Lean Healthcare Needs Business Process Management

[This post is prompted by #HITsm chat 6.03.16 Applying Lean principles in healthcare]

I have long advocated combining process improvement methods with workflow technology, such as Business Process Management (BPM). This post assembles content from presentations, blog posts, and tweets stretching over more than a decade.

Let me start with some personal background. I have two masters degrees. One is Industrial Engineering, focusing on workflow, human factors, and productivity. The other is Intelligent Systems (Medical Informatics option). During my MSIE we studied a wide variety of manufacturing workflow, quality, and productivity techniques. During my MSIS we studied theories, principles, and techniques behind many current health IT products.

Guess what? Lean and health IT need each other. However, this can’t happen until two things occur: Lean becomes more informatics like, and health IT becomes more Lean-like.

OK, I know that tweet wasn’t about Lean and BPM… I just like it! (Though to be fair to myself, whenever I think about workflow I automatically think about the related concept, workflow technology, the modern name for which is Business Process Management).

OK, here’s a more interesting tweet. It depicts two rivers, one workflow improvement and then other health IT, diverging and then reconverging, the confluence being healthcare business process management.

Now, let’s drill down on my Lean plus BPM angle.

Above comes from a question at the end of a webinar I gave about healthcare business process management. You’re welcome to read that complete transcript, but this is how I answered this question.

“If you give Lean and Six Sigma professionals [access to workflow mediated by workflow technology], you’ve give them truly plastic, instrumented, malleable healthcare workflow information management tools, I think you’re going to turbo-charge and give a great deal of help to those Lean and Six Sigma activities. In fact, the BPM professionals? They don’t necessarily know the healthcare domain that well. It’s be great to better marry healthcare domain content expertise, the Lean and Six Sigma health professional, to the software that increasingly mediates healthcare workflow.”

Here’s an interesting graphic. I actually used it as my Twitter avatar for a while! It illustrates the relationship between Lean ideas and BPM technology.

Notice any similarities?

From my 2013 webinar, The Power of Process

The Process Optimization Process: Design, Model, Execute, Monitor, Optimize

Okay. Back to workflow of workflow. If you look up business process management in Wikipedia, there’s a phrase there which is, “process optimization process,” again, it sounds meta, the process of optimizing a process. It kind of should remind you of that diagram I showed you of the workflow of workflow, the steps between bad workflow to good workflow.

Well, business process management has a life cycle. Here we have design, model, execute, monitor, optimize. It should be similar to what I just described. Design and model, that’s creating the process definition, the process model. Execute it, that’s what the workflow engine or the orchestration engine or the process engine does. Those are approximate synonyms.

Then you’ve got monitoring so while it’s executing, if there’s an exception, if it falls off the happy path, you want a human to intercede and fix the problem. Then optimization, all this data that gets generated can be fed back into reducing cycle time, increasing throughput, decreasing errors, increasing the accuracy with which the goal is achieved and achieving the same amount of work with fewer resources.

If that cycle reminds you of something called PDCA, Plan, Do, Check, Act or Adjust, it should. It’s software-based PDCA. So much of work today in healthcare is being mediated. It is being in … it’s actually in the software and so if you want to improve that work in that workflow, why not use the software to do it?

Eliminating EMR EHR Non-Value Added Workflow Steps

Over a decade ago I used to teach an annual three-hour tutorial on healthcare workflow technology. Here my slides and speaker notes for Eliminating EMR EHR Non-Value Added Workflow Steps. Note: this is just a small subset of that tutorial. It focuses on eliminating non-valued-added EHR interactions. Workflow technology can also be used to do things in parallel, and to track and monitor and intercede if necessary. It frees users to think creatively and redesign their workflows.

From 2004 to 2006 I gave an annual three-hour tutorial about EHR Workflow Management Systems (WfMSs). While some terminology is dated (for example, WfMSs are now called Business Process Management Systems), the concepts are even more relevant today. P.S. I’ve been a HIMSS Social Media Ambassador for six years in a row. Join me on Twitter at @wareFLO to to help spread the the message: Viva la Workflow! (Take me to the beginning of these slides!)

From EHR Workflow Management Systems: Essentials, History, Healthcare, TEPR Conference, May 19, 2004, Fort Lauderdale.

Value-added activities are typically those that someone will pay for. To use a manufacturing example, an automobile buyer may willingly pay for a leather interior but will be loath to pay for fixing a defect that shouldn’t be there in the first place. Encounter length is determined by a combination of value-added and non-value-added EHR activities. EHR value-added activities include entering data that may be used in a future decision or making a decision that affects the welfare of the patient. Non-value-added activities include navigation from screen to screen and searching for the next person to handover the next activity in the encounter. If these non-value-added activities, and the time required to accomplish them, can be eliminated, encounter length can be reduced.

Process definitions can be used by the workflow engine to accomplish exactly this. Instead of users having to proceed through multiple clicks to search for the next data or order entry screen, the workflow can be controlled by the process definition and the user merely needs to click ‘Next’, ‘Next’, ‘Next’…. (Of course, a user always has the option of jumping out of an executing definition to manually access a different screen than the one presented. Over time, with process definition refinement, this usually happens less and less.) Similarly, instead of a user having to find the next user to hand off the next activity, the workflow engine can do this instead, perhaps by forwarding items into a user’s To-Do list or onto a generally available status screen of pending tasks.

A general strategic principle is to shift as many value-added, and non-value-added activies from the manual to the automated category, while preserving and enhancing value-added manual activies that increase effectiveness, efficiency, and (user and patient) satisfaction.


Here is a generic representation of a workflow or process. Tasks/activities are the circles and arrows combos. Processes are networks (in this case a very simple network) of interconnected activities. Roles are kinds of resources required to accomplish each step. There are different kinds of resources, some human and some automated. The role is a container and that person (or other resource) must fit, but as long as a resource fits it is interchangeable with other resources.

