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

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!


Intelligent, Curious, Friendly People Win Medical Capital Innovation Competition

At last week’s Medical Capital Innovation Competition at the HIMSS Innovation Center, in Cleveland, Ohio, I experienced a fascinating coincidence!

Wow! What A Coincidence! Or Was It Really A Coincidence?

The coincidence? The day before the winners were chosen, I tweeted exactly two selfies with contestants and myself. When the winners were announced, they were the folks in my selfies! According to my rusty combinatoric probability calculating skills, there was less than a two percent chance picking the actual, ultimate winners out of a hat containing 27 potential winners.

Here are the two selfies. (Note dates. They were tweeted the day BEFORE they knew they’d been chosen as winners.)

Virginia Pribanic from Team MedRespond:

Prateek Prasanna and Gagandeep Singh from Team NeuroRadVision (because there were three of us, and I wanted the makerspace into the selfie, we asked a passerby to take the photo of us).

Obviously, everyone participating in the Medical Capital Innovation Competition is highly intelligent, else they’d not even be there. But this “coincidence” got me to thinking. If I were to imagine participating in a similar challenge, with a $100,000 in prizes, I imagine that I’d be driven. I’d be focused. Like a laser! I’d not allow myself the luxury of stopping in front of a pile of 3D printers, laser cutters, drones, robots, and development boards, and asking, hey, what is all this about?

And yet, the two ultimate winners, of the Open and Collegiate Divisions, were drawn to the makerspace, and then chatted amiably for over a half an hour!

I’ve been thinking about this a lot. Was this “just” a coincidence? Or is there something potentially more profound here? I’d like to think the latter.

If I were to characterize Virginia (Ginny), Prateek, and Gagandeep, the words that come most easily to mind are “curious” and “friendly.” And, upon, further reflection, I began to doubt this was a mere coincidence. I suspect that Virginia (Ginny), Prateek, and Gagandeep (and their respective teams) won not just because they were intelligent and driven, but also because they were curious and friendly.

Curiosity may have killed the cat, but it also discovers breakthrough ideas. Google “curiosity” and “entrepreneurship” and you’ll see lots!

What about friendliness? If you Google friendliness and entrepreneurship you won’t find a lot of material, as was the case with curiosity. It’s mostly about creating friendly work environments and which countries are most friendly to entrepreneurs. So, I’m going to have to speculate.

You’re a smart, driven, curious person. Curious enough to explore the world. Smart enough to recognize an opportunity. Driven enough to exploit that opportunity. But you can’t do it alone! That initial band of startup partners are first, and foremost, also friends, or able to become friends. Then, at the beginning, when you have no resources, you’ve got to beg and borrow resources. Guess what. Being a nice and likable person is extremely useful when begging and borrowing.

So, you see, it was not a coincidence, that the ultimate winners of the Medical Capital Innovation Competition stopped to find out about the #HIMSSmakerspace Innovation Makerspace, and then chat long enough for us to form a temporary personal bond, so much so I wanted to document our interaction with a tweeted selfie.

While we are on the topic of curiosity and friendliness, there’s also this tweeted video of Sandeep Konam talking about cancer patient matching.

Why did I shoot this video and then tweet it? Not just because the subject was interesting to me, but also because Sandeep wanted to know what I was doing and was so personable and sociable. And, yes, Sandeep’s startup, EXAID, placed third in the Collegiate Division.

More About the Medical Capital Innovation Competition Itself

I also just happened to catch on video (and then tweet) an excellent overview of what to expect from Matt Miller, of BioEnterprise Corp. Matt covers:

  • mentoring stations,
  • pitch practice,
  • problem and problem solution,
  • go to market plan,
  • viability and scalability,
  • ten minutes to pitch (tomorrow),
  • five minutes for questions

Great overview of intellectual property…

Here is the press release from Medical Capital announcing all of the final winners. Inaugural Medical Capital Innovation Competition Winners Announced: Winners receive $100,000 in Cash Prizes and Access to World-class Healthcare Expertise.

Social Media Surrounding The Medical Capital Innovation Competition

By “Social Media” I mean Twitter. I know there are many other platforms, including Periscope (which I do) and Facebook (which I don’t). But nothing beats Twitter for real-time information and local color when it comes to health IT conferences! Here are the stats for the two days of the conference blue the day before. 113 Twitter accounts tweeted (or RTed) 414 tweets. If you add up the followers for these accounts, times their tweets, there were over two million impressions.

I happen to catch an excellent presentation of branding and social media for startups.

  • Audience
  • Channel
  • Pipeline
  • Connection
  • Community

I like it…

  • Build
  • Tell
  • Listen

…nuts and bolts practical knowledge, literally the step-by-step workflows for startups to use social media to create their brands.

Just A Bit About My Pet Project: An Innovation Makerspace!

Last but not least… This is my baby. You can think of it as a popup “makerspace” in a box (though, in three boxes on a dolly, plus a backpack, is most accurate).

A makerspace is a collection of tools, such as 3D printers and laser cutters, and platforms, such as Arduino and Raspberry Pi development boards. Makerspaces are used to create functional prototypes, such as of medical devices. I had wonderful conversations with Medical Capital Innovation Competition contestants, mentors, judges, and staff about the Maker Movement in Healthcare. Some said they’d not heard of it, but recognized 3D printers and small robots their children were using a school. Others not only had heard of, but actually belonged to, local makerspaces.

Makerspaces are not just about tools, but they are about community too. Here are three HIMSS staff and myself showing off some custom coasters cut engraved by the makerspace laser cutter.

I had a unique perspective on this year’s first annual Medical Capital Innovation Competition. It’s hard to beat hanging around with smart, driven, curious, friendly people. I’m already looking forward to the 2018 version!

