#HIMSS18 Social Media Ambassador five years in a row. Three HIMSS Davies Awards. Designed first undergraduate medical informatics program. EHR CMIO. Premed-Accountancy major (#1 ranked Illinois), Healthcare Systems Engineer (MSIE, Illinois), MS Intelligent Systems (Artificial Intelligence), ABD (All But Dissertation) Computational Linguistics (CMU). Dr. Workflow. King of All Workflow in Healthcare. The Workflow Bear. Owner of JETS! @HealthITDog and Maker of @MrRIMP (Robot-In-My-Pocket), both on Twitter!. Run the HIMSS17 Makerspace.
I searched every website of every Health 2.0 Fall Conference sponsor, 87 in all. I found three companies that emphasize Business Process Management (BPM) and/or workflow engine technology. As I am always trying to encourage more use of workflow tech in healthcare and health IT, I am writing this post to highlight these progressive Health 2.0 sponsors.
The three progressive bringers of workflow technology to healthcare and health IT are…
(about use of Alfresco Business Process Management software: very complimentary!)
“When we set out to design our Mobile-Enabled Healthcare Platform one of the biggest decisions we made was to use Alfresco for our Business Process Management (BPM) and Electronic Content Management (ECM) services. This decision had a major impact on our product, and we’re convinced we made the right choice, so I wanted to walk you through how we made it.”
“Workflow processes are a fundamental part of our platform. We have a number of core principles that we use to help guide us when we build product. Firstly, everything we build must be driven by the user need and all our applications must be mobile first, interoperable and extensible. eForms and Workflow is one way we make our platform extensible. We want our customers to use our tools to quickly build forms and model entire care pathways. We want them to do this independently without having to wait on features to be added to a product roadmap. But in a modern healthcare environment, traditional BPM is not enough. We need tools that are simple and easy to use, yet flexible.
Clinician’s behavior can not always be mapped using rigid processes. We need modern tools enabling ad-hoc tasks to be generated, dynamic processes to be modelled, simple collaboration between care providers and care recipients and analytics to measure and report on outcomes.”
ECM and BPM are traditionally two very distinct things. When we embarked on this journey we had a very clear vision to select the best tools for the job. This meant we wanted the best ECM product and the best BPM product from the best vendor in each space. We performed two separate and distinct evaluation exercises and I fully expected to be working with two products from different vendors. But midway through our journey it became clear that Alfresco offered something unique that didn’t exist anywhere else on the market. Yes, they have two separate products – Alfresco One for ECM and Alfresco Activiti for BPM, but in combination what they have created is something greater than the sum of its parts and so unique that I don’t really recognise it as either ECM or BPM. In fact, these terms describe something that I don’t really relate with. When I see the words ECM and (especially) BPM I think complex, heavy-weight, closed. Stale. Alfresco have created something different – something simple, something light-weight, something open. Something fresh. I don’t know what the term is to describe this. It’s not ECM and its not BPM, but its definitely the future.
From the Axway website:
“Axway ProcessManager Key Capabilities
Use the BPMN-based graphical modeling environment to design processes and specify attributes
ProcessManager’s graphical modeling environment is based on the Business Process Management Notation (BPMN) 1.1 standard, which allows business analysts to represent business process logic and patterns by drawing a diagram.
Business analysts can then specify the attributes for the process objects, such as:
Relevant communication service (e.g., OFTP 2) for an incoming order
Back-end integration service for processing the order in the ERP system
Transformation service for converting the file (e.g., EDIFACT or XML)
The modeled process can then be tested and refined before it is put into production.”
“Business Process Management Systems (BPMSs) are extremely powerful, as they allow process automation and offer visibility on how an organization performs in its overall value creation network.
In fact, BPMSs can also provide visibility without automating anything, simply by consolidating flows of events. For instance, probes can be used to fetch information from legacy applications and generate events, which are consolidated by a BPMS providing visibility on parts of process instances about which one has very little information. Another important usage of non-automated processes is the control of events coming from business partners, ensuring that every collaboration’s participant provides the appropriate information at the right time (and in the right format) as defined per the service level agreement.
BPMSs make many aspects visible, most notably these two: the proper state of process instances and the different variables associated with each step, such as its cost or completion time. Hence, BPMSs can help predict the future state of an organization based on its current situation. For instance, BPMSs can help identify a potential bottleneck before it arises, and can easily correct it through something called “dynamic resource re-affectation.” BPMSs can also provide real-time visibility on specific customer cases and answer important questions (e.g., “Where is my order?”), ease human work and interactions, and identify who is responsible for what and who did what. A BPMS is simultaneously the rearview mirror allowing you to understand what happened, the windshield through which you view what is about to happen, and the steering wheel empowering you to modify and adapt your course of action.”
From a review of CareCloud:
“CareCloud has an innovative workflow engine and systems architecture”
“automatic notifications when anything takes place in your medical practice with a live feed. In real time you will know when charges are posted, when a patient checks in, or if an appointment gets rescheduled”
By way of context, every year for the past 6 years I have searched every single HIMSS conference exhibitor website (1400+!) for “workflow engine” or “Business Process Management” (15% in 2016!). Health IT is gradually, but ever more quickly, moving from a purely data-centric orientation to a more balanced emphasis on both data and workflow. The primary area in which this trend manifests itself is in software architecture. The best known specific terms-of-art associated with workflow technology are workflow engine, workflow management, business process management, process orchestration, and process-aware (academia), to name a few. As workflow engines and BPM become better known in healthcare and health IT, the increasing presence of these phrases on health IT conference websites is but one harbinger of a much needed transition from data-only, to data-and-workflow, emphases.
Note, workflow tech diffusion into health IT is still a bit under the radar, so to speak. Other Health 2.0 sponsors likely leverage proprietary or third-party workflow engine and process-aware technology. It just isn’t on their website! This will also change, as the sterling qualities of workflow tech — automaticity, transparent, flexibility, and improvability — increasingly become valuable competitive marketing collateral.
What three health IT trends are top-of-mind for me right now?