By the way, this is my own dead-simple notation, intended to convey basic ideas about EHR workflow. Business process management, research and industry, is full of notations (such as Petri nets and BPM Notation) and machine readable formats. My purpose and method here is to emphasize relevance to EHR usability and eschew methodological complexity. This is what I call my cat-dog-tree approach: what are the simplest ideas expressed most simply that only combine in one simple manner.

Suppose step two is navigating from screen to screen or searching for the next person required to complete the process or an opportunity to acomplish the task automatically without relying on expensive manual human labor.


Now the following is a little complicated. I included a number of animations in the original EHR Workflow Management Systems: Key to Usability PowerPoint slides. It was easy to trigger the animations and talk about them. It’s a little different here on the Web. There are ways to include embed animations in web pages. I’ve done elsewhere on this blog. However, I’ve found, these are not usually very cross-platform friendly, and especially so with advent of smartphones. So I decided to screen-capture intermediate animation states and publish a series of screen captures from the original slides.


The slide generically shows customer value incrementally growing during execution of workflow. I’ve only labeled the three steps from the previous slide. Steps 1, 3, and (implied) 5 are value-added so their execution moves graphed customer value up and to the right. Steps 2 and (implied) 4 (in green) consume resources and, especially, time, but do not contribute to accumulated customer value.


This is just a visual representation of the previous paragraph. The phrase “Value-Added” points to steps 1, 3, and 5. The phrase “Non-Value-Added” points to steps 2 and 4. (If this slide reminds you of Value Stream Mapping. It should.)


In the original slide animation steps 2 and 4 disappeared and steps 3 and 5 slipped to the left. The result is a graph that shows steadily increasing accumulated EHR value during execution of workflow and a new, shorter, cycle time (length of patient encounter).

The following slides depict intermediate animation states showing essentially the same idea as above: elimination of non-value added EHR steps results in a shorter patient encounter. The slides look different because I took them from the 2004 tutorial slides.


Animation Step 1


Animation Step 2


Animation Step 3


Animation Step 4


Animation Step 5


Animation Step 6


Animation Step 7

In Conclusion (applause…)

My basic point is two-fold. First, traditional process improvement techniques don’t scale without leveraging information technology. The most relevant IT is what academics call “process-aware” informations systems. More generally, it used to be called workflow management systems. It is now called Business Process Management.

Second, for BPM to become most successful in healthcare, it must incorporate, support, and enable sophisticated healthcare “process optimization processes”. I’m reminded of the Reese’s commercial: Better Together!

Hey You Got Peanut Butter (Lean) in My Chocolate (BPM)

Here are the questions for #HITsm chat 6.03.16, plus some notes to myself I’ll probably tweet.

Topic 1: Without the use of Google, what is your definition of #Lean techniques? #HITsm

“be in or move into a sloping position…a deviation from the perpendicular”

Just kidding. Since I filter everything through the lens of workflow…

IMO Lean should include giving health IT users tools to systematically eliminate waste & increase value & usability (AKA workflow tech)

Topic 2: What are some areas of healthcare where #Lean principles can have the most benefit? #HITsm

What healthcare areas can benefit from combining #Lean & workflow tech? All areas, literally cannot think of any exceptions

Topic 3: What’s the biggest challenge in adopting or practicing #Lean? #HITsm

Biggest challenge adopting #Lean? IMO Role of health IT mediating HC work. The workflows are frozen! Must unfreeze!

Topic 4: How can health system create a culture of continuous improvement? #HITsm

Many do not think there is a connection between culture and workflow. They are so wrong!

Topic 5: What are some ways you’ve seen technology companies support #Lean efforts? #HITsm

Workflow tech companies providing ability to users to systematically improve workflow efficiency, effectiveness, and usability.

@wareFLO On Periscope!


P.S. Here are a bunch more of my tweets re Lean and BPM!

Workflow Quotes From 10 Percent Of 460 Open EHR Workflow Analyst Positions

Preparing for this evening’s blab about EHR workflow improvement coordinators I searched for job + workflow + EHR OR EMR on Google. The following list of 460 open job positions came up. I searched the first 46 jobs for “workflow.” Here is what I found.

Clinical Analyst

Working knowledge of hospital and surgical processes and workflow

Epic Inpatient (Orders) Analyst

Perform in-depth analysis of workflows, data collection, report details, and other technical issues associated with the use of Epic software

Work with Application Managers/Directors/etc. and the entire Project Team, to collect, analyze and document business operations and workflow.

With support, create, review, and update test scripts to reflect proposed workflow solutions.

EPIC Ambulatory Analyst

Create documentation of business requirements, current and future state workflows

Application Systems Analyst, Sr.

Reviews issue logs, plans and implements workflows, upgrades, and development projects

Electronic Health Records (EHR) Analyst

The primary focus for this role is maintenance, support, workflow analysis, and systems development associated with the Software systems, specifically the Electronic Health Records System (EHRS).

Assists in developing Policies and Procedures around electronic health records and supports and documents the continued use of Foothill Family standards and workflows in the EHRS.

Creates and maintains workflow diagrams based on system functionality to assist in troubleshooting.

Identifies, recommends, and implements workflow improvements in relation to the EHRS by working with users, super users, and vendors.

Demonstrated ability to design and documents workflows.

IT Clinical Analyst

Understands the functional workflow and processes of the Departments the analyst supports and maintains system functionality and design in support of workflow efficiency and user/department productivity.

Must have ability to learn system functionality and workflow in depth


Serves as a change management resource and manages the changes in the workflow process that will need to be made with the transition to EMR.

Division EMR Analyst

The Division EMR analyst works closely with the integrated support team (HCAPS, IT&S, CSG, SSP, etc.) to provide content build, workflow analysis, optimization planning, training, and live support of clinical users on the EMR.