@wareFLO On Periscope!


Powerful Content Marketing Needs Empathy for Customer Workflow

(Screenshot of DM from @jslentzclifton included here by permission!)

[This post was written in preparation for Healthcare Content Creation for the Audience Economy #HITsm Chat with @jslentzclifton, @sarahbennight, and @shimcode.]

The opposite of empathy is apathy:

“By definition, empathy is the opposite of apathy. Empathy is defined as “the ability to understand and share the feelings of another” — within + feeling or inside + suffering. Apathy is defined as “a lack of interest, enthusiasm, or concern” — not + feeling or without + suffering.” (On Empathy and Apathy)

The opposite of useful is useless (I don’t think you need a quote!)

Now comparing the following possible combinations:

1. Empathic but useless
2. Useful but apathetic
3. Apathetic and useless
4. Empathic and useful

Which combination do you think is the most attractive and relevant to marketing health IT? Of course: Empathy and usefulness!

Now, empathy and usefulness do seem kinda, sorta, almost at odds. I don’t mean they are contradictory. What I mean is that the kind of content that establishes empathic connection is very different to the kind of content typically used to establish the utilitarian goal of illustrating usefulness. Think: romantic novel versus technical manual.

What if I told you there is a foolproof way to create content that is both empathic and useful? Yes, you know where I am going: workflow!

At this point, rather than repeat myself in great detail, see my 2015 post Marketing Workflow Is An Incredible Opportunity To Differentiate Health IT Products, And You!

But I will summarize that post:

Everyone is an expert on their own workflow. If you can vividly and credibly show ME, an expert on MY workflow, that your product fits perfectly into my workflow, I’m yours! There is no more intimate AND utilitarian act than to truly understand someone’s workflow in terms of how your product can make their lives better. This is why I so often tweet and write about “empathic workflow.”

Today’s #HITsm tweet chat pivots off last week’s ultra successful #HITMC (Health IT Marketing & PR Conference). The questions really resonate for me. I like to think of myself as a healthcare workflow SME (Subject Matter Expert), but the real SMEs are the folks who use health IT every day to do their work and live their lives. These people are actually, literally, embedded in their healthcare workflows. Forget pretty computer GUI screens. The true user interface between people and technology is the workflow of those people and that technology. Health IT marketing SMEs need to partner with healthcare workflow SMEs to tell their workflow stories, in all their warts and glories. (Many thanks to @sarahbennight for reminding me that the HITMC crowd are also SMEs themselves!) Tell that story! All the way from the programmers who create the software that partially determines workflow, to the users who partially determine workflow, to the dance between software and users that completely determines workflow.

Whew! I enjoyed writing that.

Emphasize your customers workflow and make your content both empathic and useful!

I look forward to enjoying this weeks #HITsm tweetchat about #HITMC!

In order to optimize my workflow during the tweetchat, I’ve written drafts of tweeted responses to each other topics (plus the de rigueur introductory tweet). See you there!

Chuck, #cbus (but in #DC), workflow! I’m a workflow SME (Subject Matter Expert). Workflow posts, tweets, webinars, white papers, videos: LOTS! #HITsm #HITMC #HITMCworkflow

T1: What are some of the ways content & messages can be made inspirational and humanized? #HITsm

Stories = workflows. No, really! Linguists analyze narrative using workflow like systems of notation. I studied this! #HITsm #HITMC #HITMCworkflow

T2: What are characteristics of a ‘good’ SME and how do you identify SME’s in your organization, tribe, circle of associates? #HITsm

Great question! Whoever is most systematically kept AWAY from marketing folks, that’s the most valuable subject matter expert. #HITsm #HITMC #HITMCworkflow

T3: What are most effective types of ‘personalized content’ to share w/ a buyer & at what point in their journey? #HITsm

Whenever you can describe YOUR product in terms of THEIR (detailed!) workflow, that is the most powerful way to communicate your value. #HITsm #HITMC #HITMCworkflow

T4: What are some of the ways video can be used to market and support healthcare products/services? #HITsm

My favorite? #Periscope a story/workflow behind the scenes. Group video chat (#Blab #Firetalk) w/Subject Matter Experts #HITsm #HITMC #HITMCworkflow

T5: What’s not going to change in Healthcare in the next 10 years and how will content remain the same as it is today? #HITsm

Respect for expertise. That is what will not change over the next 10 years. You’ve got to get to and cultivate your Subject Matter Experts: they are gold #HITsm #HITMC #HITMCworkflow

Bonus: What are some of the best content marketing tips you learned at the HITMC? Or would like to share if you didn’t attend? #HITsm

I had some excellent feedback re my #HITMCworkflow Top Ten at the 2017 Health IT Marketing and PR Conference post. Basically, you’ll see more-and-more workflow at future #HITMC conferences!

@wareFLO On Periscope!


Why Do Most Current EHRs Suck? How to Fix? Hint: Workflow!

Yesterday I was quoted in Healthcare IT News. (Thank you!) I was asked three questions. Are EHRs getting better? What would make them better? Would physicians prefer to go back to paper medical records? My answer to the first question was quoted. For the record, I herein include my answers to all three questions.

My questions:

1. In your view, are EHRs getting better? If yes, how? If no, why not?

(Quoted in Doctors Demand Extreme EHR Makeover … Right Now)

Yes, EHRs are getting better, but not fast enough and there are fundamental limits to how much they can be improved. The workflow of even workflow-oblivious systems can be tweaked and made marginally better. However, at some point, the effort and cost of straining toward more automatic, transparent, and flexible workflow within systems not specifically designed to make that possible, will be greater than the resulting improvements.

