Month: June 2013

Google Glass: Longest possible video? What’s it like to wear? Can it empower patients? Other healthcare uses?

I picked up Google Glass in NYC on Saturday last week. I got Shale (of Shale, Tangerine, Charcoal, Cotton and Sky). You can see it on me in the profile pic to your right. Below is a short, 1:08 minute, intro to the Glass user interface on YouTube.

I just wanted to post some initial bits and pieces: impressions, reactions, an experiment to see how long a video Glass can capture, thoughts on how patients might use Glass. Plus, I’ve tweeted lots of links to articles and blog posts about potential uses of Glass in healthcare. The best of the best tweets are embedded at the end of this post.

Longest possible Google Glass video?

First of all the video: I kickbiked (shown and explained on the video) from Bethesda to Fletcher’s Cove along the Capital Crescent Trail. Google Glass lasted 48 minutes. The Capital Crescent is one of my favorite trails. I’m glad I had the opportunity to capture this first-person video on such a gloriously sunny second day of summer. If you watch it, you’ll hear me talk to myself all the way.

Here are a few technical notes. I didn’t actually capture video until the battery gave out. I got to Fletcher’s Cove, debated whether to continuing video capture just to see how far I could get. I decided to shut down and take a look at the battery level, then extrapolate. Interesting, at least to me, *after* I stopped the video, Glass shut down. When I tried to restart it, I got the battery symbol in the view finder (which is how I think of the Glass 640 by 360 tiny “heads-up” video monitor.

I suspect Glass was on its reserves and shortly would have shut down gracefully (I hope). So my 48-minute video from a full-charge to depleted battery is approximate. Routine use (mostly monitoring and occasionally responding to email and tweets) lasts about seven hours. I also get New York Times headlines. If I tap the touchpad on the side, Glass will read a short story abstract. There’s no web browser, at least not yet. There’re just a few third-party Glassware apps available, though I’ve not tried any. Glass To Do looks interesting. That will change. I’m looking forward to seeing an explosion of Glassware. Especially interesting are tools to allow non-programmers to create apps for Glass.

Back to the video. Once I got back to Wi-Fi, I tried to share the 48-minute HD video to Google+. No luck, but I really didn’t think it’d work since I expected the file to be a couple of gigabytes. Then I attached to my MacBook via micro-USB cable. No luck. Tried the Android File Transfer application on the MacBook. Nope. Connected to a Windows 8 laptop, which obligingly offered to import media files. Copied the 1.75G mp4 file to a USB and over to the MacBook. And uploaded to YouTube.

I’ve actually walked, and kickbiked, around with cameras on my head of years: early off-brand solid-state handycams (lousy video), FlipCam (great video), and most recently Looxcie (used for my HatCam One-Minute Interviews and walking the floor at health IT conferences). Viewing the original video file I noticed two advantages immediately. Subjectively, images seemed to cover a relatively large field of view, left and right, up and down, without any apparent fish-eye effect (such as you can see here in one of my HatCam videos). Second, there’s dramatically less wind noise than the other half-dozen cameras I’ve used (I’ve not tried GoPro). Even when I’ve going downhill fast (for me) you can hear me talking conversationally to myself. Only when I turn my head to look left and right does the wind drown me out. I suspect this is designed into Glass. I’m impressed. Congratulation to an aerodynamically-minded designer someplace.

I am unsure if this version of Glass has image stabilization or not. I intentionally did not try to “image stabilize” while shooting. I wanted to see what the result of simply ignoring Glass would be. To my eye, video images seem more stablized than other head-mounted cameras I’ve used, especially after upload to YouTube (though I did not tell YouTube to stabilize either). This may be due, in part, to the wide field of view. I’m not sure. You can be the judge if you watch part of the video. It can still be a bit dizzying on a large HD screen (my wife says). I’ll likely try to avoid jerky or sudden movement in the future while videoing. But I don’t think it will be as much work as before.

By the way, at minute 44, when I look across the Potomac River, yes, I know I misspoke. I was looking at Virginia, not Maryland. 🙂

What’s it like to wear Google Glass?

As an experiment, a couple years ago, I walked around our neighborhood in downtown DC with a noticeable camera clipped to my baseball cap. It wasn’t on. I just wanted to see how folks reacted. Never got a negative reaction. I did get an occasional enthusiastic question, such as “Are you live-streaming right now?” and they’d be disappointed when I said no. However, Google Glass has gotten a lot more press.