The “workflow-ization” of health IT
Pragmatic interoperability in healthcare
These health IT trends are all top-of-mind for me because they are coming together and interacting. Individually, they are notable. Together, they may be transformational, to use a tired and over-used word. But in this case it is completely true and appropriate.
By “workflow-ization” of heath IT I refer to the diffusion of workflow technology into healthcare. 15 percent of HIMSS16 conference exhibitors refer to “workflow engine” or “business process management” someplace on their websites. Five years ago virtually zero exhibitors used these workflow industry terms of art. Health information systems are increasingly proactive, transparent, flexible, and improvable, when it comes to workflow, and therefore when it comes to data too, since workflow drives the creation, transformation, and use of data.
“Pragmatic Interoperability” is a phrase I introduced to health IT in 2014, though it existed outside health IT before then. Pragmatic interoperability is the third leg of the healthcare interoperability stool. Syntactic and semantic interoperability are the other two legs. All of these words, syntax, semantics, and pragmatics come from linguistics. Syntax is about the structure of health data. Semantics is about health data’s meaning. Pragmatics is about health data’s use to achieve goals, and to assign, monitor, and accomplish healthcare tasks. When healthcare workflows cross organizational boundaries, this is pragmatic interoperability. When a message is sent from one healthcare entity to another, does the actual effect of the message match the intended effect of the message? If so, pragmatic interoperability is achieved.
Blockchain addresses one of the most important aspects of pragmatic interoperability: trust. Healthcare needs more than just trusted data; it needs trusted workflows. Back in 2015, in a five-part series titled Task and Workflow Interoperability in Healthcare, I argued that workflow interoperability requires workflow transparency between collaborating healthcare organizations. Also see my 10,000 word, five-part series on Pragmatic Interoperability, the linguistic theory behind Task Workflow Interoperability. By combining blockchain and business process management (BPM) technologies, healthcare can achieve exactly this.
To understand how blockchain and BPM can come together to achieve pragmatic interoperability, you have to understand trust. Trust is a hypothesis about future behavior used to guide practical conduct. I trust you, if I believe you will, though action or inaction, contribute to my well-being and refrain from inflicting damage on me. My hypothesis is supported by rationality (it is in your best interest to not harm me), routine (you’ve always delivered in the past), and reflexivity (I trust you because you trust me). Further more, if your goals, resources, intentions, plans, workflows, and activities are transparent to me, I am more likely to trust you. Pragmatic interoperability can be achieved through workflow transparency.
Is workflow transparency possible? Yes. To support my claim, I draw your attention to an important paper, presented at BPM 2016, in Rio de Janeiro, Brazil, Untrusted Business Process Monitoring and Execution Using Blockchain. The use case is supply chain workflows among five organizations and individuals. As I read it, I imagined a similar paper, with a healthcare focus, titled Untrusted Clinical Workflow Monitoring and Execution Using Blockchain.
If I can see your workflows, I am more likely to trust you. In the paper I just referenced, workflow models, and their execution status, are shared across multiple interacting suppliers and consumers in a distributed manner. Instead of a single central meditator directing workflows among subordinate partners (orchestration), blockchain shares workflows as smart contracts among co-equal partners (choreography). Blockchain keeps everyone apprised as to which steps in which workflows achieve what status. There’s even a cool YouTube video demonstrating, step-by-step, workflow execution and changing workflow state.
(The following paragraph is for programmers! Feel free to skip, or not!)
The aforementioned paper is a good introduction to not only blockchain, but also a number of important BPM concepts, such as orchestration (workflow requiring a central conductor) vs. choreography (true peer-to-peer workflow). The researchers translate BPMN (Business Process Model and Notation) models of workflow into a programming language executed on blockchain nodes (Ethereum Solidity). GoLang and Node.js are also involved, so geek out! The research software is a one-of, but future similar platforms will be wrapped in APIs (Application Programming Interfaces) and access workflow, task, and patient data in other health IT systems through FHIR (Fast Healthcare Interoperability Resources) and non-FHIR APIs (see Blockchain as a Platform) Note: trusted choreography among healthcare organizations, to create virtual healthcare enterprises, is especially relevant to workflows between healthcare competitors (trust, but verify!). Finally, you don’t get something (automated trust/trustless consensus) for nothing. A blockchain implementation of BPM-driven workflow across organizations is slower and more expensive than a similar setup without blockchain. However, I believe both can be managed and made small enough to be tolerable.
I’ve been in medical informatics and health IT for over three decades. As an industrial engineer who went to medical school, I’ve long been frustrated by what I regard as insufficient emphasis on not just healthcare workflow, but workflow technology, in health IT. But I’ve never been as excited about the possibilities for creating trustworthy process-aware cross-organizational health information systems. These systems will greatly surpass current EHR and health IT systems in terms of clinical outcomes, efficient use of resources, and patient and user satisfaction.
Viva la workflow-ization of trustworthy healthcare interoperability!
You know what “critical mass” is, right? It has two definitions, one from physics and the other outside of physics. In physics critical mass is the minimum amount of material to cause a nuclear chain reaction (in other words, an explosion). Outside of physical critical mass is the minimum amount of something to start or maintain a venture.
I’ve been trying to drive two areas of technology together for years… For the last half decade I’ve used social technology to do this. I hope, eventually, to achieve the minimum interaction between medical informatics and workflow informatics, and between the health IT and business process management industries, to trigger a chain reaction, a chain reaction of ideas and conversations and technologies and successes that will feed on itself.
That will lead to widespread automatic, transparent, flexible, and systematically improvable healthcare workflow systems.
You [@MSharmas, @HCITexpert] know what I’m talking about when it comes workflow tech and BPM, where did you get that experience/knowledge?
Manish’s emailed answer:
Before starting out to be an entrepreneur in 2012, I was leading teams to develop a cloud based EMR solution for the company I worked for, wherein we wanted to incorporate the following in our core frameworks:
In the process of selecting the workflow engine in our Product, we had done an in-depth analysis of the various technologies available to enable tweaking of workflows. We looked at open source solutions and proprietary and had worked with the teams from Skelta towards PoCs for billing, insurance, inventory, pharmacy and CPOE workflows.