Mature understanding of clinical application support processes and workflow, ambulatory EMR preferred

Staff Clinical Informatics Analyst

Clinical Informatics Analyst – Staff is responsible to perform workflow and system analysis and functional design for software development / configuration activities associated with iCentra and other HIT-related initiatives

Documents and recommends workflow changes and functional requirements, specifications, and design solutions needed to support the business requirements for common and moderately complex problems.

Collaborates with key clinical and business stakeholders to determine business rules, needs, specifications, feasibility (workflow and cost), and priorities for application development / configuration / acquisition requests and projects with a basic to moderate level of complexity and according to organizational standards and processes.

Meditech Clinical Analyst

Collaborate closely with and communicate between – IT and the hospital’s clinical staff to be up-to-speed on product features and functionality in aligning daily workflows and strategic objectives.

Clinical Application Analyst

Develop forms and specialized reports in EHR to ensure timely and accurate flow of information crucial to clinical operations and workflows as well as business and billing operations, utilizing MSSQL/T-SQL, EHR software and reporting tools, SSRS and Crystal reporting.

Experience writing workflows.

OpTime Anesthesia Analyst

Routinely perform in-depth analysis of workflows, data collection, report details and other build, design and configuration issues associated with Epic use

Ensure test scripts are created, reviewed and updated to reflect proposed workflow solutions

Familiarity with anesthesia scheduling and staff workflows, resource management and regulatory requirements

Ability to conduct detailed assessment of current state workflows & develop efficient future state workflows


Able to collect data regarding current data processing environment and documents workflows and system access

Ability to make recommendations for workflow based on system capabilities.

Serves as member of various employee committees to discuss workflow, system needs and changes

Healthcare IT Analyst (EMR)

All candidates must have an in-depth understanding of workflows, policies and procedures, patient care/clinical business objectives, regulatory requirements and industry best practices for patient care.

The Application Analyst assists hospitals in optimizing their workflow processes through building applications that are tailored to meet the hospital’s needs.

They will learn the EMR system’s capabilities and functional use and apply their knowledge of Patient Care Business workflow to assist in the implementation of a system that meets process needs.

Basic understanding of clinical workflows and terminology preferred

Create documentation of business requirements, current and future state workflows

Clinical Information Systems Analyst

clarify needs, prioritize requests, recommend workflow enhancements, and execute change and adoption management of the Cerner Millennium EMR and other healthcare information technology (HIT) initiatives (i.e. Meaningful Use, Clinical Documentation, CPOE, and HIE).

The Clinical Systems Analyst will assist in documenting current workflow processes, performing gap analysis, and identifying needed process changes to ensure compliance with the use of technology to optimize care delivery processes and effectively communicate patient care activities.

Systems Support Analyst

Assists in the development of system workflow, templates and forms

Applications Analyst III Job

Clinical background and/or knowledge of Rehab/Therapy workflow a plus.

EMR Applications Analyst

Develop a comprehensive working knowledge of the applications currently used in assigned practices, as well as the design, build and workflow associated with the EMR.

Software Product Analyst

Developing application and data workflow diagrams

Meditech Clinical Analyst

Collaborate closely with and communicate between – IT and the hospital’s clinical staff to be up-to-speed on product features and functionality in aligning daily workflows and strategic objectives.

IT Clinical Analyst

The position is visible to clinicians with significant impact on patient safety, JCAHO, HIPAA, departmental and patient workflow.

Independently facilitates design of clinical workflow in conjunction with the clinicians; workflows will focus on improved efficiencies, solving complex workflow issues and incorporating quality initiatives.

Systems Analyst

Analyzes workflows and recommends alternatives for deriving input data, considering impact on existing systems and downstream effects (i.e. using approved change management procedures).

Epic Clarity Reports Analyst

perform analysis, development, and testing of complex reports and analytics with minimal supervision; design and develop high-efficiency reporting solutions based on end-user requirements and understanding of the Epic EMR system and workflows;

Clinical Business Analyst

Prepares workflow charts and diagrams to document business and systems workflows for existing and new applications

Plans and prepares business documents, reports, memoranda, and instructional manuals as documentation of project requirements and workflows

Privacy Analyst

Ability to use various computer applications to optimize workflow and data analytics to detect, prevent and investigate privacy incidents.

IS Clinical Applications Analyst II

Design, document, and implement future-state workflows consistent with clinical best practices and system functionality in collaboration with other team members, clinical department representatives, or under the direction of IS management/project manager.

Analyzes current state workflows/needs and translates these into the system design.

Design, build, and validate the application to conform to desired workflows within assigned area.

Coordinates with principle trainers in the design development of role-based training to support the workflows implemented.

Provide tier 2 end user application support with an understanding of the Health Information Systems modules including functionality, technical architecture, workflow, routine and non-routine processing.

Technical Support Analyst I

Understanding of clinical workflow in a medical imaging environment.


The role will be a primary member of the onsite go-live support team, reinforcing application and workflow training and assisting with issue resolution.

Training and reinforcement of standard organizational workflows, both operational and clinical.

Ability to act as a team leader for small projects or work groups, creating a collaborative and respectful team environment and improving workflows.

Clinical Informaticist

The Clinical Informaticist works closely with the medical staff to incorporate workflows into system design and keeps current on new system functionality that will improve system acceptance and usage and strengthen the clinician-patient relationship.

Clinical Systems Analyst

Manage the clinician experience with the EMR by guiding the solution design, training resources, and supporting processes to ensure the successful engagement and sustainment of the solution while considering associated workflows and how the application(s) integrate with the clinical environments.

Clinical Analyst IS Configurators

identifies opportunities where the clinical information system can be utilized to optimize workflow for clinical processes.

Clinical Informatics Support Analyst

development of clinical workflow changes as it relates to implementation, upgrade, and optimization of clinical applications

Works with nursing department, physicians and other clinical staff to review, recommend and implement workflow and technical solutions that address operational, procedural and systems related issues within and across hospital departments and physician offices.