2. What would make EHRs better?

A time machine? To go back and design EHRs on top of workflow platforms instead of database platforms? Current EHR technology is essentially “pinned”, by the combined legacy of Meaningful Use and current MACRA incentive-driven mandates. Healthcare’s boil-the-ocean approach to healthcare data and physician micromanagement needs to stop. Stop directly incenting outcome measures. By all means measure outcomes. But, to paraphrase Goodhart’s Law (please Google it), “When a measure becomes a target, it ceases to be a good measure.”

We are unfortunately quite limited in our ability to improve the current installed base of EHRs. Instead, we need to implement a new layer of workflow technology atop the current existing layer of workflow-oblivious databases with lousy user interfaces. This is happening. Every year I search every website of every HIMSS conference exhibitor. I’ve seen workflow thinking and workflow technology essentially go from almost non-existence to large minority of vendors. Technologies not called Electronic Health Records will increasingly encroach on the original vision of EHRs, and supply the seamless and intelligent workflow current EHRs cannot deliver.

3. I know docs had to document before EHRs came along (remember all those manila folders?). Was that easier?

Your bipartite timeline should be a tripartite timeline:

1. Pre-EHR
2. EHR pre-MU
3. EHR post MU

Most physicians today would not go back to pre-EHR days. However, many who had EHRs before MU, would definitely go back to pre-MU days. Those physicians and hospitals loved their EHRs. Medical centers who self-developed their EHRs had staff who loved their EHRs. In the ambulatory medical practice world, some physicians wrote personal checks for their EHRs. They wouldn’t have done so if their EHRs sucked. After MU came along, EHR user satisfaction dropped. In many cases, EHRs that were designed pre-MU, and originally had high user satisfaction, were redesigned to obtain MU subsidies. Subsequently user satisfaction dropped.

Thank you! I’m eager to see your answers.

You are welcome! Viva la workflow! Onward Workflowistas!

The #HITMCworkflow Top Ten at the 2017 Health IT Marketing and PR Conference

I’m like a truffle hound when it comes to sniffing out workflow. Yes, I know there is another animal that likes truffles. And I do have a big appetite for workflow and can be a bit of a bore on the subject… But that’s not important! I just spent two days searching every tweet and associated websites of the more than speakers at the 2017 Health IT Marketing and PR Conference. Here is the Twitter list if you’d like to subscribe or follow some or all the 67+ HITMC speakers and/or speaker organization (in some cases).

I am impressed! First of all, John and Shahid are to be congratulated. What an impressive collection of speakers and attendees! And what variety!

I shouldn’t have been surprised (about the workflow). Health IT Marketing professionals are workflow savvy for at least three reasons. First, marketers increasingly leverage IT to manage marketing workflows. Marketing automation is a prime example (See Marketing Automation for Healthcare IT and Marketing Automation Software: Are You Using it Right? on Second, marketers increasingly represent products and services that are themselves great examples of workflow technology. Third, HIT marketers increasingly focus on patient experience in an experience economy, and patient journeys are most usefully described as complex workflows. When I took my three credit undergraduate marketing course decades ago, its spine was the Marketing Mix, four Ps standing for Product, Price, Place, and Promotion. Since then, a fifth P was added: Process! Other lists of marketing concerns now exist, such as the four or seven Cs, and they all include or imply workflow and process ideas.

In other words, workflow is becoming an important and powerful health IT marketing meme!

Here are The Workflow Top Ten at the 2017 Health IT Marketing and PR Conference , in no particular order (except for that @burtrosen guy!)….


What can I say? I love workflow too. You can see the almost visceral marketing workflow connection. If you love marketing, and you love digital tools and platforms, you gotta love workflow and process too!


Jess, who tweets lots about workflow, nails it! #HITMCworkflow! Why didn’t I think of it!


Dodge Communications caught my eye four years ago.

Dodge tweets lots about workflow …

… and recently published a fantastic multimedia video animated introduction to marketing automation.

“Using marketing automation to find, engage, convert and keep customers this video shows how marketing automation works to find prospects, keep them engaged, convert them into customers and ultimately create advocates for your brand.”

Dodge Communications @DodgeComm is represented at HITMC especially well by Kelcie Chambers @kelciechambers and Michelle Morris @mmorris135, who also tweet about workflow!


Cool! HITMC has a speaker, Sonali Nigam, Director, Healthcare & LifeSciences, from Newgen Software, a BPM (Business Process Management) company! @newgensoftware has many hundreds (1000s?) of wonderful tweets about workflow and BPM and many about healthcare! From their Twitter profile: “Newgen Software is a leading global provider of #BPM, #ECM, #CCM, #DMS, #Workflow, #CaseManagement and #Process #Automation #Software.” Newgen Software has a great post explaining BPM: What is Business Process Management (BPM)? I am delighted to see a modern BPM company at HITMC!


Shereese said “workflow” a million times! w00T! @ShereesePubHlth, frequently tweets about workflow. Keep it up, Shereese!


Chris Slocumb, of Clarity Quest, shows what I mean when I said earlier that there are important connections among marketing workflows, health IT workflows, and marketing automation? To appreciate and understand any one of the three is already half way to doing so for any of the others!


Colin and I have lots of fun bouncing workflow ideas and memes off each other. I’ve found his (and @JoeBabaian) #HCLDR invaluable for forcing me to think about connections among workflow and a wide variety of healthcare subjects. Colin has tweeted about workflow at least 74 times since his first workflow tweet, in 2011. By the way, I just found out Colin is a certified professional (mechanical) engineer! In marketing! Engineers are systems thinkers who really “get” workflow. As workflow becomes more and more important in healthcare, marketing health IT, I think we’ll see more engineers move into health IT marketing positions.