This is when I was able to learn about the benefits of having a workflow and rules engine in our product.
And hence I understand the concepts you talk about and the need for incorporating workflow tech in Healthcare, simply because I believe every Healthcare Facility is unique and most times I have found companies sell the product, but deliver a “Service” to their customers by trying to do a GAP analysis to come up with the actual solution required by the Client.
Now in it’s third year, the BPM & Case Management Global Summit is my favorite annual conference (BPM stands for Business Process Management). I love the annual HIMSS conference, for its size, energy, and grandeur, but 41K plus attendees can be overwhelming. #BPMCM16 (its Twitter hashtag) is just right, just a couple hundred of the smartest workflow tech folks around. Oh the conversations!
This is not a blow-by-blow coverage of every keynote and breakout session and demo I saw. It is, as it usually is, a selective search for the healthcare workflow relevant ideas. (Here is my trip report from a couple years ago.) Also, as usual, I’ll use my tweets during the first day of the conference as a sort of graphical, social backbone to this post.
I arrive early, because @NathanielPalmer (BPMCM16 organizer) serves one excellent Ritz-Carlton breakfast.
I’ve written before about Clay’s exciting ideas on how to use BPM to connect data and workflow silos into “empathic workflow” reflecting and supporting customer journey. While he did not directly visit healthcare, in previous presentations one of his examples was about a daughter worried about her mother falling, her mother feeling anxious and ambivalent, and using backend BPM connecting legacy systems to better support their customer journey.
My favorite breakout session was “Supporting Complex environments with BPM” presented by Steve Kruba (@Krubast), Northrop Grumman. Here are a couple of his healthcare-relevant slides. BPM is the “glue” connecting disparate applications. I’d say this is healthcare-relevant, because this is exactly what healthcare needs, see my series on Pragmatic Interoperability.
Here is a screencapture of the healthcare workflows, connecting people and systems, that Steve created with Northrop Grumman’s e-Power BPM suite. Note, these are not just pretty workflow pictures. These workflows are executable. Changing the workflow “picture” changes the workflow application behavior.
Every year I see some cool new technology (new to me, often they’ve been around for years, but just not in healthcare yet). This year the product was Kintone. Here Jana Berman (Account Exec at Kintone) is demoing enabling “process management” in Kintone, that is, popping open the workflow editors, adding, moving workflow steps, tweaking their business logic, etc. Previously Jana showed how easy it is for users to create and edit screens. If you put together non-programmer users creating both screens and workflow, well that is what is increasingly called a “citizen developer.” Healthcare needs citizen developers. This demo was about sales leads. But just think about clinical and health management users creating their own workflows. (Reminds me of the Maker Movement, which I’ve written about here… Makers in Healthcare | Health Standards)
Kintone is no new wet-behind-the-ears startup. 4,000 companies and 130,00 users have created 250,000 workflow apps. This kind of low-code/even no-code workflow application creating could transform healthcare (and I should note Kintone is not the only company in this space). Imagine if healthcare users could create and customize their own software screens and workflows…
I spoke with Dave Landa (@DaveLanda), who heads up US operations. Kintone is working with a number of US healthcare organizations. I’m excited to see the results of these partnerships.
Two more highlights. During my talk about BPM in healthcare I mentioned process mining. Scott Opitz (@ScottOpitz), President & CEO of TimelinePI (@TimelinePI) came up to introduce himself and his company. What he said was fascinating, from a healthcare workflow informatics point-of-view. I’ve not yet seen any demos, but I do wish to include this quote from TimelinePI.com.
“TimelinePI is specifically designed with one purpose – to provide a new view into operational data focused on business processes. The TimelinePI engine consumes data from a variety of sources, often the same exact data being used today for other simpler analyses, to detect and present detailed views of your business processes. This new insight is delivered via a variety of new process and timeline visualization tools developed to not only make these new insights easier to understand but also to allow users to manipulate the information to gain deeper understanding of those processes. Users armed with this insight have concrete facts on which to take actions to improve operational efficiency by promoting clearly superior best practices and eliminating costly inefficiencies that previously went undetected.”
One last highlight!
Every time I happen to bump into Keith Swenson (@SwensonKeith) at a workflow tech conference, I systematically pick his brain about his ideas about work, workflow, BPM, case management and related topics, as they relate to healthcare. Keith finds healthcare an interesting area of problem solving and collaboration, and we both agree there’s a great fit between healthcare’s workflow management problems and the BPM industry’s workflow management solutions. During BPMCM16 I enjoyed listing to Keith participate in fascinating debates (especially with @denisgagne) about how to represent decision making in BPM and case management systems. The results of this debate will be important to better clinical decision support systems in healthcare.
Here are the #BPMCM16 Twitter statistics, as of the morning of the second day of the conference. The reason there appears to be a dip right at the end, is that it is still early, so lots haven’t tweeted yet today. 180 tweets (139 yesterday, during the first day of the conference), 58 tweeters with a potential reach of over a half a million (basically, aggregate users times their followers). Given the intimate size of the conference, these are pretty good statistics!
I gave the following presentation, Digitizing Healthcare: Business Process Management’s Unique Contribution, at two back-to-back Business Process Management (BPM) conferences. This post consolidates a video of that presentation, plus slides and transcript. The two BPM conferences were…
I’m combining content related to both conferences into this single post since it is essentially the same presentation. However, I have 15 extra minutes at the Summit, so there will be more time for questions and discussion there. During the Summit, I’ll tweet out this post and video on the summit hashtag, #BPMCM16.
The first presentation was virtual (in Portugal), so I uploaded a special presentation to Youtube. The complete 30-minute transcript is a postscript to this post.
The plan was to deliver via Skype, but fall back on the Youtube presentation if Skype was iffy, which was exactly what happened. However, Skype worked well enough immediately afterwards to take a question.
Question? How to Encourage BPM Adoption at Our Hospital?