Strategy Analyst

combine problem-solving, data-analysis, and technical skills to identify, quantify, and solve real-world healthcare workflow problems

You will directly contribute to improved financial and clinical workflow performance for providers, allowing them to focus on the business of delivering healthcare


Provides analysis for department workflows & identifies EMR requirements as supported by evidence and policies and procedures.

Develops and maintains department specific workflow documentation.

Assures standardization of policies, procedures, workflows, in accordance with the organization’s approved EMR practices. Identifies, escalates and works to resolve deviations.

Manager of Clinical Software Applications and Development

Significant experience and thorough understanding of EMR systems, clinical workflows and implementation

Interface Analyst

Work with end-users and project teams to analyze and document data and workflow processes.

Clinical Data Business Systems Analyst

provides a bridge between clinical workflows and technical workflows, leverages knowledge and skills to ensure technology meets clinical needs and regulatory requirements.

EHR Application Analyst

-Understanding both the clinical and business workflows to achieve strategic outcomes for the implementation

Clinical Business Analyst

Prepares workflow charts and diagrams to document business and systems workflows for existing and new applications

Plans and prepares business documents, reports, memoranda, and instructional manuals as documentation of project requirements and workflows

EHR Application Analyst

-Understanding both the clinical and business workflows to achieve strategic outcomes for the implementation

Two years of Epic software/domain/workflow

Clinical Process Analyst

Knowledge of systems analysis methodologies, workflow process analysis, and software application systems implementation is required.

Clinical Systems Analyst

Working knowledge of hospital and surgical processes and workflow

I Found Workflow at National Health IT Week!

I spent the day at the National Health IT Week Second Annual National Health IT Collaborative for the Underserved Conference. As usual I went looking for the workflow angle. 🙂

And I found it. During the HIT Innovation and Research Panel, which I Periscoped (archived to Katch), Aysha Corbett, MD., Deputy Chief Medical Officer and VP for Quality Improvement, Provider Recruitment/Education at Unity Health here in Washington, discussed the workflow problems they’ve had since they bought one of the most popular EHRs in 2009. You can listen to Dr. Corbett, starting around 30 minutes into the video. Or you can skip to my running paraphrase of her comments, just after the embedded video.

Yes. I know the video turns sideways part way through! 🙂

  • the emr has brought a lot in safety and getting information out
  • but there’s been a lot of change in our workflow, in our life
  • we’ve have to change the way we do things, because of the way the tool is built instead of the other way around
  • instead of coming to see how we work, and building the tool … [same for patients re portal]
  • a tool that makes daily workflow easier instead of harder is a must
  • people are really burning out, they say they’re glorified data clerks
  • spend so much time with data fields instead of writing coherent notes that make sense to readers
  • the notes are hardly readable, due to their structured data format
  • [please] make our lives easier, not more difficult
  • we’ve become data entry and treasure hunters [info finding-wise]
  • [the EHR] needs to easily adapted to lots of different kinds of providers

If only modern EHRs were built on modern workflow platforms, instead of user interfaces plastered on databases! All of the above could have been easily achieved. By creating user-editable workflow definitions, executed by an EHR workflow engine, if the Dr. Corbett didn’t like the workflows, she and her users could have changed the workflow definitions to fit their own workflows. This is exactly what the first three winners (2003, 2004, 2005) of the HIMSS Davies Award for Ambulatory EHR use did. I know, I helped them edit those workflow definitions. And then help them write all three of their HIMSS Davies Award applications. Feel free to read their original HIMSS Davies applications. They specifically outline that success was due ability to customize EHR workflow to their own needs, instead of having to fit their workflows to the EHR.

After the excellent presentation, Dr. Corbett and I mused about how to fix this unfortunately almost universal experience with that I call “workflow-oblivious” EHRs. I suggested that while EHRs will likely improve somewhat, they’re basic character, that of forcing relatively frozen workflow on clinical users, is unlikely to change much, if it all. Instead, I suggested, there will be a new layer on top of EHRs, which will provide the kind of process-awareness I’ve written about extensively.

I hope you’ll read my most recent posts on the subject, ten in all! There is my 7000-word, five-part series on task and workflow interoperability. And then there is my five-part tutorial series on healthcare workflow technology, usability, patient safety, interoperability, and population health and care coordination.

Lucky for all of us, health IT is indeed becoming more process-aware. This year five percent of 1500 HIMSS Conference exhibitor websites actually mention “workflow engine” someplace on their websites. This statistics doesn’t count the other almost synonyms, such as orchestration engine, or other indicators of a workflow engine under the hood, such as “customizable workflow” or “workflow-driven”. For the last five years I searched every website of every HIMSS conference exhibitor for workflow and workflow technology related material: 2%, 4%, 8%, 16%, and this year more than a third, so much I couldn’t finish what had become my annual survey.

Further, I can no longer count on one hand, or even two hands, fellow workflowistas on Twitter, LinkedIn, and in the bloggosphere. To them, to you, now is not the time to let up on the pressure necessary to move from workflow-oblivious to process aware health IT systems! Viva la workflow! Onward workflowistas!

P.S. Whether to cheer me on, or tell me I’m full it, please join my mid #NHITweek blab today (Wednesday) at 2PM EST!

I Used To Design EHR Buttons: Here Are Some Of My Favorites

Pediatric practices usually look a bit different from other medical practices in that they often include childlike elements. Sometimes even their websites reflect this: featured crayon artwork, handwritten-like fonts, and exhuberent silly humor (I love the sound of children’s laughter that automatically plays when you visit www.cooperpediatrics.com).


Pediatric EMRs and pediatric EMR workflow systems are important visual elements of the patient-pediatrician encounter. Toys in the corner, cartoons on the wall, and a continuously playing “The Little Mermaid” DVD are all reassuring signs that this is a child-friendly environment. Children see what we see and focus on what we focus on, and that includes EMRs. In other words, pediatric EMRs and pediatric EMR workflow systems unavoidably participate in this ecosystem of meaning.

