Happy Valentines Day, Workflow, My Love!

Sometimes wonderful tweets get lost in the mist of time,
Sometimes they get archived in blog posts about rhyme!

Shared Social Virtual Reality Networking for Health, Healthcare, and Health IT Marketing

I’ve fallen in love with the potential of a new social media medium. First there was blogging. Then there was Twitter. About three years ago I fell in love with social video (Periscope, Blab, and Firetalk, RIP the last two!). And now I am gaga over shared social virtual reality networking! I know that is a mouthful. I’ve seen it called at least three things: social virtual reality, shared virtual reality, or virtual reality networking. So I decided to mash them all up, until one becomes the generally accepted moniker.

Think of it this way. There are these virtual characters in a virtual place: a meeting room or conference, a shopping center, or perhaps a beautiful windswept hill or floating somewhere in the stars. You’re wearing a virtual reality headset, and can see out of the eyes of one of these virtual characters. You control it. You move it, point it, and gesture with it. You can customize it to make it look like whatever you wish. (Yep, sometimes it gets freaky. @ReadyPlayerOne anyone?) And there are other people strapped in their virtual reality gear, controlling… stop. No, “controlling” is too detached. You literally feel like you are in this virtual space, interacting with virtual people. And they feel the same way. It’s amazing!

Consider the following quotes:

“Shared VR is about sharing your virtual experience with another human who is also in virtual reality. This is the next step in communication mediums.” (Shared VR Explained)

“Virtual Reality is one of the most social technologies ever created…. Meet people from around the world, attend free live events, and play interactive games with friends. Day or night, there’s always someone to hang out with.” (The Top Social VR Networks You Can Hang Out In Now)

“why the world’s biggest and most popular social network [Facebook, would pay $2 billion] to own a virtual reality company…. Social VR will be entirely about inhabiting virtual space together, and driven by real human interaction…. Social networking has grown from text-based communication to largely visual, through the sharing of pictures and videos…. Virtual Reality is therefore tailor-made to be utilized as a social platform. It is, at its very core, about communication” (Virtual Reality in Social Media: Introducing Next Level Networking)

Shared social virtual reality networking is relevant to health/care/IT marketing in several ways. First of all, virtual reality, itself, without the shared/social/networking aspect, is a great way for prospective clients to kick virtual tires. Outside of healthcare, it is taking off, allowing consumers to more viscerally and immediately experience furniture, cars, and real estate. In healthcare, VR is taking off for educational and clinical purposes from learning to perform surgery, to preparing for a specific surgery, to distracting patients from the pain of surgery. It’s only a matter of time before it comes to health, healthcare, and health IT marketing,

About 15 years ago I was put in charge of researching whether it would be possible to replace our annual EHR user conference with a virtual online conference. I was amazed at the ambitious platforms out there. Many actually simulated a 3d conference space, allowing participants to customize their avatars, and upload and present PowerPoint slides on virtual screens projected to from virtual projectors in virtual meeting rooms. But there were three problems: expense, stability (ambitious but immature software), and lack of the virtual reality experience. It was like playing a game in which you controlled a character on the screen. But it was not immersive. You didn’t feel like you were actually “there”. Today is completely different. I’ve researched a bunch of shared social virtual reality networking platforms. Free: check! Stable: Tolerable (occasional crashes). Virtual reality? Check!

What about shared social virtual reality networking and health IT marketing? Set aside marketing virtual reality products in healthcare. Obviously, allowing someone, from the comfort of their home or office to experience a virtual reality product, while guiding and interacting with a them, will be a great tool. But consider marketing non-virtual reality products. How might virtual reality be used to market an EHR? A patient experience management platform? Imagine being an EHR vendor and being about to “spin-up” an entire virtual reality hospital and clinic, and allow clinicians (and patients!) to wander around and see how the health IT affects healthcare workflows and experiences!

And, further, imagine creating an entire health IT marketing conference one can attend in virtual reality! All (well most, forget the food) of what we love about real-life health IT conferences can be replicated (within a modest time frame, as the VR tech evolves, I am convinced!), from the milling around, to serendipitous bumping-intos, to lectures and panels. And, they can inexpensively be held in exotic places from Hawaii …. to Mars!

OK, enough palavering about the insanely exciting possibilities of shared social virtual reality networking. What are the nuts-and-bolts of getting started, now?

My First Attempt at Hosting a Shared Social Virtual Reality Networking Experience

Since the summer eclipse (during which I attended an eclipse watching party in virtual reality) I attended occasional events in virtual reality via AltspaceVR. When I realized I could, for free, host my own virtual reality event, I began thinking about hosting a health IT marketing VR event. So, about an hour before a recent #HITsm tweetchat, I decided to jump in with both feet. I actually didn’t expect anyone to show up. But what the heck, at least I could still always be able to say I tried it first.