It’s hard to believe, but Colin’s 74 tweets edged out John Lynn’s 73 tweets. However, @TechGuy has been tweeting about workflow since 2009. And there are over 2000 hits on just one of his many websites.

Aside from an enthusiastic curiosity about everything, I suspect that John’s early experience implementing and EHR, in combination with managing complex social media content marketing workflows, give him a unique perspective on just how truly important workflow is, in healthcare, in marketing, and life! In fact, I think I see a trend. I’m seeing John more and more address patient workflow! Also see Neil Versal below re this.

PS. I miss John’s almost weekly blabs about everything under the health IT sun!


The above tweet, from @shahidnshah way back in 2013, doesn’t specific mention workflow. I specifically recall his tweet because I agreed so emphatically, and had to search for it using “interoperability”. Healthcare “workflow thinking”, and workflow technology, will be essential to the practical systems integration to which Shahid refers. Shahid also said something nice about one of my blog posts about interoperability and workflow the next year.


What can I say? Flattery, especially about anything workflow, will get you everywhere, around me at least!

But then there’s this tweet, from 2012.

Screenshots and workflow diagrams? Been there. Done that. I can see that Sarah has indeed come up through the workflow trenches! BTW, Sarah was present at the birth of one of my favorite memes: Workflow-Man!


(OK, one more person than I promised! But I just had to squeeze Neil in. You’ll see why!)

Neil Versel, a journalist who has written many insightful articles about workflow and health IT tech over the years, tweets about healthcare workflow!

More about Neil…

HIT Journalist becomes patient advocate after seeing the danger of uncoordinated care and poorly designed workflows

I think patient workflow is, despite Neil being among the first to nibble at it, the next great uncovered health IT story. One usually thinks of workflows in hospitals and clinics, but all purposeful human activity involves workflow, even if you don’t call it workflow. Call it life-flow, journey maps, ritual, or just plane ol’ “flow,” understanding, facilitating, and empowering the series of steps/tasks/activities/experiences, consuming resources, achieving goals, is at the heart of the digital transformation of healthcare. And I am so glad Neil is writing about it!

Have a great Health IT Marketing and PR Conference! Next year I think HITMC should be held in my current home town, Columbus, Ohio. It’s a day’s drive from 60 percent of the population of the United States and just six hours to both Chicago and DC!

@wareFLO On Periscope!


AI and Machine Learning in Health IT Marketing, PR, and Social Media

“Many tasks commonly performed by marketers are being augmented by machine learning, deep learning and cognitive computing” (Introducing the Marketing Artificial Intelligence Institute)

There’s a great fit between this week’s #HITSM (AI and Machine Learning in Healthcare, hosted by @AmyinMaine and @HBI_Solutions) and next week’s #HITMC (Make the Most of the Healthcare IT Marketing and PR Conference) tweet chats! If I know @ShahidNShah and @Techguy, there will be lots of discussion about this intersection at the HITMC conference itself (May 5-7). Therefore I combined topics and adapted HITSM topics to apply to marketing health IT.

One of my degrees is a masters in Intelligence Systems (half AI and half cognitive science). I’m old enough to have lived through a previous AI hype cycle and then AI winter due to disappointment with results compared to expectations (but also see AI Winter Isn’t Coming). Since I spend so much time marketing health workflow IT I’ve naturally thought about how AI, ML, HIT marketing, and workflow all fit together.

Of the top of my head (helped by a quick Google search, and especially 15 Examples of Artificial Intelligence in Marketing) here’s a non-exhaustive list of ways AI and ML can help (HIT) marketing.

  • Recommendations and content curation (Netflix already does this, marketing automation systems are starting to do so, imagine using similar to chose different health IT marketing news letters to different subscribers)
  • Intelligent search engines (Just think what search engines that actually understand what they read on the web will do for both SEO and health IT conference web content. For example, I’d like to search all and only HIMSS18 exhibitors for workflow related content, and to have that search engine understand web site content regardless of whether the string “workflow” actually appears on a webpage)
  • Smart social sentiment analysis (understand not just what folks are saying about your brand, but also how they feel…, this is getting awfully close to journey mapping…)
  • Product pricing (Price is one of the classic Ps of the hoary old, what if you could truly optimize your prices relative to profit … and in realtime! Price Optimisation Using Machine Learning)
  • Predictive customer service (imagine if you could predict complaints on social media and provision necessary resources to instantly solve a customer’s problem, and just think of their reactions on social media)
  • Ad targeting (“machine learning helps to increase the likelihood a user will click”, no brainer!)
  • Chatbots and conversational UIs (guess what, your brand is going to become a personality that can actually talk to customers and potential customers, kind of like a virtually intelligent Flo from the Progressive insurance commercials! )
  • “Have a question about a particular insurance package? Flo can answer your question. Want to get price comparisons between Progressive and Geico? Again, Flo can help, with the same sassy personality that the consumer has come to expect when thinking about the Progressive brand. This will extend throughout the entire customer journey, starting from the top of the funnel with marketing campaigns (TV commercials, digital advertising), continuing to the sale of product (ecommerce checkout, reducing shopping cart abandonment), and maintaining the customer relationship through support (automating call center inquiries), which ultimately comes full circle and leads into the next customer journey cycle.” (The 200 billion dollar chatbot disruption: part two)

  • Customer segmentation (obvious relevance to patient risk segmentation, here artificial intelligence, machine learning, and marketing combine to aid population health management!)
  • Content generation/marketing (yes, computers now write news articles and blog posts… therefore computers will, if not already do, write health IT news and blog post marketing content).