But the following three were my favs of all time: Check out that last one with a martini and a cigar. Appropriate? Perhaps not. But when we offered to change it, well, it almost caused a mutiny.

button_virus Immunizations (OK, no child would likely recognize that this is a virus called a bacteriophage, but pediatrician users do seem to llike it)
button_stork Gravidity and Parity (Not sure about the educational implications of this one, but it’s still a favorite)
button_social_history Adult Social History (We did this button custom for a family medicine physician. Another user claims he bought the EHR *because* he liked this button. His first issue to support was “Give me my martini and cigar button back!”)

Almost 25 Years Ago I Co-Developed A Prototype Of A Radiology Imaging Workflow System

Almost 25 years ago I co-developed a prototype of a radiology imaging workflow system at Shadyside Hospital in Pittsburgh. We published details in the 18th Annual Symposia on Computer Applications in Medical Care (SCAMC, now AMIA). I’ve been meaning to resurrect some of that detail for a long while. I finally have.

We’d been tasked with replacing a radiology information system from the sixties with a system based on what was then current tech. By the way, if you follow along the screens, you’ll see it is indeed a workflow. The next step would have been to control tasks and screens from a workflow engine, though we didn’t get that far. Anyway, this was when my interest in healthcare workflow management systems technology really gelled. SGML? Standard Generalized Markup Language, which predates HTML. This system was essentially a clinical domain-specialized web-browser (and back-end servers) before the advent of the World Wide Web.


FELIX (FELIX Enables Limitless Information Exploration) provides a generic graphical interface for browsing medical and administrative information. FELIX relies on a large number of industry standards such as TCP/IP, X11R5, SQL and SQL-II, Postscript and SGML. In particular, the interface was developed using a high-level X-windows graphical scripting language called Tcl/Tk (Ousterhout, 1990, 1991,1994). We used real patient information and based our targeted applications on analysis of patient care processes at a local urban community referral hospital. We intended FELIX to be a vision of what is possible, a prototype to force us to confront the necessary integration of disparate technologies, and an inducement for clinicians and administrators to press for open systems file formats, programmatic interfaces and network protocols.


A magnetic resonance image scan has been completed and is ready for interpretation.


By pushing the button titled “Record Report”, a tape recorder with the standard buttons appears on the screen, which allows the physician to verbally enter their findings.


A document that looks like a “document” (left), but which is actually derived from a database, can be printed, FAXed, or electronically mailed.


Patients are tracked into and out of rooms using bar code readers on a network and the information is periodically used to update bar charts. Each bar represents a room. Height represents length-of-stay. Red indicates length-of-stay larger than an adjustable threshold.


The digitized image of a peripheral blood smear has annotated areas that correspond to high-lighted phrases in the textual clinical report.


This resource scheduler represents doctors, nurses, rooms, and equipment across the top, and times down the side. Constraint processing indicates in green the times during which resources are available to be committed together.


On the left is a list of procedures and referring physicians, which can be used to plot procedure volume over time. Decreasing rates of referral may suggest need to intervention.

Transcribed Slides For My 42-Minute Webinar on Ebola, EHR Workflow Engines, Editors, and Visibility

(This is a full-text transcription of one slide from my November 5th 42-minute webinar on Ebola and EHR Workflow Engines, Editors, and Visibility. Please excuse occasional “typos” as I’ve not proofed every word. Consider watching the Youtube video. My original post announcing the webinar includes motivating context and an outline. Thank you!)


My name is Charles Webster. I’m @wareFLO on Twitter, W-A-R-E-F-L-O. All of my slides are tweets. People sometimes say they think I’m tweeting PowerPoint slides. That’s what I use them for. If you are on Twitter, please use #EHRworkflowNov5.

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Youtube Recording of My Webinar on Ebola and EHR Workflow Engines, Editors, & Visibility

Missed the webinar! No prob! Here it is on Youtube! Cheers!

The hashtag is #EHRworkflowNov5.

This webinar is not just for physicians (the domain is pediatric workflow). It’s for patients, providers, payers, policy wonks, and politicians too. Literally everyone, who comes into contact with healthcare workflows and processes, is affected by our workflow-oblivous information systems! This webinar is not just relevant to Electronic Health Records either! The basics of workflow, workflow tech, workflow engines, editors, and visibility apply to all health IT information systems,

We (“workflowistas” on Twitter) are making remarkable strides in raising Health IT awareness about the importance of healthcare workflow and relevance of workflow technology. Unfortunately some of this progress is due to the unfolding tragedy of Ebola (missed) diagnoses and (mis) management. Whether or not EHR or human or some combination of workflow is to blame, EHR workflow has entered newspaper, cable news, and blogosphere headlines in a way not previously seen.


In this webinar, I’ll cover the basics:

  • What it workflow?
  • What is workflow technology?
  • What is a workflow engine?
  • What is a workflow editor?
  • What is workflow visibility?

And why healthcare so desperately needs the above, embedded in the EHRs and health IT systems we use daily.

Even if you already are a workflow expert, and know the above topics, I hope you’ll attend and show your support. I’m trying to make “workflow,” the problem, and “workflow tech,” the solution, into first-class health IT topics, up there with Social, Mobile, Analytics & Cloud.

Help coordinate and educate health IT about the process-aware angle on understanding and managing healthcare tangled workflow problems. Follow me on Twitter at @wareFLO or contact me with this blog’s contact form.

Xcite Health Pediatric EHR Webinar Features Ex EncounterPRO CMIO Dr. Webster On EHR Workflow

(Webinar registration link!)


Here’s the official webinar description:

Award-Winning Pediatric EHR Workflow System is
Back and Better than Ever

(My original title was “3-Time HIMSS Davies MU Stage 2 Pediatric EHR Workflow System Is Back!” but it was deemed to wordy. In retrospect, I agree: boo-boo!)