Digitizing Healthcare: Business Process Management’s Unique Contribution (45 minutes, Washington, DC)
The following are the slides delivered at the BPM and Case Management Global Summit, in Washington, DC. The transcript is from the BPM Conference in Portugal (word-for-word informality and occasional typos due to mis-transcription, but, all-in-all, in my opinion, quite readable!):
I’m delighted to be able to speak to the Portugal BPM (BPM and Case Management Global Summit) conference. I’m going to be talking about digitizing health care, business process management’s unique contribution. I kind of nicknamed this talk, healthcare’s workflow singularity. My name is Charles or Chuck Webster. I am president of EHR Workflow inc. I am very active on twitter where I am wareFLO, no ‘w’ at the end. There is my email. Feel free to use the #healthos at any time during this presentation.
I have been a proponent of workflow technology or business process management even before it was called BPM in healthcare for over two decades. You can think of me as Dr. Workflow on health IT social media. Blogging, twitter, youtube, blab, periscope, and I’m not above using humor. These are various characters that I play. People at Workflow and Dr. Workflow and so forth and so on. The Workflow king.
Health care has hit what I call, the workflow wall. There are many discontents in healthcare and they are discontented with invisible, inflexible, ineffective, inefficient workflow. If you as business process management professionals say, “Well wait a minute, we provide transparent, flexible, effective, and efficient workflow.” Well yes, there’s a great fit between healthcare’s workflow problems and BPM’s workflow solutions.
I’m basically going to talk about BPM in health care, and I’m going to go back a bit a few years and then also go forward and predict what I think is going to happen.
This is actually a quote from a blog post I wrote in 2009. Picture a graph that depicts progress towards higher and higher levels of market understanding of, and appreciation for workflow management systems, EMR workflow systems, and business process management. EMR stands for electronic medical record. I actually did some qualitative analysis of workflow content at various conferences. The various colors represent the different conferences. This was just my attempt to show an increase over the 2000, ’99 to 2009 decade.
I’ve continued to track this and to promote business process management in healthcare. For example I just attended the America’s health insurance plans conference. The US pays for health care differently than other countries. I’ll get to more generic health IT in a moment. My most popular tweet was this representation of the complexities of paying for health care in the US. I mentioned the need for modern business process management. Now, do I think that all the folks who re-tweeted it and favorited it understand business process management? Not necessarily, but they know that there is a problem, and the more the merrier. They’re welcome to new ideas.
More on point, the Health Information Management and Systems Society Conference is held annually. Last year, most recently in Las Vegas over 41,000 attendees. It’s the largest health IT conference in the US. For the last six years I have searched every single exhibit or website, which is about 1,350, can be like a million square feet, just an enormous exhibit hall. I look for workflow stories. Starting back six years ago, not much. Then 2%, 4%, 8%, 16%, and now somewhere close to 50% of those 1,350 vendors have some kind of health care workflow story. We fit into your workflow, we make your workflow better and so forth. Of that 1,350 I actually found 111 vendors that specifically mention workflow engine business process, for business process management.
The evolution of workflow technology in healthcare is similar to the evolution in other industries, it’s just a lot slower. If you’ve been around for a couple of decades, you know that at one time, data, and business logic, and user interface code were all mixed together in applications. Then we pulled the data out into databases and we manipulate or access that data through data base engines. Then we pull the user interface out. It used to be people drew from x1, y1, to x2, y2, a button. Now you just hand that off to the operating system and say, draw a button. Now we are in the process of taking workflow and business logic out of these applications and storing them in databases and using workflow engines and decision engines to interpret them.
Other industries are further along than healthcare. Obviously, business process management over there on the right is the most process aware industry. That’s because that’s what it has to sell. Many other industries are crossing a kind of singularity. They are widely implementing declarative representations of workflow and work, and along with the workflow engines and other kinds of interpreting engines to make work more efficient and flexible. However, health IT is still just beginning to appreciate the need for workflow technology. It’s kind of moving from a workflow obliviousness to a kind of a dim awareness of the potential. It knows that there’s a problem with workflow, not yet sure what to do, but open to suggestions. That’s a good thing.
I sometimes refer to that healthcare workflow wall as a workflow singularity. A singularity is, most folks today popularly today associate it with the idea that when self improving artificial intelligence comes along, then there’ll be an explosion of technological innovation. Then these AI’s will run away and become really smart, and people are debating about whether that’s a good or a bad thing. I refer to something called the workflow singularity. The workflow singularity will occur when a sufficient amount of our infrastructure and applications are based on re-representations of work and workflow that can be executed automatically, and which can be instrumented, so as to provide the workflow analytics to feed back into and to more systematically improve those workflows. Specifically, this singularity is pivoting on an emphasis almost solely on clinical data to a more equal emphasis on clinical data and clinical events driving workflows. Representing those events, representing those workflows and harnessing those representations. Literally representing them in the computer to drive and to systematically improve a [variety 00:07:59] of through put, reduce medical errors, improve user satisfaction with the systems, including patients.
What’s happening now, is we have basically boiled the ocean in terms of capturing data. We have more data than we know what to do with, but this data is in silos and in databases. We are laying down on top of that, a new workflow layer. Some of that workflow layer is health IT kind of re-inventing the wheel and some of that workflow area is based on workflow technology, and business process management, orchestration technology such as is present in the modern BPM industry. Just because the workflow layer is being laid down on the data layer, doesn’t mean that the data is the platform. The data is being consumed by the platform, and what’s going to happen is that this new layer that’s coming down on top. That is going to become the platform, on which a variety of workflow savvy applications that are interoperable, that are safer, that are more usable and provide patients with a better experience with the health care system.
Predicting BPM’s health care future. I’ve been tracking this for over two decades. I can say with great certainty that we’ll continue to see growing workflow and workflow type thinking. People in health IT and healthcare will think about workflow similar to the way that health workflow technology, and business process management, and adaptive and dynamic case management of professionals and vendors think about it. You will see, we have an incredible installed base of traditional health IT, database, data centric databases with thin layers of user interface slapped on top. They will retrofit workflow technology they will add rudimentary workflow engines. They’ll also leverage third party workflow technology.