Luckily, Lisa, and then Becky, saved me from failure. I tweeted out a link to the virtual reality space, plus two links to PC and Mac clients to download, install, and join me. Now, these are not full-blown VR experiences. They are 2D AltspaceVR clients. They remind me of the 3D user conference software I investigated 15 years ago. However, I am convinced, once one experiences the 2D experience, I think you’ll consider some extra investment to get the 3D VR headset and experience the full 3D immersive experience.

Let’s start with a short (17 second) video. I’m welcoming Lisa, who’s appeared in the doorway of the meeting space (customized! Nice outfit!). I’m in a blue shirt looking up. I’m actually shooting the video from @MrRIMP’s AltspaceVR’s account, so I can capture myself in the third person. Then, in the middle of the video, Becky materializes behind me (to the left of Mr RIMP). Becky and I successfully got our audio to work. Lisa and I didn’t. But you can text between avatars by clicking on someone and popping up a text box.

We all agreed, it was very cool, and worth trying again. Becky has a Samsung S7 so I pointed her toward the Samsung Gear V R (about $100). Both participants looked around the meeting space (and Lisa wandered around a bit outside the meeting space building).

Here is what I tweeted in order to invite folks to install the necessary software and join me in virtual reality.

Don’t bother clicking that link to the virtual realty space. It was just temporary. But do, if I tweeted out a link during a tweetchat, find THAT link to join me in social VR. Click and download a PC or Max 2D AltspaceVR client. Perhaps visit the “Campfire”, an always on virtual reality space, where newbies pop in and out, trying to figure our how to control their VR avatars. Got to events to see what happening, right now, or register your interest (so you’ll be notified when one is about to start): music, comedy, science, software development (especially VR), current events like eclipses or rocket launches. Just hang around in the back of the crowd, if you are shy. Then ask someone near where they are in the physical world to start a conversation.

Some Caveats about Shared Social Virtual Reality Networking

“Meeting a friend in a space like this is not the same as real life, it is something quite different but it still makes you feel “in touch”. When used with realistic expectations, social media should satisfactorily accompany real life interaction. Virtual social media offers the same benefits, but is more sensory…. Virtual Reality will probably not replace physical interaction – there is too much to be gained from being “with” a person in real time and space. … You dip into it, and it’s as fun to play as it is relieving at times to come out of. Personal interactions through virtual reality will, at best, serve to supplement our social lives as social media already does” (Social VR: Will Virtual Reality Increase Or Decrease Loneliness?)

I ended up focusing on health IT marketing, but social virtual reality has great potential for non-health IT folks, such as healthcare provides, patients, anyone interested in health, to get together to chat about common interests. I hope using virtual reality as part of social media becomes an easy and commonplace experience. And I think one important role for the health IT social media community will have will be to help support the less technical, but nonetheless enthusiastically interested, network in shared social virtual reality!

From Big Data to Smarter Care: The Workflow Dimension

One of the best things about being a HIMSS Social Media Ambassador (four years in a row!) is being asked to write about anything that has anything to do with healthcare workflow. It is both flattering and satisfying. So, when I was had an opportunity to write about the upcoming Big Data & Healthcare Analytics Forum (Boston, 10/23-24) I jumped at the chance! Also, please join the #PutData2Work Twitter Chat (today, 1PM EST, immediately after #KareoChat).

The relationship between data and workflow in healthcare is an interesting one. The Forum illustrates this. It emphasizes “action” based on data: “actionable information,” “actionable strategy,” and “actionable insights.” Action is part of the definition of workflow, since workflow is a series of actions, consuming resources, achieving goals. In fact, big data, data science, machine learning, and business intelligence platforms are helping to bring sophisticated process automation tools to healthcare.

In my three-series just before the HIMSS17 conference, I describe how workflow technology makes modern machine learning and data science initiatives possible. It is simply no longer practical, to manually download, transform, then put into a format causing useful action at the point of care. Data sets so large they cannot fit on puny desktop drives, and then so slow to upload and download and upload again, force us to, essentially, model data workflows and then execute these models, in the cloud, without continuous, direct, manual, human intervention. I discussed this at length in A guide to AI, machine learning and new workflow technologies at HIMSS17 Part 1: Machine learning and workflow.

In particular, I hope you’ll pay attention to the following three presentations at the Big Data & Healthcare Analytics Forum…

…and ask yourself:

  1. How does workflow and process automation help make machine learning and smart systems practical?
  2. How does workflow and process automation make generated insights “actionable”?

I’ll close with a quote from Hal Wolf, President And Chief Executive Officer, HIMSS:

“We want to maximize the patient experience at each clinic, and thus it’s important that we not be too rigid about workflows and systems. The clinics have room for flexibility and innovation.”