Torn from the headlines: “EHR Workflow Flaw Led to Initial Release of Ebola Patient.” Workflow has suddenly achieved its place in Health IT’s sun that Charles Webster, MD, MISE, MSIS has always believed it should. Dr. Webster, “Healthcare IT workflow & Business Process Management expert,” is a frequently quoted in the news about health IT workflow issues. On November 5th, at 12 noon EST, he will layout the ABCs of EHR workflow tech: workflow engine, workflow definitions, and workflow visibility. Following, Pediatrician Dr. George Rogu will describe exactly how a true EHR workflow system dramatically increases his productivity and patient satisfaction. This webinar appeal to pediatricians and other primary care physicians, plus anyone interested in healthcare workflow and workflow technology.

Here’s the webinar background:

Very influential on my thinking about EHR and health IT workflow and workflow technology was my experience as Chief Medical Informatics Officer for an EHR called the EncounterPRO Workflow System. During the 90s I developed the first medical informatics curriculum to equally emphasize medicine, computers, and business. When my wife moved from Pittsburgh to Atlanta, a hotbed for health IT, I went to the HIMSS conference in Atlanta, resume in hand. I looked at dozens of EHRs (yes, there were that many!) but didn’t like any of them. They were all basically Microsoft Office clones. Too much clicking! But then I saw the EncounterPRO EHR — big buttons, automatically presented screens, user-customizable workflows — the Industrial Engineer in me (MSIE, Illinois) realized I was looking at a classic workflow management system.

I loved my time at JMJ Technologies and then EncounterPRO Healthcare Resources. It was the perfect match between my own background (Accountancy, Industrial Engineering, Artificial Intelligence, and Medicine) and the kind of true workflow automation that we see so little of in healthcare, until recently. Our customers won the first three ambulatory EHR HIMSS Davies Awards. (Unconfirmed rumor: judges picked us the fourth year too, but, well, you can understand how that made our competitors feel….)

I’ve moved on. I now do for an entire industry what I used to do for EncounterPRO, educate and market about healthcare workflow and workflow technology. I sometimes refer to myself as a CMIMO: Chief Medical Informatics Marketing Officer! 🙂

So I was delighted when I learned that the EncounterPRO Workflow System was rebranded as the XciteEHR from Xcite Health. And, (important), EncounterPRO/Xcite EHR just achieved Stage 2 Meaningful Use certification. If you know me, you know I have mixed feelings about MU (I can hear a couple chuckles out there). Nonetheless, Stage 2 MU certification is still an impressive technical and marketing achievement. Congratulations Xcite Health, for polishing a diamond-in-the-rough and the certification.

OK! That’s the background!

On November 5th, at 12 noon EST, I’m keynoting a webinar from Xcite Health. Basically I’ll be talking about what I always talk (and blog and tweet) about: workflow and workflow tech in healthcare. I’ve been convinced for years that “workflow” will join SMAC (Social, Mobile, Analytics, Cloud) as a “Big Idea.” But I didn’t know how: Ebola.

Inadvertent release of a patient infected with the Ebola virus was blamed on EHR workflow. Suddenly “EHR workflow” was everywhere on social media and health IT trade journal websites. As Dr. Workflow on Twitter, lots of folks contacted me for comments about what may have happened. You can read my series of blog posts here. So, what I’ll be talking about during my webinar with Xcite Health will be the ABCs of EHR workflow technology and their relevance to EHR workflow in the news. Then George Rogu, MD, pediatrician specializing in international adoption, will then talk about using a true EHR workflow system in pediatric practice.

P.S. I’m very active on Twitter at @wareFLO, where I tweet about healthcare workflow and workflow technology, and cat videos. If you’re a fellow or fellowess twepe, be sure to tweet me just before my webinar. I’m hoping to give a shout out! 🙂

P.S.S. Here’s the portrait version of the above banner announcing my webinar. Feel free to grab either and plaster them on your blog or tweet them out. Be sure to let me know, so I can return the favor. We Workflowists gotta stick together! Viva la workflow!


A Pediatric EHR Workflow System: 10 Questions For Barry Hayut, Xcite Health

Just in time for the American Academy of Pediatrics National Conference in San Diego, here is one of my increasingly infamous 10 question in-the-weeds interviews! This time about a remarkable pediatric EHR workflow system (also used by other primary care specialists). It used to be named EncounterPRO, under which name it won the first three ambulatory EHR HIMSS Davies Awards. This EHR workflow system is now called XciteEHR and my interview is with Barry Hayut, of Xcite Health. By the way, Xcite is hosting a free webinar, featuring me! I’ll talk about the difference between traditional EHRs and EHR workflow systems on November 5th at 12 Noon EST.

As a side note, this is a special interview for me because I was involved with the early design and implementation of this particular pediatric EHR workflow system. I expect many AAP attendees may remember EncounterPRO (originally developed by JMJ Technologies) and will find this interview of special interest. Creating and customizing EHR workflows for our customers, when I was EncounterPRO CMIO, really drove home the importance of true workflow technology at the point of care. Some of the older posts on this blog, EHR Workflow Management Systems, were about EncounterPRO.

  1. How did you end up in the pediatric EHR workflow system business?
  2. Could you discuss Meaningful Use 2 and why it’s important to be MU2 certified?
  3. Do you also sell a Practice Management system?
  4. What’s the difference between EHR workflow systems and mere EHR systems?
  5. Would you share your workflow, writer, editor, publicist analogy?
  6. What does a true EHR workflow system *do* for physicians?
  7. Would you show us the XciteEHR Office View and explain its functions?
  8. What physician specialty practice areas does the XciteEHR cover?
  9. How will you educate the world about true EHR workflow systems?
  10. Thoughts, Barry? About EHRs, workflow, and physician happiness?

