workflow. I look forward to the What’s The Fix For Healthcare Conference! By the way, last night the Healthcare Leadership Blog tweetchat featured discussion of themes relevant to the What’s The Fix Conference. Here are my answers to four #HCLDR questions.

T1 What aspect of healthcare is most broken/What would you fix first? Why?


T2 What solution, technology or process do you feel holds the most promise for fixing healthcare?

Workflow technology!

T3 Is there an effective alternative to social media, for patient advocacy? Or has SoMe supplanted all other channels?

Healthcare social media and other communication channels (video, F2F/IRL, email, phone, etc.) are merging into a single “funnel” from unstructured entertainment and socializing to structured communication and collaboration to achieve common goals.

T4 Patient stories are powerful, how could their impact be increased without saturating the space?

Guess what? Stories are workflows! (See my Patient Narrative and Healthcare Workflow: Story Informatics!)

How can we use this insight to increase impact without over-saturation? First of all, social scientists are increasingly analyzing stories to create workflow-like representations. These are life-flows. We need to understand more about real-life, outside healthcare, personal workflows, and then to understand how they interleave with healthcare workflows. Second, we need better ways to walk a mile in each other’s shoes. I happen to think workflow technology can play a role here too, but these ideas are nascent (half-baked!) so I’ll save them for future post (hint: combine virtual reality with workflow technology!)

I’ll see you at the What’s The Fix? A Free Health Care Conference for Everyone!

P.S. One more thing. I’m a big believer in EHR and health IT users making their own workflows. Guess what! Patients will also design the very healthcare workflows that in turn drive patient experience! Viva la workflow! Onward workflowistas!

@wareFLO On Periscope!


Is eClinicalWorks 100% At Fault? No, Ultimate Culprit Was Meaningful Use

While not excusing eClinicalWorks, they were trying to help their customers get the meaningful use subsidies, by gosh or by golly. So, I imagine, if ECW clients reflect on this, they may sympathize with ECW and stick with them… for a while. If the government attempts to claw back those meaningful use payments, possibly as a stick to get ECW customers to migrate to alternative certified EHRs, I’m sure ECW will lose some clients.

On the other hand, while moving data from one EHR to another EHR is difficult enough, migrating workflows from one EHR to another EHR will be even more problematic. Once users customize EHR workflows, or force themselves to adapt to EHR specific ways of operation, they are loath to move to another EHR, if only to avoid another painful training, configuration, and go-live process again.

In the long run, if the financial penalties and additional requirements of the settlement result in diminishing ECW ability to add new features, and support existing ones, then ECW will find it more-and-more difficult to compete in the EHR marketplace.

While I am likely in the minority view here, I think blaming ECW (and other EHR vendors) for this sad situation is shortsighted, unless one also acknowledges the role of the entire meaningful use program, in distorting not just the EHR market, but also the ethical and moral principles of many EHR vendors. It was an expensive mistake, the unintended consequences of which we will be living with for many years.

@wareFLO On Periscope!