At the same time this is happening, we will see the so called SMAC technology social mobile analytics in cloud serve as vectors. A vector is an agent that brings an infection into a community. Social mobile analytics in cloud, startups, and initiatives from other enterprises, increasingly are created through low code application assembly techniques in the cloud, running on mobile without you having to write a lot of objective C java code and often, increasingly often, these have workflow engines. Representations of workflow and this workflow interacting with the business or the clinical logic. We are essentially head for what I call, “Full-stack” healthcare interoperability. Full-stack refers to developers. Someone who can install the operating system and run the databases and design the database models on the back end, on the front end create the mobile applications and the code running in the browsers as well as understanding the user and the design.
There’s all those layers. They’re all related. They’re all required to work together. This person has kind of a hands on knowledge and experience with each on those layers and how they fit together which can be enormously valuable. We need something that I call Full-stack healthcare interoperability, which I’ll discuss in just a moment.
Then business process management isn’t going to be the only new technology in healthcare. We’re going to see a variety of new technologies, and BPM will interact with those new technologies. It’s useful to think about those interactions when you’re predicting the future. These include an order of exoticness, application programming interface, the internet of things, and various kind of distributed computing including Blockchain.
What is Full-stack healthcare interoperability? Well, there are two popular terms in healthcare IT which are syntactic interoperability and semantic interoperability. Both of these terms are borrowed from linguistics, by the way I’m all but dissertation in computational linguistics. I took many courses in syntax and semantics. Syntactic interoperability is the structure of the information. It allows you to assemble it so you can serialize it, send it someplace and then [parce 00:12:50] and retrieve the contents. Semantic interoperability is the interpretation of those contents. The interpretation, the meaning must be the same in both systems. Healthcare has a variety of coding systems for diagnoses and treatments, drugs, and so forth. You rarely hear about something called pragmatic interoperability, although in the general IT and computer science community you’ll find more material about that.
Pragmatics is the next layer up in linguistics. You have syntax, the structure of sentences, semantic, the literal meaning of a sentence, and then pragmatics which is how we use words to achieve goals. That’s the non-literal interpretation. There, pragmatic interoperability is the match between the actual effect of a transmitted message and the intended effect of the transmitted message. If I say something, I have a goal that I want to achieve in the world. If that goal is achieved, then pragmatic interoperability between us two humans is achieved. Similarly, when information is sent between one organization and another, as part of a cross organization workflow, there’s a goal and if that goal is met then it’s pragmatic interoperability.
The most important context necessary to interpret these messages in context are goals, plans, workflows, tasks and activities. Which are just simply the bread and butter of the workflow technology, workflow management systems, business process management, and adaptive, and dynamic case management case software communities.
We’ll start with API. First of all, modern API’s have been around for a long time, and healthcare is only just starting to adopt them. Right now, we are creating a lot of data. Increasingly, we can move that data around and have it mean approximately the same thing. In order for this new layer of workflow interoperability to function it has to get at the data. It has to be able to pull that data. It has to be able to add to that data. That is going to be through application programming interfaces. I kind of interchangeably talk about pragmatic interoperability, data use, and workflow interoperability. Pragmatic interoperability is kind of like the linguistic theory, and task workflow interoperability is kind of the engineering.
By the way, an important API is FHIR (fast healthcare interoperability resources), but it only encompasses a small subset of clinical data that will likely increase. There are many, many other API’s that are being created using for example, a modern API generation technologies to allow this new layer of pragmatic interoperability, task workflow interoperability to be laid down on top of the data interoperability layer.
If you’d like to read more about these ideas of pragmatic interoperability and task workflow interoperability you can go to EHR.biz that’s sort of my short URL utility. EHR.biz. Pragmatic in one case and [interop 00:16:24] in the other case. Thank you very much.
I’m going to pause here for a second just in case anybody is writing that down.
Okay, now what about healthcare plus internet of things and business process management? If you cross index on Google BPM and things you’ll see a lot of interesting initiatives that is sensors are triggering state changes and little devices that are connected to the cloud. This is being transmitted to some kind of orchestration engine. Folks are creating complex interoperable internet of things platforms. You’ll typically see the ability to draw data flows and workflows, and then some kind of workflow engine. Possibly a community of workflow engines interacting with each other. Each of these little things is basically a CPU. It has some actuators, it has some sensors, and it has a way to communicate with other layers of the internet and things. BPM will play an important role in making that possible.
A big area of interest right now in health IT is getting outside of the electronic health record, and the doctors office, and the office and into the home and the lives of individuals. You’re going to see more sensors in homes and be computing wearables. The amount of data and the complexity is so great that you’re going to require workflow thinking in order to manage these systems. This is an example actually of a processed mind system of someone’s, you might call life flow or home workflow. You could easily imagine turning this into an actual executable representation and making things automatically happen. Reminding folks to take their medications or detecting if the low fat milk is low in the refrigerator and so forth.
Okay, now the most exotic technology that seems to be in the [inaudible 00:18:31], is Blockchain. Blockchain is a distributed database hardened against tampering. I’ve got a copy of it, you’ve got a copy of it, other people have a copy of it. Changes to this database are essentially voted upon. If everybody agrees that, or above a certain percentage agree that this update is valid then that gets replicated everywhere. Bit coin, virtual currency is based on blockchain, but blockchain is being suggested for a variety of other purposes including in healthcare. For sometimes addressing for example, healthcare interoperability, quote “ownership” patient ownership of data. Blockchain will obsolete somewhere close. If you think about having to go through a bank to get paid by a business partner verses having that automatically happening by virtue of the bit coin and Blockchain’s smart contracts. These workflows will enable other workflows which will need to be managed. When you need to manage workflows, workflow technology seems like a good way to do it. You’ll see Blockchain harnessing workflow technology in that way.