Here are six observations about AI and the future of marketing:

  • “2017 will be the year of the bot” (bots won’t replace websites, they’ll power them)
  • “The “marketing conversation” will become a human-machine conversation” (see above comments about conversational UIs)
  • “AI will accelerate marketing and sales” (“autonomous, self-driving, marketing automation”, BTW IMO workflow tech will play big-big role here!)
  • “Marketers will not be replaced by AI and will be able to skip the boring stuff” (Whew! That’s a relief! ““Anything that seems rote or mechanical … it’s all going to go to AI”)
  • “Algorithm development will become a commodity and data will become the key differentiator” (you can buy ML algorithms “off the shelf”, the difference will be the data fed to them)
  • “The Link Graph is going to be replaced by the Engagement Graph” (“quality of content is determined by the number of people listening, interacting, getting engaged”)

What do all of the above have in common? You knew I’d get to it… Workflow! Or, more specifically, process-aware workflow technology, such as data and machine learning pipelines, modeling conversation as workflow, and orchestrating of cloud-based services. Please see my three-part HIMSS17 series on what I call the New Workflow Technologies.

OK! That’s a lot of think about. Let’s the early morning of an AI/ML savvy and empowered HIT marketing and PR professional….

6:00 AM I glance at hundreds of email subject headers that are just the tip of the iceberg of thousands of possibly relevant news, brand, and social media alerts. I say…

“OK Hitmike🤖 (get it? HIT-M(i)C(ke)!) Please summarize this morning’s incoming health IT and workflow alerts”


(Hitmike🤖’s holographic UI flickers into existence above my bed, and two hands gesture the scare quotes around “workflow”)

Thank you Hitmike🤖. Do any alerts involve past or current clients?


Have I had any Twitter interactions with any of the others?


Hitmike🤖, what is the total number of alerts involving past or current clients, plus Twitter follows and DM conversations.


Hitmike🤖, please convert all 32 alerts to tweets and upload to Hootsuite and assign them draft status. Make sure you include Twitter handles. Schedule for times that optimize impressions and replies.


Please remind me to review and schedule after breakfast but before 9AM.


Hitmike🤖, today’s #HITSM tweet chat scheduled today during my dentist appointment. The subject is e-prescribing. Find all tweets about that and related subjects on my @wareFLO account.


Combine those tweets with #HITSM topics and create a one-time, one-use chatbot.


Configure @MrRIMP to attend the #HITSM and use the chatbot.


Immediately after the first #HITMC tweet asking who is participating, tweet the following on the #HITMC hashtag. UNFORTUNATELY @WAREFLO CANNOT PARTICIPATE IN THE #HITSM TODAY. CHUCK SENDS HIS REGARDS. LUCKILY I AM AVAILABLE.


Oh, have @MrRIMP favorite and retweet every tweet mentioning “workflow” or “workflows” during the tweetchat.


Hitmike🤖, any interesting health IT marketing automation news today?


Summarize press release.


Summarize blog post.


Have any tweets from any accounts I follow mention either the press release or the blog post?


Please auto schedule a comment retweet contain the word “Cool” exclamation mark, an applause emoji, and relevant hashtags.


Thank you, Hitmike🤖! I am working on a project all day today researching the latest trends regarding use of workflow technology in marketing automation platforms. Please turn off all notifications except those potentially relevant to this project.


Here are the HITSM topics adapted to apply to healthcare IT marketing:

T1: What are the most promising applications of #machinelearning based #AI in health IT marketing today? #HITsm

T2: What challenges do health IT marketing organizations face in implementing #machinelearning technologies? #HITsm

T3: What political, cultural, or other factors drive adoption of #machinelearning or other #AI technologies in health IT marketing? #HITsm

T4: For orgs that have implemented, what’s the impact been (pos or neg) on health IT marketing lead generation and sales? #HITsm

T5: With so many options, what are some do’s & don’ts for health IT marketing orgs looking for a #machinelearning #AI partner? #HITsm

Bonus: Some say #CognitiveComputing is a buzz phrase & synonymous with #machinelearning or #MachineIntelligence Thoughts? #HITsm

I will see you there!

@wareFLO On Periscope!


Cognitive Technology for Goal-Driven Healthy Habits: An Intelligent Systems Approach

I am truly delighted to do my research in preparation for today’s #HITsm tweetchat with @melissaxxmccool. I have such fond memories of her marathon Blabs (3, 4, 5 hours?). The topic of today’s chat came up frequently: How Technology Helps and Hurts Healthy Behavior Change.

I usually introduce myself an industrial engineer who went to medical school, hence my interest in healthcare workflow and workflow technology. I don’t often mention I when to medical school and then studied Cognitive Science, which was one half of my MS in Intelligent Systems (the other half being Artificial Intelligence). The CogSci portion included psychology, linguistics, philosophy, and neuroscience. As a graduate student, playing my way, I worked on computer models of aphasia, dementia, and depression. I even spent a week studying with the man who founded of cognitive therapy, Aaron Beck, in Philadelphia.

I took a look at using tech to change patient behavior from the point of view of cognitive scientist. In doing so I hit on this paper (full text freely available!), Habits, Action sequences, and Reinforcement Learning. It summarizes and synthesizes a number of topics I studied decades ago. Topics I feel are relevant to using tech to move human behavior away from unconstructive toward constructive.