Wearing Glass outside, a ball cap (minus HatCam) still helps a lot. If it’s a sunny day, I just pull down the brim to use as a dark backdrop. Before I walk into an establishment I take Glass off. After I’ve sat and acclimated for a while, if I’m not facing directly toward someone, I’ll put them on. Each time a tweet, email, or headline arrives, Glass dings (only I can hear) and I glance up to turn on the Glass monitor and view the newly arrive information. In settings you can calibrate an angle above which the Glass monitor lights up.

Interestingly enough, outside the recent conference, few “officially” notice Glass. I’m sure some folks do notice, I’ve seen a sidelong glance or two, but no one has said anything, one way or the other. I suspect this is due to a combination of factors. Shale (gray) is an inobtrusive color. I wear Glass over glasses, which works fine, though I think it depends on lens prescription and frame shape. The combo of Glass over glasses appears, to me, somewhat less odd than Glass without lens. I tend to keep my ball cap on; Glass is tucked up under its brim. And, finally, I live in a relatively urban neighborhood, where civil inattention is the rule, not the exception.

I don’t wear Glass (yet) when conversing with someone, unless the conversation is about Glass, that is. I’ve seen reported surveys that as many as one in five Americans look forward to wearing Glass (or Glass-like competitors) but that also as many as one in five thinks they should be banned. I suspect that when we see more folks using such devices, that survey numbers will morph. If we ever get to the point in which ten percent of folks are wearing them, then the percent of folks interested will go up, not down. I’m not so sure about the opposing contingent. It will be fascinating the watch the whole wearable technology diffusion and public attitude dynamic!

As other folks wearing Glass start walking into places with them on, I’ll likely do so too.

I attended a health IT conference last week (Workflow Platform Themes at the 2013 Long-Term and Post-Acute Care Health IT Summit), where I wore Glass all the time, at least until the battery gave out at the seven or eight hour mark. I’m sure that will go up in a retail version. There, I was a celebrity! Below are some photos snapped with Glass, the first of me, the rest of others trying on Glass for the first time.

I’ve had a lot fun turning on Glass “Guest Mode” (swaps my timeline of tweets and emails for a canned series of interesting cards: weather, traffic, headlines, pictures, videos, etc.) and handing them over to folks.

“OK Glass. Take a picture” seems to be the first thing most folks say, so I’m certainly collecting lots of pictures of me looking like an optometrist. Here I am, critically examining Glass’s fit to your ears and nose, then looking pleased when you see something cool in Glass.

chuck-selfie-onlooker

Hmm. Let’s See. I think it’s OK!

chuck-selfie-future-healthcare

Hmm. Let’s see. I think it’s OK! (Redux)

chuck-selfie-bar

Perfect!

Can Google Glass empower patients?

What I’ve written about so far, in this post, regarding video capture and battery life and reactions and etiquette are, in fact, relevant to Glass’s healthcare angle.

So much technology today, including healthcare technology, is driven by consumer electronics and digital entertainment. Glass (and its cloud infrastructure and app ecosystem) won’t evolve and improve as fast as it might, unless it takes off in everyday life. What I’ve described so far is as close to everyday life as I can get. It’s my everyday life. I like filming stuff with cameras on my head. I like walking into restaurants and coffee houses and accessing tweets and emails, without causing anxiety. And, while this momentary, mostly positive, notoriety is not exactly representative of a future steady-state taking-such-tech-for-granted, it is happening to me and I am having fun with it.

In that light, I do have some initial thoughts about Glass in healthcare, though I’d put it the other way. I have thoughts about healthcare in a larger society of people wearing Glass. I’ve heard some folks worry about what will patients think when their physician wears Glass. (Some of the more lurid rumination involves gynecologists and YouTube. Honest.) Glass, used by medical workers, will be a useful enabling technology. It’ll be just another medical instrument, less intrusive than the old-fashioned head mirror physicians used to wear.

head-mirror

But Glass won’t be nearly as “disruptive” and “transformative” as when lots of people, including patients, wear Glass. The question isn’t what patients will think of physicians, nurses and physician assistants wearing Glass, but what physicians, nurses and physician assistants will think of patients wearing Glass.

I’m thinking of three broad classes of people.

First of all there are the healthy, who want to stay that way. I’m looking forward (well, sort of) to Glassware that, when I reach for that second slice of cheesecake, tells me, during the 30-seconds or so I take to reach of for it, how many calories it represents and that 65-percent of my Twitter friends forego (forwent?) that second slice.