Then there are some other interesting connections between the two. That is, these databases do not contain just data. They also contain code, much of this code are what are called smart contracts. They’re contracts that execute so that if you fulfill the necessary requirements of the contract you automatically get paid. It’s a way in a sense, cutting out the lawyer or potentially the court. By the way, these smart contracts are state machines. If you’re familiar with the theory behind workflow technology and business process management, under the hood you have models of workflow and these are state machines essentially. The blockchain has implications for cross organizational workflow. I have a copy of the database, you have a copy of the database, they both replicate and stay consistent with each other. That’s relevant to cross organizational workflow, therefore cross organizational workflow in healthcare.
Then, blockchain is a fairly new technology and it’s really complicated. It’s hard to write these contracts, it’s hard to set up and do the kind of [devops 00:21:03] necessary to set up blockchain systems. You’ll increasingly see a variety of blockchain process orchestration engines to support that.
There’s an internet of things angle, ad that is when some little device out there interacts with some little device, you’re going to see micro payments. If you’ll give me a little bit of information about the weather, I’ll pay you one-tenth of a cent automatically. At that level it doesn’t scale unless you can do it automatically. Then of course these blockchain systems will have their own application programming interfaces that BPM will operate against. If the data’s healthcare data then you’re going to see an intersection with the API-zation of healthcare.
In order to predict the future, you have to look into the past. Here we are in 2016, eight years ago, cloud, social networks, app store, Google chrome, financial crisis, now you go all the way back to 2000. I wrote a paper in 2000 and presented it at [HMMS 00:22:16], that conference, I mentioned at the beginning about eleven paperless physician offices. It was, I believe the first example of a clinical electronic health record based on a workflow management system.
I’m not going to make you read this text, but I did abstract a bit of it. This is sixteen years old. Keep in mind that what I’m going to be talking about here is incredibly well known, and understood, and accepted, [inaudible 00:22:46] in the workflow technology industry, back then – because I track this – nobody was talking about health IT or workflows in this fashion. Today, sixteen years later, we’re just starting to see systems that do this routinely.
Let me start at the top here. Workflow automation refers to the automation of the business process in whole or in part during which documents information or task are passed from one person to another for action according to a set of procedural rules. That should sound familiar, that is the definition from the workflow management coalition. Then I talk about workflow systems, tasks, actors, roles, processes. I talk about workflow engines extensively elsewhere in the paper. Keep in mind, sixteen years ago, if you subtract this paper there was virtually zero of this kind of conceptualization or technology.
Now, what is the relevance of this to predicting the future? Well, a science fiction writer is quoted as saying, the future is here, it’s just unevenly distributed. If you want to predict the future, you can go and find that local example of the future and then extrapolate. What I wrote about here and presented here sixteen years ago is coming true today in health care. I would say that I’ve got some props here, some credibility. The other thing is that health IT moves remarkably slowly. That also makes it easier to predict the future.
I want to mention, I really like this answer to Peter [inaudible 00:24:29] daily BPM question from David [inaudible 00:24:33]. If David is here I hope I’m pronouncing your name right. Now, I’m going to read this and it is IT supplies the infrastructure, hardware security and the legacy to be used by the new outside in systems driven by BPM principles. Hold that phrase in mind, new outside in systems driven by BPM principles. IT is not required to build this next generation of applications, the build is direct with users and their input is in their language. The leader in the build would be the business focused well within the business analyst skillset. In healthcare, you’ll increasingly see clinically focused well inside the clinical analyst skillset.
Now, at a conference last year I saw a Passion for Process, on his twitter handle, had this wonderful slide in which he was showing the relationship between customer journey, sales process, delivery process, and servicing process and how they sales, and the delivery, and the servicing workflows need to be driven by what’s happening at the customer level. This is an example of outside in.
Now we get to the prediction. Okay, so here’s I’m going out on a limb. Of course this is so far out in the future that if I’m wrong, so what? I do hope to be around, I do archive this stuff an look back on it. I believe that in the next eight years you will see modern business process management enter the mainstream in healthcare and health IT. Healthcare BPM will leverage and be leveraged by fire and non-fire applications programming interfaces, the internet of things, and Blockchain. We’ll see major progress toward full-stack pragmatic interoperability and the system behind the smiles become reality. The system behind the smiles is this idea that half of the interaction between a consumer or a patient and a organization or the healthcare system is due to the attitude, the culture, the personality of who they’re dealing with. Half of it is due to the systems behind the smiles, whether they work or not. Those are the systems that we need to fix and that business process management can help fix. The system behind the smiles will become a reality.
Now we’re really off into the distant future. Although no farther into the future than into the past when I talk about my sixteen year old presentation about clinical workflow systems. There will be technologies and new terminology that there’s no way I can … I wouldn’t have the temerity to predict. I do want to offer a kind of a concept, a kind of a steady state of where I think we’re headed. It’s based on the analogy to an operating system. I spent a lot of time arguing that we need more workflow and more process management, not just date; well, what systems out there do both data and process as well?
Well the modern operating system. In fact I’ve argued that the modern operating system is the single most important technological development of the second half of the last century. Where we are is down here at the bottom, data persistence. That’s the syntactic and semantic interoperability there. We are virtualization that data through a layer of API’s and other technologies and then we are adding on top of that a concurrency management layer. Concurrency, virtualization, and data persistence are the three main topics. If you were to take a course for example in operating systems theory and we’re building a vast healthcare operating system. We’ve partially data persistence, we’re starting on the virtualization necessary and we’re just in the beginning of starting to build the workflow and the process management component of the healthcare operating system architecture. I don’t think, and since the operating system idea has been around for a few decades I don’t think that this is going to be necessarily outdated in the year 2032 when we look back.
Thank you very much. These are some of the ways to contact me. I’m chuckwebstermd Gmail. I’m on twitter, very active on twitter. I’m also on blab, which is kind of like a talk show. Periscope, in fact I’m periscoping this and my Skype ID is chuckwebstermd
This year’s 2016 America’s Health Insurance Plans conference in Las Vegas was my second AHIP Institute and Expo. Last year and this year I focussed on workflow tech in healthcare, specifically Business Process Management (BPM) and workflow engines.