Most folks think of workflows in terms of day-to-day tasks of clinicians and staff. Obviously these “flows” influence patient experience. However, data-flow is also a kind of workflow. These workflows exist as both models of data flow, and executions of these models by various kinds of engines (workflow, process, orchestration, and data pipeline engines). Big data, business intelligence, and machine learning platforms have, at their core, sophisticated models and engines necessary to strike the right balance, between efficiency through best practice standards, and flexibility for healthcare organizations to innovate.

I also hope to see you at the #PutData2Work Twitter Chat: Building a More Informed Healthcare System, at 1PM EST, on October 12,

with @HealthITNews, @SullyHIT, @ShahidNShah, and @drstclaire!

Viva la workflow-powered data, and data-powered healthcare workflow!

If you are interested in the fascinating relationship between healthcare data and healthcare workflow, I hope you’ll follow me on Twitter at @wareFLO (for soft(ware) work(FLO)w).

3rd Annual NHITweek Firetalk: 3Dprinting in Healthcare w/@Brouwers_3D & @wareFLO

It was great! 18 viewers and 56 comments! Watch, learn & enjoy! (more details after the embedded Youtube archive of the Firetalk, tho here is original link https://firetalk.com/events/BkEvXDesW)

#3Dprinting in Healthcare! @Brouwers_3D @wareFLO: 3rd Annual #NHITweek #Firetalk

Hosted By: Charles Webster MD ⎌ Tuesday, October 03, 2017, 10:00 AM to 10:30 AM

10:00AM EST on Tuesday, Oct. 3rd, during National Health IT Week (http://www.healthitweek.org) I’m excited to speak with Lars Brouwers, MD, MS (almost PhD!) about 3D-printing in healthcare. I hope you’ll join our Firetalk, make comments, ask questions, and even take a video seat! (I’ll publish your best segments as mini Youtube videos, and tweet them out during the rest of National Health IT Week!)

Here are couple quotes from Lars:

“3D-printing is the most important invention after internet. I use it on daily basis”

“Our goal is to investigate the added value of 3D-printing, and implement a low-cost workflow for many hospitals worldwide”


Later in the week Lars is speaking about his 3D-printing in surgery research in Vancouver, Canada, at the Orthopaedic Trauma Association’s 33rd Annual Meeting. So we are lucky to have this opportunity. Check out a recent article in Physician’s Weekly, “Implementing In-Hospital 3D Printing”, to learn more about Lars’ exciting use of 3D-printing to improve surgical outcomes.


If you are a patient, or a health IT professional, who’d like to learn more about 3D-printing and how it will affect your life or profession, this is a great opportunity to peek into your near future. Please join us, first watch and listen, and then to take a video seat and probe further and express your opinion.

By the way, this is the third time I’ve hosted a Firetalk group social video during National Health IT Week. It’s always fun, and it will be even more fun this year, during this years 2017 National Health IT Week!

2016 National Health IT Week Blab, I Mean Firetalk, Was Fun! 23 Participants, 50 Comments (w/@MichaelGaspar)


Replay Mid National Health IT Week Blab: Many Thanks to Participants!


Drones In Healthcare: Lessons and Imaginings From Harvey and Irma! #KareoChat 9/14

Imagine ordering fresh food, clothing, & batteries from Amazon, while sitting on your roof due to a flood. Imagine, lying on your roof in the dark and cold and rain, and being addressed by a friendly drone offering assistance. Imagine that drone calling in a big brother drone, large enough to airlift you to safety. Imagine waterproof drones fanning out and sampling floodwaters for unhealthy substances and organisms. Imagine being a quadriplegic and being able to fly like Superman, remotely piloting a drone while wearing telepresence goggles.

All of the above possibilities are technically possible, or folks are actively working to make these possibilities possible. In fact, during Harvey and Irma I saw dozens of news articles about the use of drones.

During the upcoming (Thursday, Noon EST, Sept. 14) #KareoChat tweetchat about drones in healthcare, I’ll tweet examples of all of the above, and more! Drones can deliver to your phone using its GPS coordinates. Drones can find people in the dark and cold using thermal imaging. Drones can talk to onlookers (think, drones + Alexa). Drones large enough to lift people exist, and are being proposes as air ambulances. Quadriplegics are learning new careers as drone pilots.

I’m saving most of my links to cool uses of drones in healthcare for the actual #Kareochat tweetchat, but I encourage you to watch these two videos.

Immersion Drone Piloting for People with Disabilities

Quadriplegic flying Quadcopter FPV (First Person View)


T1 Did you see any news about drones during Harvey & Irma? About what? Any controversies? #KareoChat

T2 If you were bed-bound, and could return anymore in the world for a drone’s eye tour, where & why? #KareoChat

T3 Drones are cool w/great potential, but what kinds of problems might they cause? Any ways to fix?

T4 If medical supplies could be delivered anywhere, within minutes, for virtually zero transport cost, how disruptive might that be?