By the way, Barry, congratulations on making the XciteEHR is a Complete MU2-certified EHR! You must be mighty proud of your certificate!

Starting Saturday, I’ll be updating and tweeting answers to the above questions on the AAP conference hashtag #AAP14. Stay tuned!

1. Barry, could you tell us a bit about how you ended up in the business of selling the award winning pediatric and primary care XciteEHR workflow system?

I was the CEO of a company that owned and managed multiple radiology outpatient centers. We experienced first-hand the needs of the physicians, office staff and patients for software that enhances productivity.

When we saw the EncounterPRO EHR’s superior workflow engine, Office View, and configurability, we decided to adapt it and integrate it with our Practice Management system and patient portal for seamless integration, productivity and ease of use.

2. In choosing an EHR for a physician practice, can you discuss Meaningful Use 2 and why it’s so important to be MU2 certified?

As you mentioned, XciteEHR is indeed Meaningful Use Stage 2 certified. Thank you.

Meaningful Use 2 is a set of very ambitious standards implemented by the Office of the National Coordinator for Health Information Technology, designed to create robust digital clinical records, track Meaningful Use metrics and Clinical Quality Measures, increase interoperability among various vendors, create uniform standards for reporting data to health agencies, and create standards for the secure communication of electronic health data to patients. Certification of an EHR is tied to incentive payments from the government to physicians with Medicare and Medicaid patients and eventually is expected to be the standard imposed by health insurance companies for all physicians.

3. Do you also sell a Practice Management system? (Scheduling, Billing, Accounts Receivable, etc.)

Yes, Xcite Health also has an integrated cloud-based Practice Management System with the EHR. It has scheduling, registration, billing, revenue cycle management, provider credentialing and vaccine inventory management. All of the billing codes such as CPT codes, ICD-9 codes, and in the near future, ICD-10 codes, flow seamlessly into the practice management system from the EHR so, as the physician finishes charting the patient encounter, the billing information is finished and sent to the payers, as well.

4. Talk to me about what it means to be an EHR workflow system, in contrast to a mere EHR system.

Let me first explain what we mean by workflow. As the leader in this area it is important that I explain how this ‘changes things forever’—for many physician practices!

If you feel that, as a physician, you are constantly giving instructions to your staff—and always following up to ensure things have been done—then XciteEHR is for you.

If you feel that you are being asked to change the way you practice medicine to adapt to the strictures of your EHR software, then XciteEHR is for you.

Or, if you feel that you should not take a productivity hit when you implement an EHR and feel instead that your productivity should improve and finish charting as the exam is done, then the XciteEHR is for you

This is what truly sets us apart.

5. I love your workflow system / writer, editor, publicist analogy! Could you please share?

Our EHR workflows drive action, ensure consistency, and increase visibility by connecting your people with relevant tasks and information. It helps you rapidly transform your practice—with applications that connect the right people to the right information and the right work.

Other systems may claim to be “workflow systems.” However, a TRUE workflow system has 3 components—much like an author who needs three things to be successful. An author needs a writer—himself, an editor, and a publicist.

With a true workflow system:

  • YOU are the author, deciding how you practice medicine, and the XciteEHR was built to allow you to author the fine details of how workflow works in your office.
  • You need an editor to perfect and optimize the way you work and on-the-fly workflow editing tools allow your practice to fine-tune your office workflow.
  • And then you need a publicist – to PUBLICIZE this information to your whole staff—so they know ‘when and how’ to do their work – thereby meeting your expectations!

These three components: an engine, an editor, and a publicist, to provide visibility, are critical to having a blockbuster success when you implement an EHR.

XciteEHR is an easy-to-use tool built on top of a workflow engine that maximizes your success; it makes your team more efficient, your life easier, and your practice more profitable!

6. OK, that’s a true EHR workflow system *is*; what does a true EHR workflow system *do*?

Simultaneous processes take place as physicians and staff naturally and seamlessly interact with the program.

As an example, when physicians order vaccines from inside the exam room, the system simultaneously displays the tasks involved in completing the order on the office view screen prompting the appropriate staff members to respond wherever they may be.

While the physicians are finishing in the exam room, the nurses are already preparing to give vaccines. Not only that, the system is automatically queuing up the desired authorization forms and education materials as workplan steps. Before physicians walk out of the exam room, nurses can be ready to complete the necessary paperwork and administer the shots. Precious minutes are shaved off of the time that the exam room is occupied. Patients spend less time in the waiting room and less time in the exam room. The efficiencies yield happier patients and higher revenues.

There is no other system that has this sort of workflow. Because of this simultaneous processing, we are able to improve overall efficiency—and make the workday fly by—and end on time!

7. I know that the most visually striking feature of the XciteEHR is the Office View. Could you show us a screenshot (with de-identified data, of course!) and explain what we’re seeing—and its benefits?

The office view screen is what really sets us apart and is the heart of the office workflow.


The first thing you’ll notice on the office view screen is that it’s tailored to each individual office, with the exam rooms shown on the screen.

Also, each user or role is assigned a color for his or her task bars. For example, this doctor is assigned green and knows immediately that he/she has a patient waiting in room (4).

Each task is time-stamped in real time, so the user knows exactly how long the patient has been waiting for that particular task to be completed.

On the left taskbar, you’ll see that the patient has been waiting in the room for 9 minutes. And, on the right taskbar, it shows that the patient has been waiting on the physician to perform an exam for 3 minutes.

In reality, this prompts the physician to go and see the next patient, or to perform the next urgent task. The patient in room 8 is waiting on the nurse to give a vaccination. This is what I mean by simultaneous tasking—allowing for increased efficiency and a smoother work day and far, far greater coordination and patient satisfaction!

8. What physician practice areas does the XciteEHR cover?

We currently market to and are exceptional in the primary care areas of Pediatrics, Family Practice, Internal Medicine and Obstetrics/Gynecology. However, our workflow engine could be adapted to any medical specialty.