Believe it or not, (and I suspect you’ll believe it, given my workflow-centric reputation) there is a workflow angle. A workflow is a sequence of actions, consuming resources, achieving goals. Humans evolved from more basic animals. These animals exhibit, what may be thought of as, instinctive workflows. A fixed action pattern is species-specific characteristic sequence of behaviors (actions), which, once triggered, runs to completion. For example, if an egg is displaced from a nest, certain geese will roll the egg back into the nest, even if the egg somehow magically disappears. They continue to maneuver the imaginary egg back into the nest. The animal kingdom is rife with FAPs. We even know a lot about the neural networks that generate FAP behavior.

What do FAPs have to do with human behavior? Well, FAPs are a lot like habits, a sequence of behaviors, automatically executed, in the presence of some “releaser”. They happen automatically, seemingly without purposeful or mindful control. Of course, unlike FAPs, human habits are not instinctive. Through a variety of techniques, we can break old habits and create new ones. However, doing so is difficult! This is where technology comes it.

However, before we get to how technology might be useful in this respect, it’s useful to have a model of what is going on inside our heads. The degree program I mentioned, Intelligent Systems, viewed robots, software artificial intelligences, humans, and even some animals, as “intelligent systems” that, to vary degrees, shared certain properties and characteristics, including perception, memory, action, reasoning, and learning. Further, intelligent systems research combined techniques from cognitive science (psychology, linguistics, neuroscience, philosophy) with artificial intelligence and machine learning, to actually create computer simulations of these intelligent agents, to better understand them. We’d create software simulating them, and then we’d conduct experiments, comparing their behavior in response to manipulated environment stimuli, and to intelligent agents in the real world. Sometimes we’d even “break” the intelligent agents, to try to simulate mental and neurological disease. As I mentioned previously, I worked on a variety of such projects, from aphasia (language difficulties), dementia (memory, reasoning, personality), and depression (where I actually published a number of papers!).

All of that, and it is a lot of personal history, is backdrop for what I will do next, which is describe our human mind as if it is computer simulatable intelligent systems, with an eye toward thinking about changing bad habits into good habits.

The Habits, Action Sequences, and Reinforcement Learning paper describes an intelligent system in which there are two complementary but also competing information processing modules. One module is “closed-loop” meaning it has a model of the world and in that model of the world it behaves (acts on its world) to move the world toward a preferred goal state. The perceiving-reasoning-acting loop is closed in the sense that the difference between the current world state and the preferred goal state is continually fed back to the intelligent system so it can continually chose actions that will eventually achieve it’s goals.

Contrast above with the second behavior module. This module is similar to a Fixed Action Pattern. It has a set of “hardcoded” workflows, sequences of behavior, which, once triggered, execute from beginning to end, without reference to whether they move the world from a bad (less preferred) state to a good (more preferred) state. The great thing about these automated personal workflows is they are fast, consistent, and require no thought. The bad thing about these automated personal workflows is that they are fast, consistent, and require no thought. If you change the environment, “good” habits can become “bad” habits.

The two systems can profitably work together. Once one’s environment changes, fall back on the closed loop thoughtful goal-oriented behavior. Over time find new personal workflows that work, then turn them into open loop fast, consistent, and “thoughtless” workflows. This frees up the closed loop goal orient system to focus on other, higher level, more strategic issues. Also, you can think of an intelligent agent has having different bundles of related workflows for different environments. As it move through these environments, different clumps of workflow potential become active. Let’s suppose an intelligent agent has about a dozen different environments it frequently or occasionally needs to navigate. Eight or nine may be stable and the current open loop personal workflows are perfectly appropriate. However, several environments may be problematic. So our closed loop problem solving systems focus there. Over time, as all of our different occasionally frequented environment change, each is dealt with in turn, converted from open loop to closed loop and back to open loop personal workflows. But imagine if all your environments change at once! That is indeed stressful and even your wonderful dual system, open and closed system partnership, can be overwhelmed!

On a moment-by-moment basis, current thinking is that these two, open loop and closed loop, modules compete with each other. Consider the following quote:

“some have suggested that these processes may compete for access to the motor system…. in which the goal-directed and the habitual systems work in parallel at the same level, and utilize a third mechanism, called an arbitration mechanism, to decide whether the next action will be controlled by the goal-directed or the habit process”

So, now let’s think about how technology might be used to help these two, open loop and closed loop, systems work together.

Let’s consider the open loop personal workflow system. How might we extinguish is highly automated responses, in preparation for instituting new, healthier responses?

  1. Prevent the workflows from being triggered in the first place.
  2. Detect when the workflows are executing and disrupt them.
  3. Emphasize the negative consequences of these workflows running to completion.

This last device is interesting because it is essentially attempting to convert open loop behavior into closed loop behavior.

I can imagine technology being used in all three ways.

  1. Don’t go there! (You know what always happens if you do…)
  2. Look! Squirrel!
  3. Ouch. Be honest with yourself. That hurt! (But also be constructive, give yourself a brief scold, and lay plans to avoid triggering similar future behaviors, or at least figure how to stop one if it get started.)

At the same time we are trying to hobble destructive open-loop personal “workflows,” we need to enable constructive closed-loop personal workflows.

  1. Make the future preferred world goal state particularly vivid.
  2. Figuring our how to solve new problems, or old problems in new ways, is hard. Provide help.
  3. Once you find a tentative solution, capture it! Institutionalize it in some way, to make it more the more likely to execute open loop behavior than the old destructive open look behavior.

Regarding the arbitration mechanism, both the open loop and closed loop personal workflow system spring into operation, race along in parallel, and then demand that they be given control. In this last regard, a basic insight is this. One way to become more “meta-cognitive” is to have some sort of model of yourself. This model can be used to explain and understand, and to guide what to do. I think this model of you and intelligent system in eminently teachable and learnable. In fact, cognitive theory works a bit like this. One of its goals is get you to think like a “personal scientist”. Scientific thinking involves weighing evidence and conducting experiments. Simply viewing yourself as a “scientist” is itself esteem elevating. I think something similar might be true of viewing yourself as an intelligent system.