T5 How can FEMA (Emergency) & FAA (Aviation) best work with thousands of enthusiastic drone pilot hobbyist who want to help during disasters?


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

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

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

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

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

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

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

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

  • Cost
  • Experience & Usability
  • Interoperability
  • Incentives

Let’s start with healthcare cost.

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

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

Now let’s tackle experience!

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

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

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

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

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

What about interoperability?

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

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

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

Finally, incentives….

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

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

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

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

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


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

Workflow technology!

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

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

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

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

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

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

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

@wareFLO On Periscope!


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

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

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

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

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

@wareFLO On Periscope!


Virtual Reality At eHealth Week on Malta

I recently returned from Malta, in the Mediterranean, where I attended eHealth Week (see I’m going to Malta as a HIMSS Europe eHealth Week Social Media Ambassador!). It was lots of fun. I learned a lot. And I especially liked meeting the other eHealth Week social media ambassadors. The highlight of my trip was my visit to the Oculus booth. There I experienced, for the first time, virtual reality! It was awesome. The implications for medical training and for helping patients deal with fear, stress, and pain are tremendous.

Let me start of with the most obvious observation. Virtual reality feels real! So much so, that when an angry T-Rex chased me down, and roared at me so hard I could see (and imagined I felt) its spray of spittle (ewwww!), I was really, really frightened. Just imagine how virtual reality could be used to treat phobias. I couldn’t help but video @tbaupuig‘s reaction to what I’d just experienced. (I think I must have jumped back from that marauding monster twice as far as Teresa!)

Coincidently, I’d already read about one of the virtual reality projects presented at eHealth Week.

So I was delighted to see Devi Kolli (@kolli_devi), of @AiSolve, and Kumar Jacob, of Mindwave Ventures (@mindave_), present during the eHealth Week session Using Virtual Reality to train Clinicians of the Future. From the session description: “The applications of virtual reality (VR) are much more than simply playing a game in a more immersive way these days – and are having truly life-changing effects within the healthcare industry – not only for patients, but for healthcare professionals and organizations too.”

Here are their slides:

If you know anything about me, I’m all about the workflow. So I especially appreciated this slide, from Devi Kolli’s presentation, about VR game workflow in the service of clinical training.

During the discussion and question period, the following points were made:

  • VR experience is less expensive than real world experience
  • VR does not necessarily change tried-and-true approaches to medical training
  • VR training can be integrated into traditional training so as to augment that training
  • VR is great for visual learners
  • VR induced motion sickness is a thing of the past, due to modern headsets and content curation (by Oculus, for example).

The most interesting question from the audience was, “How long until the EHR is built into the VR experience?”

Answers from the stage: “Not long!” (plus ideas for using VR to train users on EHRs, perform usability research, and visualize patient physiologic signs).

In summary, we are at the pilot stage of using virtual reality in clinical settings. As VR tech becomes less expensive and more widespread we’ll see that people do with it! In fact, if you look at using VR gaming techniques for training, healthcare is probably the most obvious place to leverage virtual-reality-based training.

I’ll close this post with an interesting twist on an old saying in medical training.

  1. See one!
  2. Do one!
  3. Teach one!

Will become:

  1. See one!
  2. Experience one!
  3. Do one!
  4. Teach one!

That Experience one! is THE 4TH STEP in Kumar Jacob’s (Mindwave) excellent presentation.

I’m so excited about virtual reality, I bought a VR headset and several 360 VR cameras. As a sometimes programmer, I’m already poking as various VR SDKs (Software Development Kits) and wondering what I can accomplish. Follow me on Twitter at @wareFLO to see what I conjure up! Certainly, “conjure” is the right word, the immersive impact of the “reality” that VR can create is, well, magical!

P.S. Here is a collection of great tweets about, or related to, virtual reality at eHealth Week on Malta.

The above 360 photo of the eHealth Week exhibit hall was taken by @stefanbuttigieg.

I’m going to Malta as a HIMSS Europe eHealth Week Social Media Ambassador! Join My Co-Hosted Tweetchats!

I’ve been to cool places — Lisbon, Beijing, Zurich, London, Hong Kong, St. Petersburg — but I’ve always been fascinated by Malta, an island in the middle of the Mediterranean. Why? I’m a history buff. I’ve read about the Phoenicians, who sailed the Med 3000 years ago. I’ve read about the clash of civilizations, between Christian Europe and the Muslim empire. And I’ve read about World War II in the Mediterranean. In all of these accounts, Malta played dramatic and important roles.

From Wednesday to Friday, May 10-12, the annual eHealth Week Conference comes to Malta. I’ll be there, tweeting of course! In fact, please join one or both tweet chats I’m co-hosting.