[CW: I’d like to interject here. The ability to customize workflow is critical for multi-specialty pediatric practices. See my Why Specialists Need Speciality-Specific EMRs That Understand More Than Their Specialty.]

9. I think it’s fantastic to see the kind of physician’s practice clinical workflow technology that the XciteEHR represents stepping into the health IT limelight, especially now that there’s health IT social media. How are you planning on educating the world about this type of award-winning EHR workflow technology?

We want to teach physicians to demand true workflow management technology from their EHR vendor. There is no excuse for lost productivity when a medical practice adopts an EHR. With true workflow management technology, a practice should see an increase in productivity in the first three to six months of use, not a decrease. Physicians do not know what to demand because they do not understand the efficiencies that a true workflow system can deliver to them.

We are going to conduct a series of webinars and marketing campaigns to educate physicians about how to make the EHR system to work for them and NOT how the physicians and their staff must conform to the EHR system.

10. Last thoughts, Barrry?

Unfortunately the term workflow has been too commoditized. It seems that if you can string together a serious of computerized actions you can call it workflow.

In many of the other systems, the physicians are choosing from menus, templates and options to figure out next steps. Each practice role player is on his/her own with their tasks, as if everybody is on their own island.

Since getting involved in this field way back in the late 90’s, I have looked at every EHR out there. What is now the XciteEHR, looks and works completely differently from every other type of EHR on the market.

In the XciteEHR once configured by the physician the way she/he likes to practice medicine, the workflow engine will present the right task screens, based on the action taken by the physician, to all relevant practice role players simultaneously and can be viewed and tracked on the Office View screen.

The XciteEHR is built on a strong history and experience of having been in the market for over 20 years—but its features currently surpass every other EHR on the market today—exponentially surpassing all others in one area. Happiness.

I believe that true EHR workflow, customizable to specialty and user needs and preferences, is the single most important key to dramatically increasing physician happiness (yes, happiness) to use an EHR.

[CW: Excellent, Barry! Thank you for working to improve healthcare workflow with information technology! In fact, I even have a special badge I give to the folks in the white hats, the cavalry, as it were, rushing to the aid of physicians ensnared in workflow-oblivious IT systems! See below…]

Ebola, EHRs, and Evidence-Based Workflow: We Need Open and Transparent Healthcare Workflows

Thomas Eric Duncan, the Ebola patient released from Texas Health Presbyterian Hospital, died this morning at 7:51 a.m. The hospital first blamed a flaw in EHR workflow, but then retracted that claim the next day. Social media has been fractious. Basically, whether you like EHRs, as currently designed and implemented (“See, I told you so!”), or dislike EHRs, as currently designed and implemented (“Statement retracted, no flaw, case closed.”), predicted most reactions.

Unfortunately, I fear, we well never know for sure, the answer to the question, “”What did the EHR users know and when did they know it?” Barring some enforced Epic EHR contractual gag clause, accounts will be forthcoming. But, given the variety of strong biases many stockholders bring to the subject of EHRs and EHR workflow (and I am one of them), it seems unlikely that all will be satisfied. There are too plausible reasons why hospitals, EHR vendors, nurses, and physicians might be reluctant to potentially admit culpability.

We need an evidence-based workflow account of the complete who-what-why-where-when-and-hows sequence of EHR-mediated user activity that may, or may not, have contributed to Mr. Duncan’s release. The problem is, even if a blue-ribbon panel of experts, akin to the Rogers Commission that investigated the Challenger explosion, takes up the matter, current EHRs, of which Epic is emblematic, don’t represent workflow in a way that allows us to make the necessary inferences to explain what when wrong and who or what is to blame.

What do I mean by “represent workflow”? What I mean is, just as current EHRs represent data about patients and drugs and procedures and such, EHRs need to explicitly represent sequences of tasks (data gathering, order entering), the resources consumed (time, money, user attention), and, most important of all, the goals the tasks are intended to together accomplish. Why is representing goals so important? Because goals go to intent. Why was the nurse or physician trying to do when they clicked that button or spoke that command?

What I have just described — the explicit representation of tasks, resources, and goals — is how workflow management system work. True workflow systems, sometimes also known as business process management or dynamic and adaptive case management systems, execute or consult models of work and workflow to automatically do for users what would normally require users to do for themselves. Since these models are easier for clinical users to understand than computer code (Java, C#, Mumps, etc.) it’s easier for users to tell analysts how to design their preferred workflows. Sometimes precocious users even start tweaking workflows themselves. It makes them happier, to make workflow fit their work than make their work fit programmers workflow.

But here’s the important thing, EHR workflow systems leave a detailed, time-stamped trail of who-what-why-where-when-and-how users interacted with the EHR workflow systems. Right now, this kind of data is either absent, locked up in opaque event logs, or misleading, even if one were to be able to extract it. The very best event logs are generated by workflow management and business process management systems.

Even more important than open source and open data, is open and transparent workflow. I call this kind of EHR workflow “figureoutable” and “buildonable.” Mere mortals, who are not programmers, can figure it out and leverage it in ways that the original programmers might not have specifically imagined. These mere mortals include investigators trying to piece together what went wrong.

I’ve written several other blog posts about how process-aware EHR and public health IT systems might have operated to prevent Mr. Duncan’s release (see below). But even if even they will have failed us, they’d at least leave a trail of time-stamped workflow context from which to reconstruct past workflow and improve future workflow. So they won’t fail us the next time.

We, as a nation of patients, providers, payers, policy wonks, and politicians need more evidence-based workflow data, to create more effective, efficient, and safer workflows. We need the kind of open and transparent workflow that will only result from what academics call process-aware information systems.

If you’d like a well-received short course on workflow technology in healthcare, I can’t do any better than suggest my own five-part series:

BPM-based Population Health Management & Care Coordination: Workflow, Usability, Safety & Interoperability Perspectives