I tweet lot and I try to be substantive in my tweets (as in summaries of conversations, quotes from keynotes, etc). I’ve found that collecting some of these tweets into a blog post is a fast and efficient way to remember and reflect back on ideas, themes, people, and products I encountered. Let’s start with the vibe! One of my most popular tweets was this panorama of the AHIP audience from the back of the room. Thank you AHIP for including it (first!) in your Social Media Buzz from Day 1 of AHIP Institute & Expo 2016.
If there was a zeitgeist that could be boiled down to one word, there certainly was competition! Engagement? Interoperability? “Action-ability”? (I know, not a word). But if I was forced to settle on s single, solitary work, it’d be: Simplification. Take a look at my most popular tweet!
Here is the interesting thing. The complexity of the diagram struck a chord in 2015 and 2016. In both tweets I mention “Business Process Management.” Now, do I think folks RTed because I mentioned BPM? No. I think folks simply like the idea that something needs to be done to simplify health insurance (and if BPM might be helpful, sure, why not? The more the merrier!).
But I do wish to focus on the BPM at AHIP. I participated in a blab about innovation during AHIP. Almost the entire blab, I’m sure due to my stubborn persistence, was about how Business Process Management is rapidly seeping into healthcare, health IT, and health payer IT. If you are a video-visual person, you could do a lot worse than watching this Youtube of that blab (start about 6:30 to skip introductions and get to the substance).
Last year, since it was my first AHIP (focusing on healthcare insurance payer IT) while I poked around looking for evidence of what academics call “process-aware” IT, I spent most of my time simply trying to understand the health plan space and workflows. This year I searched every exhibitor website for “Business Process Management” or BPM or “workflow engine” and came up with a list of 14 companies, out of almost 200 exhibitors. I then created a set of questions about BPM/workflow tech that I could use to systematically visit and dialogue with these progressive members of the health insurance plan payer community. The questions were just a framework. In some cases, some questions didn’t apply. In every case, new topics organically inserted themselves into the conversation. And, finally bowing to convention, I got a selfie with denizens of each booth. And tweeted out a short précis of what we discussed.
I only made it through seven of the fourteen vendors with interesting workflow angles (plus one), but I had previously prioritized the order so I feel I got a very good sense of the current state of Business Process Management -style tech at AHIP.
I started my tour of workflow duty at the Intersystems booth. By the way, I actually used their object-oriented Caché database back in the ’90s. When I Google “Business Process Management” during HIMSS, and now AHIP, Intersystems always occurs near the top (their Ensemble tech, on which HealthShare is based). I had a great convo with Clint, Clayton, and Brian about the nitty-gritty of what it takes to empower users and organizations with intelligent, flexible workflow. They get it! I’d love to go into more detail here, but if I did, for every vendor, this post would be 10,000 words long. So let me just leave this as this. C, C, and B, I’m greatly looking forward to more world-class conversations about BPM in healthcare.
I’ve been following Box relative to workflow since 2014 (see my Box Brings Cloud-Based, Intelligent, Open Workflow Engine to Healthcare) Recently I’ve seen demos of their Orion workflow technology, which allows Box users to create their own automatically triggered, executed, monitored, and managed workflows, driven by their content stored in Box (the “user-driven process management” in the following tweet). Great to see Box adding workflow tech to their already sophisticated cloud/content tech. I look forward to seeing Orion’s growth and evolution. I could write another couple thousand words here, but I already gotta move on the next AHIP exhibitor vendor with a cool workflow tech story. 🙂
Virtusa Polaris was an interesting conversation because, unlike Intersystems and Box, they don’t sell software. They sell the ability to understand a healthcare customer and to design, implement, deploy, and management business process management solutions in healthcare. I’m reminded of early days, when clinical folks needed IT folks to implement EHRs. Workflow is a whole other layer and wrinkle. Traditional health IT folks know about data and databases really really well. About workflow and workflow tech? Not so much. Healthcare BPM consulting organizations such as V-P fill that void. Again, I could write a lot more about Virtusa, but I gotta move on in this particular post.
This was a very interesting conversation with Nick Bennett of Cognizant about their TranZform product. But instead of me telling you what Nick said, just skip to the next tweet below and play the embedded 30 video of nick explaining how TranZform uses digital workflow, from enrollment to outcomes, to transform healthcare.
The following conversation was interesting because Availity wasn’t actually on my initial list. However, they saw me tweeting about AHIP vendors and workflow and basically demanded I come to their booth. I’m glad I did. As Mark Martin explained, they provide the APIs (and a portal) which can be consumed by workflow tech. In fact, if you think about it, even if you have the best workflow engine in the world, you still need the data you need to achieve whatever strategic goal you set. Availity goes beyond currently, typically available standard APIs to empower necessary administrative workflow between healthcare organizations. I love it. Thank you for your enthusiasm, seeing my #AHIPinstitute tweets, and reach out about this important topic.
Kofax was interesting to me because of the way they combine a traditional (but still seldom seen in healthcare) workflow technology, a workflow engine executing workflows created with a workflow editor, with sophisticated document capture, from scanning paper to parsing emails to etc. They showed me an example of automatically understanding a form, and then moving that structured data through a structured workflow, in which lots of workflow stuff happened automatically: archiving, notifying, escalating, etc. And, since these workflow are created in a workflow editor, non-programmers can change the workflow behavior to best suit their needs and preferences.
My last stop during the last day of the AHIP exhibit hall was the Appian BPM booth. Appian’s product is fascinating, because it allows non-programmers (non-Java/C#/MUMPS) to create from scratch, in a matter of weeks, sophisticated workflow apps running on a wide variety of devices. After you design your forms and draw your workflow, native iPhone, iPad, and Android apps are literally one radio-button click away. If the idea of “citizen developer” intrigues you, I hope you’ll ready my lengthy interview with Scott Polansky (@sppolan1 on Twitter), who is on Appian’s health plan payer side.
But I’ll end with a quote from Fritz Hamburger, who is on Appian’s provider side.