The #MEQAPI tweetchat, with @stefanbuttigieg MD (also an eHealth Week Social Media Ambassador) and @MLoxton/@MEQAPI, occurs at 3PM Thursday, or 9PM Malta time. Thus, #MEQAPI occurs the evening after the first two full days of #eHealthWeek. The subject is what we can learn from European healthcare systems, health IT, and digital health history and experience. See below for questions/topics.

The #AskAvaility tweetchat (Provider Front-End Workflows: A Tweetchat), with @Availity (Mohammed Mansoor @elpmma) occurs Friday at 1PM EST (right after the noon #HITsm tweetchat), which is 7PM Malta time. The subject: again, workflow, though more specially, front-end workflow immediately affecting physician EHR/HIT users and their patients. Also see below for questions/topics.

If you’d like to prepare, I’d recommend taking a look at the following.

My own tweets about #eHealthWeek https://twitter.com/search?vertical=default&q=from%3Awareflo%20%23eHealthWeek&src=typd

Also check out videos from my recent Firetalk with @stefanbuttigieg, Dr Hugo Muscat @HAgiusMuscat, Presidency Coordinator, #eHealthWeek 2017, Danielle Siarri @innonurse (eHealth Week Social Media Ambassador).

Next, the #MEQAPI (Thursday!) and #AskAvaility (Friday!) topics…

#MEQAPI (Measurement, Evaluation, Quality Assurance, and Process Improvement) Questions/Topics


T0: Introduce yourself! Are you at #eHealthWeek? Why? #MEQAPI regular? Where based? @stefanbuttigieg @mloxton @MEQAPI @wareFLO welcome you!

T1: #Malta has a national patient ID. Advantages? Disadvantages? Should US do the same? #eHealthWeek #MEQAPI

T1: Europe healthcare is predominately single player. What are/would be, implications for health IT? #eHealthWeek #MEQAPI (joint tweetchat!)

T3: EU has 28 nations & 24 languages. US is becoming more diverse. How does culture influence HIT? #eHealthWeek #MEQAPI (joint tweetchat!)

T4. Do any US based #MEQAPI regulars have questions for any #eHealthWeek attendees? Visa-versa? (#eHealthWeek #MEQAPI joint tweetchat!)

T5: #MEQAPI regulars, quick, look at recent #eHealthWeek tweets, your favorite? Visa-versa? (#eHealthWeek #MEQAPI joint tweetchat!)

T6: Workflow is a global & universal healthcare concern. It’s also incredibly localized. Discuss! #eHealthWeek #MEQAPI joint tweetchat!

#AskAvaility Front-End Provider Workflow Questions/Topics

(Front-end healthcare workflow is just as important in Europe as in the US, so I hope we see some participation from #eHealthWeek tweeps!)

T1: Why are efficient front-end processes so important in today’s healthcare market? #AskAvaility

T2: What are some challenges healthcare orgs face with manual front-end processes? #AskAvaility

T3: How do inefficient front-end workflows contribute to provider pain points like denials and collections? #AskAvaility

T4: How do front-end workflows affect patient experience? #AskAvaility

T5: What are some ways to enhance patient experience through changing front-end workflows? #AskAvaility

T6: Where do we start to improve front-end workflows? #AskAvaility

Phew! Busy week! 😅

In closing, watch this 2-minute video about Malta…

If I’m someplace with a cool view, and I have connectivity, I’ll try to simul-Periscope…

@wareFLO On Periscope!


Designing with Patient & Provider EHR Workflow in Mind: My Conversation with AdvancedMD

Every once in a while I get to have a really, really meaty conversation about healthcare workflow. I’m especially interested in so-called “front-end” workflows, the ones most directly affecting (one might actually more accurately say “effecting”) provider and patient experience. So I was especially excited to sit down with Jared Alviso, PMI-ACP, Senior Product Manager at AdvancedMD, to discuss the shift in the company’s mindset toward designing workflow- and process-aware healthcare technology.

By the way, this is a hectic week for AdvancedMD, they’re at three conferences!

Plus I, myself, am an eHealth Week Social Media Ambassador at the eHealthWeek conference on Malta (#eHealthWeek on Twitter).

(I’m tempted to put an animated GIF referencing the admonishment in Ghost Busters, to not “cross the streams,” but … oh what the heck!)

All in all, this week is an incredible conjunction of opportunities to press that same case I’ve now been making for decades. Healthcare needs to dramatically up its game when it comes to improving workflows to improve patient and provider experience!

Let’s found out from Jared about AdvancedMD’s advanced thinking about front-end healthcare workflows.

1. CW: What is “integrated workflow” at AdvancedMD?

JA: Our client base at this time is a smaller private practice. In that practice, a medical assistant could also be the front-office person taking phone calls and making appointments. One thing we are looking to do is put the practice management features and functionality needed to fully run an office into the EHR. We know that most EMRs/EHRs are all about the clinician side of things, so from an integration perspective, we put some of the key [practice management] workflows and functions into the EHR. A medical assistant can now take care of appointment scheduling and track the charge slips from the EHR itself in visible day-to-day appointment workflows.