Anyway, back to what technologies could be useful.

The stimuli that trigger personal workflow are often spatially and temporarily circumscribed and specific. Here wearables and the Internet of Things can be the eyes and ears of a system to detect you may be heading into a bad workflow stimulus rich environment. If a bad workflow can’t be avoided, and starts to execute, workflow execution itself can be detected. (This is currently an active area of artificial intelligence and machine learning research, recognizing which goals, plans, and workflow of an intelligent system are currently active.) Once the bad workflow is detected, mid-execution, send notifications, call someone to call you, ring the fire alarm, whatever it takes (no, don’t ring the fire alarm unless there is a fire, but you know what I mean!)

And if, heaven forbid, that bad-bad-bad personal workflow can’t be prevented… document it. And do so in such a way that the next time it can be held up and waved in front of the intelligent agent… NO, YOU REALLY DON’T WANT *THAT* TO HAPPEN AGAIN, DO YOU?

Relative to closed-loop problem solving and workflow creation, preferred workflow goal states might be vividly representing using virtual or augmented reality. (THIS is what you’ll look like in that bathing suit, this is what will feel like when you walk across that graduation stage!)

Relative to helping to find new workflows that work, that’s what many workflow and task management systems do. They help manage potentially useful tasks, to string them into candidate workflows, and then, when executed, keep track of state (success, in progress, timed out, failed, escalated, etc.)

Finally, one you find new workflows that work, you need to move that insight and actionability down into the system that senses whether you are in danger of executing one of the bad-bad-bad workflows, and offers a different, more constructive workflow instead. Increasingly, every single digital device we interact with is aware of each other and work together. They will talk to your fridge and your minibar. They will, if necessary, act on your behalf, perhaps even stepping to literally prevent you from doing what you are about to do.

Yeah, scary. But also, possibly, fascinating, in positive and constructive sense.

A lot of the technologies I just listed already exist in bits and pieces. Some are already being woven together, to act in purposeful and useful manner, at our behest, to help break and make personal workflow habits. In a sense, there will be (at least) two intelligent systems: you and the system you create around you.

@wareFLO On Periscope!


Health IT Marketing and Boomer, Gen X, and Millennial Workflows

I gotta brag. I’m not an anthropologist, but I love reading about anthropology, and lots of my friends in medical school were medical anthropologists. I use ideas from anthropology to inform my systems engineering thinking about health IT. With some trepidation, I finally waded into the anthropology of health IT, and wrote a blog post. Eventually I sent it to the former HHS CTO, who happens to have an anthropology degree. And she tweeted this!

That’s my brag! Made my week, it did!

Since that Eat Your Beans post, I’ve been thinking a lot about digital and computational anthropology … wait! Don’t run away! This really is connected to health IT marketing and generational divides. First, just a little background. Anthropology is the study of human societies and cultures and their development. The theory of generations (generations X, Y, Z, did you know that “Boomers” are Gen I?) was proposed in 1923 by Karl Mannheim, a sociologist. Sociologists and anthropologists both study societies and how humans behave. Sociologists focus on the big picture, such as social groups and society. Anthropologists drill down into the nitty-gritty of individual behavior in groups. If you put the word “computational” in front of something, it usually means the nitty-gritty is so nitty-gritty that there is enough detail to actually simulate behaviors. Closely related to computational anthropology is digital anthropology, in which anthropologists study interactions between humans and digital technologies.

Aha! Digital anthropology is clearly relevant to how “generational perspectives are influencing healthcare technology, and additionally, how can we (as health IT leaders) can strive to incorporate and include diverse generational needs into the industry roadmap” (from this week’s #HITsm chat). But computational anthropology is also relevant to “including every generation in our health information technology thinking”.

The rise of computational anthropology is fueled by so-called “big data.” Digital technology is so woven into our professional and persona lives, that its “data exhaust” (love that term!) can be used to track us, understand and empower us, but also raises enormous ethical and privacy issues. The fascinating thing in this latter regard is that the field of anthropology has adopted a sophisticated system of ethics regarding dealing with data about human behavior. In some ways, it surpasses current health IT principles for handing sensitive personally identifiable health data. For example, consider the following from the Wikipedia entry about digital anthropology…

“Online fieldwork offers new ethical challenges. According to the AAA’s ethics guidelines, anthropologists researching a community must make sure that all members of that community know they are being studied and have access to data the anthropologist produces. However, many online communities’ interactions are publicly available for anyone to read, and may be preserved online for years. Digital anthropologists debate the extent to which “lurking” in online communities and sifting through public archives is ethical.”

Lurking during a tweetchat potentially being unethical? Wow!

But let’s assume, for the moment, that anthropological ethics and Internet-Of-Things cybersecurity issues can be adequately managed.

How might ideas from digital and computational anthropology potentially guide a health IT marketer?

The first thing to realize is that digital anthropology is applied anthropology, from which marketing research increasingly incorporates methods. In fact, there is a Journal of Business Anthropology (a sub-discipline within applied anthropology) and the sub-discipline of marketing anthropology. Anthropology is an increasingly popular minor among marketing students. Degrees in digital marketing anthropology are surely just around the corner.