“Great to see workflow [in healthcare] takeoff, since Appian does it so well!”
Anyway. AHIP Institute, my second, was awesome. Both in generally, because I got to seem so many HITsm tweeps (see below), because I am seeing a surge workflow tech and business process management too.
I just live-tweeted a general session at Appian World about using the Appian Business Process Management Platform in healthcare, specifically by AmeriHealth Caritas, a Medicaid managed care company in 19 states. Phillip Merrell (VP, IS Strategy & Shared Services) was so good I’ve archived my tweets as a sort of notes slash blog post. Most are self-explanatory, relying on tweeted slides. Several are a bit terse, more reminders to myself, so this is also an opportunity to unpack and provide some context.
Healthcare and health IT is extremely focused on collecting data. Business Process Management technology can make sure that data is good clean data, not bad dirty data. Then, BPM can be used to make that data actionable, so that good clean data can trigger all the right processes and workflows necessary to systematically improve population health.
Integrated process management, cross-functional workflows, role-specific UI/content mobile & desktop, triggered tasks #Appian16#AppianWorld
Process management, making sure processes do what the healthcare organization needs and does so correctly every time, is integrated into the Appian BPM Platform. Instead of separate, disjoint, databases forcing users to switch from application to application to application, BPM knits together data from multiple sources into coherent workflows, across users, departments, and even organizations. This knowledge of workflow guides what is automatically presented to who and in what manner, so as to minimize user effort. Stuff, the right stuff, happens automatically.
Integration ability running above plumbing, versatile agile, drive change #Appian16#AppianWorld (IMO the workflow layer above data layer)
Regarding that “workflow layer above data layer”, I’m referring to the capacity for BPM to make data come alive, and to knit together disparate health IT applications. In fact, I recently wrote two five-part series on exactly this idea! Check out the following to entry points to those 7,000 and 10,000 words series, respectively.
Health IT is laying down a layer of workflow technology on top of database technology. Terminology varies, including Care Management Systems, Healthcare Operating Systems, Healthcare or Care Process Management. I speak of process-aware information systems (after the academics), workflow management systems (historical designation for workflow engine-based software), and healthcare business process management (BPM used within healthcare).
I’d like to propose a new phrase: Care Workflow Platform. Let’s understand the meaning of each of these three words. Then put them together into a definition for care workflow platform.
Workflow is a series of tasks, consuming resources, achieving goals. (my definition)
Care (as in medical care) is the diagnosis, treatment, and prevention of disease, illness, injury, and impairment. (Dictionary)
Now combine meanings. A “care workflow platform” is a cognitive system designed to run workflows (represent, execute, and support workflow tasks, resources, and goals) relevant to diagnosis, treatment, and prevention of disease, illness, injury, and impairment.
Notice I introduced two concepts into my definition of care workflow platform:
I added “represent, execute, and support.” This is the link between workflow and platform. Platforms are designed to do and support specific things. In this case the “thing” is workflow. Database platforms represent, execute, and support data. Workflow platforms represent, execute, and support workflows.
I replaced “software and/or hardware” with “cognitive system”. As a healthcare systems engineer (MSIE, Industrial Engineering) I am acutely aware that healthcare systems, including healthcare workflow systems, are not just about software and hardware. They are also about peopleware. Users and applications combine together into cognitive systems. They have memory and perceive, reason, react, and act. The most important decision, when designing cognitive systems, is what tasks the computer will perform versus what tasks the human will perform. The combination of human and computer tasks constitute workflows. Representing, executing, and supporting these healthcare workflows is what care workflow platforms do.
This proposed definition is somewhat elastic. My root definition of “platform” comes from the Wikipedia definition of computing platform. However, in healthcare, “platform” is sometimes used to refer to more than just software and/or hardware resources and constraints for executing software programs.
Workflow management systems, business process management suites, and case management systems rely on software workflow engines. These engines execute or consult representations of work and workflow. These are the “programs” that the workflow “platform” executes. However, there are many health IT software systems that either lack, or, only recently rely on rudimentary workflow engines. In these systems, it is often one or more human users who play the role of intelligent “workflow engines”. The clear trend is for more-and-more health IT software to leverage more-and-more sophisticated software-based workflow engines. However, human workflow engines increasingly influence the design of software-based workflow engines being incorporated into healthcare software.
Care workflow platforms have four primary benefits over non-workflow care platforms.
Automaticity: Workflows and tasks can be triggered automatically.
Transparency: Workflow and task state can be continually visible.
Flexibility: Workflows and tasks can be “programmed” by non-programmers.
Improvability: Workflows and tasks can be systematically improved.
I am now a two-decade advocate for using healthcare workflow technology to help manage, even solve, healthcare workflow problems. Thinking through the meaning of “care”, “workflow”, and “platform”, and how they relate each other is a valuable exercise, one to which I can point other healthcare workflowistas, in a growing discussion of healthcare workflow and workflow technology.
Question: I spend part of my time in the workflow technology industry, where non-programmers have been able to create entire applications by drawing or clicking to create workflows, for decades.
Given your goals of fast and easy creation of health IT apps, based on SMART & FHIR, in five years, do you envision users (not programmers), who know their workflows best, to be able to create their own workflow apps by dragging-and-dropping SMART apps interacting with FHIR.
Answer (conflating GG & JM): We need to observe how SMART & FHIR are used, but yes that seems reasonable within a five-year time frame.
Most modern BPM (Business Process Management) platforms already have sophisticated incoming and outgoing APIs. Many have means to extend the drag-and-drop tasks they support. It will be interesting to see which of the following comes true more quickly.
Health IT adds process-aware application architecture, such as workflow engines and workflow editors (I’m seeing this happen), capable of assembling SMART and FHIR-based sophisticated workflow applications.
BPM adds hooks so its sophisticated workflow orchestration engines and graphical workflow editors can assemble SMART- and FHIR-based components and functionality into sophisticated workflow applications.
Both! As in interesting mashups, such as BPM platforms integrated with traditional health IT, essentially outsourcing their workflow management.