The first step we’ve taken is with our new AdvancedEHR dashboard. The dashboard basically allows our clients to see a single column scheduler – a list-view of the patients they’re seeing that day. Additionally, it allows them to see non-appointment workflow items. When they’re not seeing patients, they’re actually looking at messages, pending referral requests, pending lab orders, result orders – in other words, items that need to be addressed that are not necessarily associated with an appointment, and the dashboard allows them to do that.

CW: Is it live in the sense that if you don’t touch it and you just look at it, you see things happening?

JA: Yes, it is live. If you were to just leave the dashboard there, here is what happens. As you check in the patient, you “flow” with the patient, you’re able to see that the dashboard actively updates, as well as any new messages and any new review bin or task items that come across to the user that’s logged in.

CW: Are there some kind of workflow rules behind the dashboard?

JA: That’s the case. We are making the dashboard customizable based on the workflows for that individual practice. We want to make it specialty-specific and workflow-specific out of the box. If a user has rights to see certain providers’ schedules, they will in return see the potential review bin or task that needs to be done. We know that an orthopedic doctor is not going to want to see immunizations and growth charts. Donut graphs that we currently have in the dashboard are customizable, and you can drag and drop items in a view that best suits the user.

CW: Is there a sort of an editor mode – just like you would author a report? You’re authoring or editing the dashboard view.

JA: To the extent as it relates directly to the dashboard graphs themselves, yes. You would enter into an edit mode, then drag and drop things wherever you would like to place them. And the table would directly reflect whatever changes you made. To further elaborate on that, we also are adding a filter functionality, which is going to allow users to see their review bin items, such as results review and prescription renewals. Or, they can filter to see a specific provider information should they have access to do so.

CW: What is a quick list of systems with which you integrate?

JA: Areas that we’re looking to integrate into the workflow are around patient engagement. We’ve added a rooming integration to be able to track the patient flow. That’s from our practice manager assistant to the EHR and all the way to our mobile application. We also have our patient messaging, communications that will be accessible from the dashboard in all of our platforms. They also have the ability to capture what patient preferences are – if they like to be communicated with via text or e-mail or phone, we can capture that information. We also have patient forms capture so the intake process is another key thing that can be monitored throughout all of our portfolio of applications.

2. CW: I think a good strategy for companies is to figure out how to use workflow, workflow-esque ideas and workflow thinking to market the advantages of a product. A) Do you agree? B) When and how did AdvancedMD realize that workflow is key?

From that perspective, I do agree. Now, you ask when AdvancedMD really realized the importance of workflow. From a historical perspective, AdvancedMD has at first been a practice management system. Workflow was obviously the reason for success of our practice management system. Since then, we’ve added the EHR. Today, we’re really trying to change the conversation here at AdvancedMD by indicating that flow is key. In the design phase, we’re going down the path of outright creating “certified workflows,” or we can call them “best practice workflows.” We basically say, “This is how AdvancedMD recommends you write a prescription, how you document your patient visit, how you order your labs, and how you preview your results and do your messages.” Everything we’re doing for the new design of AdvancedEHR is around the workflow definition first, so that we could help extract the requirements needed to run a successful practice. Then, we do not force the requirements into the design, but rather make the design suited to the business requirements and, in this case, the office workflow.

We feel that providing the “best practice workflows” is going to be key and that’s what we’re focusing on from a software development perspective. We know not every office is the same, but we do know that probably around 80% of practices are the same. We can do customization for the other 20%, such as specialty-specific things. That’s the big effort and we’re much vested in it.

3. CW: Do you have an example or can you paint a mental picture of how two different sub-systems such as the EHR and the practice management system, because of the similar look and feel, are going to give a better or more satisfying or more efficient or more effective user workflow experience?

JA: From the practice management perspective, we’ve made our application browser-agnostic, so it can be used in any browser, Chrome, Safari, Firefox, IE, anything. With that came a design of what we call the “new shell.” This new shell contains a menu structure that allows us to use the latest technologies as we create new software. As it relates, the design, the look, the feel, the functionality and the value that it brings to our clients is the ability to say, “You know what? It’s integrated. You don’t have to switch among multiple terminals or applications open at once. You can actually schedule an appointment from the EHR based off of your ‘persona’.”

The persona base is another big focus area for us. Based on your persona, what you see when you log in to the integrated application is what you’re going to get. If my role and persona in the office is receptionist, I’m going to get scheduling, I’m going to get access to very minimal patient information because I don’t need to see all the clinical information. Harvesting that information, and being able to do that from one application, to me, the value that it adds is like the alt-tabbing. Customers can now work within the structure that we built in the global shell, and be accustomed to the global feel of our practice management and EHR systems.