What about workflow? Digital anthropology can be used to collect and interpret consumer and patient life-flows (essentially “workflows”, but more general than mere work settings, including family and other personal activities). Computational anthropology provides representations and models into which these data and interpretations can flow and inform. At the top of this list are agent-based simulations. Agent-based simulations are really cool. So cool, I recently attended the Anylogic user conference in Nashville to learn more about agent-based simulation. Anylogic develops and markets the most sophisticated agent-based simulation software on the market. Anylogic can also simulate more traditional discrete event simulations (popular among industrial engineers for simulating patient flows, where I got my start in healthcare workflow) and dynamic systems. Agent-based simulations simulate “agents”, which are basically simplified representations of humans, though I am sure they could simulate other kinds of agents, such as cattle behavior at the level of individual cows, and so forth.

Here are some of the various workflow notations compatible with AnyLogic.

With so much compute power available today, look at the scale of current agent-based simulation research! Surely human behavior after a nuclear attack is an important public health topic!

Here are a couple animations driven by agent-based simulation.

The following is a simulation of conference attendees interacting with the lunch queue. This not as impressive as either of the previous agent-based simulations, but there is the thing. It was created, from scratch, in just a couple hours in front of an audience. Each of the “attendees” (in the simulation, not the audience in which I sat) is essentially a tiny, virtual workflow system. Each attendee is modelled as a state machine, which is the formal terminology for a model of workflow being executed by a workflow engine while interacting with environment inputs.

Watch the above animation and just think of the possibilities for modeling different generations and their interactions with digital technologies! Increasingly we have the data. We have means to model workflow behaviors and execute workflow models. We can study personal and professional workflows executing within interactive environment. And we can do so within and between demographic generations within families, among friends, and between patients and healthcare systems.

Sound like science fiction? Workflow research really is finally moving out of the healthcare organizational setting and into patient’s lives. Check out this diagram of workflow interactions and information flows between a patient outside of a healthcare organization and the healthcare organization itself (from the recent Healthcare Systems Process Improvement Conference in Orlando).

Also see out my previous post, Actuarial Science, Accountable Care Organizations, and Workflow.

“Workflow⁰ is a series¹ of steps², consuming resources³, achieving goals⁴.”

⁰ process
¹ thru graph connecting process states (not necessarily deterministic)
² steps/tasks/activities/experiences/events/etc
³ costs
⁴ benefits

If one modifies my definition of workflow, though within my subscripted limits, to …

“Process is a series of events, consuming expected resources, achieving expected benefits.”

… you’ll arrive at a stochastic process closely resembling actuarial science’s generalized individual model (page 35 in Fundamental Concepts of Actuarial Science, a great review or introduction by the way!).

During my student days, we spent a lot of time estimating parameters and distributions, and then predicting behaviors of these stochastic processes. Sometimes we did so analytically with complicated equations (Markov Models). Sometimes we fell back on computer simulation (Monte Carlo).

A quick review of actuarial science literature indicates many of these same techniques are used today.

Back to the subject at hand…

Patient journeys are workflows. If they are workflows, then we can model them, inform and test those models with data from digital medical anthropology research, and then simulate those patients interacting with digital healthcare technology using ideas from computational anthropology.

If you Google generational differences, you’ll find hundreds of tables that look like this.

These generational difference tables compare and contrast live experiences, goals and values, resources and constraints, and typical behaviors of Baby Boomers, Gen Xers, Millennials and other generations. Adapt these insights to adopting and consuming digital health technology and information. Collect increasingly available data (subject to ethical constraints). Use data to inform and drive simulations of personal and professional life-flows and workflows. Compare simulations to what we observe in the real world. And then systematically improve these simulations.

In doing so we will gain greater insight into the differences and similarities between different generations regarding adopting and consuming digital health technology and information.

Consider this scenario, one I believe will be possible within five short years.

Consider a population health system covering five million members. Imagine 20,000 medical and administrative staff (by the way, I just pulled that number out of a hat). Further, imagine various pieces of the IT systems being proactive, that is, agent-like. Roughing in the models would start with a combination of generational differences and risk stratification. Patient states include well, acutely ill, chronically ill (and if so, which chronic conditions). Staff states include off-duty, on-duty, ideal, and busy (and if so, which patient-directed activities are they qualified for). Now imagine you are a health IT marketer. Instead of working for a health IT vendor or health IT oriented marketing and PR agency, you’ve made the transition to working for a health system. You’re job is to understand and facilitate the diffusion health IT technologies into the homes and hands of covered population health system members. Here are some additional states: unadopted, adopted-but-not-optimized, optimized. Now, based on a variety of data, from qualitative and quantitative applied digital anthropology research, estimate the probabilities of transitions between states. (Possible role for machine learning here!) Workflows are series of these state transitions, which can be simulated, to fit various other data sets and generate predictions. For example, which kinds of health IT technologies (apps, calls, chatbots…) introduced to who (Boomers, Gen X, Millennials…) influence transition probabilities between which states (well, acutely ill, chronically ill…), and probabilistic models of impact on population health system resources (number of personnel required, kinds of personnel), under different assumptions about which technology initiatives are undertaken (which kinds of patients are supplied with which kinds of health IT technologies). If you think this kind of simulation requires astounding amounts of data, it does. But we now live in the Big Data era. The data is there or potentially there. The real problems with this simulation are managing its complexity and data ethics issues. However, if researchers can undertake an agent-based simulation involving between 10 million and 20 million individuals in the aftermath of multiple Manhattan nuclear blasts, then agent-based simulations of health IT diffusion and effects on clinical outcomes and costs are surely at least almost already possible!

If I have stimulated your imagination and interest, check out my Health Standards article, Marketing Workflow Is An Incredible Opportunity To Differentiate Health IT Products, And You!, which ends this way:

“Workflow: It’s not just for industrial engineers anymore!”

I’ll see you at the Including Every Generation in our Health Information Technology Thinking #HITsm tweetchat! Noon EST today.

Further reading:

@wareFLO On Periscope!