4. CW: One frequently hears EHRs are not usable because they were designed as billing systems. What does AdvancedMD respond to that?

JA: The way I feel we are responding to the needs of providers is by putting more emphasis on the clinical side of things. Billing is probably the number one thing that private practices are making sure they can achieve. But next to that, what’s the most important thing to clinicians? It is being able to document/back up claims that they’re making to insurance. So, having a good system that’s able to document that and a good process is key. We think persona-based system can address the issues that each role has in an ambulatory flow.

CW: Yes, when people think of electronic health records, they tend have a very data-centric notion. They think, well, an EHR is basically a database with a user interface on it. EHR matches the structure of the data, when you really need it to match the structure of the workflow. But if you have a system in which the workflows can be customized by person and role, you can have billing and clinical workflows existing in the same system. I’m giving my opinion here, and there’re a lot of EHRs out there that are designed, like you said, with billing being historically a number-one priority, and then of course, you have the clinical part of it. And if you can’t have different workflows for different roles and people – and I think that would be the personas in your case – then you’re going to butt heads. You’re going to have to go with the billing workflow. But if you can have customizable workflows for different people and roles and personas, then you can have your cake and eat it, too.

5. CW: Just how customizable are AdvancedMD’s workflows? What’s the basic workflow customization paradigm?

JA: One of our primary objectives for the integrated workflow project is for products to function fully right out of the box. We deliver the EHR already customized by a specific specialty; we have our core four: family practice, pediatrics, internal medicine and obstetrics. We can also open it up to a broader array of specialties.

So, out of the box functionality is priority number one. Number two is customizing specifically around how customers use the software. If there’s a tweak or two they want to make, they can actually do it on the fly. We have a huge matrix that allows them to pick—for example, if a user changes the layout of the [AdvancedEHR dashboard] donuts, the next time they log in, the donuts retain the new view. This is because they changed the look for a reason and we want the system to remember the preference. For example, AdvancedEHR today is very customizable. Users can go in and create templates for specific visits. They can create specific chart flows. If they feel like they’re not getting what they need to see in the summary, they can say, okay, I need to pull in, let’s say, an allergies card. They can go in and pull in a specific, new view element that allows them to see a patient’s allergy and they can do that on the fly.

To sum up, these are a few different approaches that we’re taking. One, we want the systems to be easily used by anybody out of the box. Two, somebody in the administrative role can go in and create custom views and then disperse them to users; and three, on an individual basis, a user can change and customize the views at will.

CW: I heard you mention the phrase ‘chart flow’ earlier. What do you mean by chart flow?

JA: The chart flow is different. There’re two main things that we’re focusing on. We have 1) non-appointment workflows and 2) appointment workflows. The chart flow is essentially going through and during the appointment workflow: from when a patient checks in, the nurse puts them in an exam room and gets all the subjective information and the provider wants to be able to access [the “rooming” information before the visit]. We are working on determining such flows. You know, the age-old conflict of somebody being in the chart while somebody else is in the chart. It can create potential data conflicts. Chart flow is something that we’re addressing not only from a data conflict point of view, but we are also making it possible to access a patient’s chart from basically anywhere.

A good example is, again, the AdvancedEHR dashboard. We have the ability to do multiple things on the single column scheduler. Customers can click through to where it opens up a patient chart, change the rooming status [showing details of a patient waiting in the exam room], check them in, check them out and put notes on the patient’s chart – all from a single column scheduler. That represents a small fraction of the chart flow. Because we put information on a scheduler card, it allows that data to flow to the chart.

6. CW: How “transparent” are AdvancedMD’s workflows? How easily can task status (pending, completed, escalating, etc.) be tracked?

JA: As far as tracking workflows, it goes back to our earlier discussion about seeing changes happen on the dashboard. For example, with the rooming module, a user can see not only the patient status and the exam room they’re in, they can also see that they are waiting for a nurse, or a provider, or for a lab tech to do a blood draw. We also track the time it takes so that the clinic and the office manager, someone from an administrator perspective, can identify bottlenecks in the workflows. So, if a patient is “sitting in a status” for a certain amount of time, visually, on the dashboard, the task item will turn red, indicating the threshold has been crossed. That would mean that the patient’s been waiting for the nurse for the past 15 mins.

The value here is to allow our clinics, our practices, to identify workflow bottlenecks from a day-to-day basis, and that’s just one example. Another example is receiving labs results or sending lab requests to be processed. As users navigate throughout AdvancedEHR, the dashboard is going to refresh every time they come back to it. We also use automated pop-up messages indicating things like priority messages. This is actually a new feature that we’ve enabled for all of our chart items within AdvancedEHR: users can set chart items as high priority. When it comes to interfaces with labs to receive results and send orders out, we’re designing automatic flags that are going to mark them as priority. Based on the way we have the dashboard configured, we have a priority bucket, we have a help bucket, and we have all other unsigned items. There are different quick drill-down capabilities for them to be notified quickly when something high-priority comes in.

7. CW: How smart are automated workflows? Does some new data, something that gets downloaded into the system, trigger a workflow to end up in the right place, to catch someone’s attention?

JA: Yes, that is something that exists today and we refer to as HealthWatcher [within the EHR]. There are rules that can be customized for specific practices and specialties. What HealthWatcher allows you to do is to set up specific rules based on, just as a quick example, a yearly physical. Users can set up lab orders and appointments based on gender, age or other criteria to automatically notify the physician or clinical staff that a particular person that they’ve selected or scheduling an appointment for is in need of these lab draws or a physical. These items are included as part of our customizable donut graphs or data that is displayed on the dashboard. Users can access the feature from the dashboard, which is what makes it automated.

8. CW: From a historical timeline, first, it was practice management system, then EHR, then patient engagement and telemedicine. What comes next? How will the new tools be integrated into existing, seamless, streamlined workflows?

JA: From a timeline perspective, we’re looking for some of the enhancements as well as integrations to be problem-based. We’re allowing the data that’s captured from a patient visit to be used to benefit the clinic. It is not about data telling the provider how they should be practicing medicine, but rather guiding them. It’s basically saying, “Based on how you diagnosed a patient with hypertension and diabetes in the past, here’re the prescriptions that you’ve written, here’re the notes that you used, here’re the images that you used, the labs that you ordered, and the plans that you’ve associated with these particular types of cases.” From a high-level design perspective, this is how we are looking to make that data work for us and for our clients. That’s probably one of the biggest things that is coming out with the integrated workflow project.

CW: How about wearables and things like that?

JA: When it comes to wearables and health records like HealthVault, we hear from our existing client base that they want this data to be integrated with electronic health records. AdvancedMD currently has a huge initiative where we focus on patient engagement, patient portal and patient-facing mobile applications. That gives patients the ability to leverage various health apps that they have on their devices and upload data to their portal, which in turn will integrate with our EHR and practice management system.

That initiative is huge for us because our clients really want to interface with these applications and apps. It’s important to the patient, it’s important to our clients, and I think that’s where the industry is going. In addition to that, we also need to integrate with [other devices’] hardware; for example, an automatic blood pressure cuff that a patient is using or other medical devices the practice wants to interface with and capture data from. So, the wearables initiative is in the forefront for us and we’ve been planning and designing our execution in that area.

CW: Are you starting to look at or already have a common workflow engine capability or is it still peer-to-peer?

To me, a part of what makes a successful EHR is being able to integrate with whatever technology the industry introduces. Our interface teams and interoperability teams specifically focus on doing lab and order interfaces, work on integrations with other PM systems and with other EHRs. Added to this effort is our work to integrate with wearables and medical devices. We are using a lot of in-house, peer-to-peer at this point in time, but we’re currently exploring the integration with a couple of third-party vendors that would allow us to quickly integrate. Eventually, we could leverage the third-party to become that one specific integration engine for us.

9. CW: Do you offer any workflow improvement consulting services? Any workflow analytics? (Cycle time, thru put, activity based costs, bottlenecks spotting, etc.)

JA: To answer the first question, we have a professional services partner that helps clients that may need some post-implementation support. The partner will help with things like documenting their patients inside of a note, writing prescriptions, or understanding the flow for ordering labs.

As far as workflow analytics is concerned, the good thing is that we audit everything we do and that allows us to put the data that we’re capturing to work. The way we extend this data to help our client base of smaller practices, two to four providers, is by allowing them to pull reports. Let’s say, we’re going to create a new report and it’s going to be called “patient check-in report.” It provides value by letting the office manager, or practice manager, know that, for example, our nurses are being kept up. Why? Is it the vital taking? Is it the note opening? Not only do we capture that data for reporting, we can also display it in the EHR dashboard to help with the clinical side of things.

CW: Well that’s truly impressive. You are moving away from what I call workflow-oblivious health IT, to process-aware. The idea is that IT needs to have some kind of awareness that there is such a thing as a workflow. Because if you don’t represent it, if it’s not a direct, explicit, intended workflow related behavior, you’re not going to get the various efficiencies and effectiveness and usability that a lot of people think is missing from a lot of health IT today.

Jared, do you have any words of wisdom or philosophizing you care to share as a closing remark?

JA: I have a passion for the new approach truly based around workflows. If we can’t expose the bottlenecks, the issues, the aches and pains that our clients and practices have on a day-to-day basis and make it easier for them to do their jobs, then we’re really missing the bus here. I agree wholeheartedly that being process-oriented and workflow-oriented is key. This mindset helps in all different avenues of business, not just software development.

CW: Viva la workflow and onward workflow-istas!

@wareFLO On Periscope!