Second, when I see a specialist, and he or she rattles off a list of options and contraindications while heading out the exam room door, I’ll have not only a video to review, but also set of links to explore.

Third, when I am weak and bed-ridden someday, perhaps not even able to lift a mouse, let alone a tablet, I’d like to be able to nod my head, or rasp “OK Glass,” and see and respond to messages from relatives, friends, and acquaintances.

Here’s another possible use of Glass by hospital patients…

Recently, I tweeted about a historic first. I tweeted about the first mention of Google Glass in healthcare that I’ve seen on the DrudgeReport.

But I have in mind another historic first (perhaps it’s already happened!). Someone, somewhere, is going to come out of surgery, and, as they groggily come out from under anesthesia, their first words will be: “Where’s my Glass? Could you put it on me? OK Glass…”


Links to healthcare uses?

Below are my #GoogleGlass healthcare related tweets that have links to interesting articles, videos, and blog posts…

Workflow Platform Themes at the 2013 Long-Term and Post-Acute Care Health IT Summit: Let’s Get Started!

Earlier this week I attended the two-day Long-Term and Post-Acute Care Health IT Summit in Baltimore (archived pdf).

A few years ago, when I worked for an EHR vendor, I investigated the state of health IT in long-term care, but didn’t find much, at all. There was some software to generate government-mandated data sets, and that was about it. So I was glad to be surprised at how much interesting health IT and workflow IT related discussion I found at #LTPAC13 (that’s the Twitter hashtag). In fact, I heard “workflow” everywhere and frequently, from the podium, in the hallways, and at lunches and coffee breaks. If I had the combined transcripts of all the attendees and counted the times “workflow” was uttered, it would have been in the thousands.


wordle-words-workflowWords and Phrases Associated with “Workflow” at #LTPAC13

In fact, there was more talk of healthcare workflow at #LTPAC13 than at some other health IT conferences I’ve been to recently. I saw lots of healthcare workflow-relevant presentations about care coordination, clinical decision support, telehealth and population health management. This health IT summit, about long-term and post-acute care, was chockfull of imaginative ideas and insights about real-world healthcare workflow.

Rather than try to summarize and synthesize a veritable word cloud in which “workflow” appears over and over, I’ll focus on two white papers. They synthesize in a way I cannot; they are written by experts on long-term and post-acute care health IT and they emphasize workflow.

The first white paper is from LeadingAgeCAST, Center for Aging Services Technologies. It has an excellent overview of the necessary steps to document current workflows and envision how HIT can help, and avoid hurting, the work of clinicians and support personnel. I’m an industrial engineer (or at least have an MSIE) and I entirely understand ends that drive the above suggestions and the means by which they are achieved.

But I will have one observation and one question.

EHR FOR LTPAC: A Primer on Planning and Vendor Selection

[begin quote]

3.2.3 Workflow and Process Redesign

3.2.3.1 Importance of Workflow and Process Improvement

Change due to HIT needs to be managed not only to help individuals overcome their concerns and adopt the technology well, but also to ensure that the change brought about by the technology is the right change for the organization.

  • Workflow and process changes must be understood and managed. Workflow and process changes should be made to take advantage of HIT, but must also point out the control points that must be present or should be added to the systems for optimal results.
  • Professional judgment must be applied when using any tool, including all forms of HIT. Computers can crunch data tirelessly and remind humans who may be forgetful in the rush of their everyday lives. However, they are not substitutes—no matter how well programmed— for the experience that trained workers bring to health care. Workflow and process changes should aid professionals, but are not substitutes for them.

3.2.3.2 Process Mapping as a Means to Manage Change

Process improvement experts suggest that the best way to help potential new users of information systems overcome resistance to the change is to demonstrate the quality efficiencies and patient safety of computer systems and to engage users in making their own changes.

3.2.3.3 Workflow and Process Mapping

Process mapping is a fairly well-defined science, with a number of tools and techniques that can be deployed to understand current workflows and processes as well as identify opportunities for improvement.

3.2.3.4 Mapping Current Workflow and Processes

The following steps should be used to map current workflow and processes:

  1. Identify processes to be mapped, those that will be impacted by the HIT being acquired.
  2. Use individuals who actually perform the process; they know it best and they need to own the impending change.
  3. Instruct persons on process mapping, why it is being done and how it is done.
  4. Map current processes. Avoid identifying opportunities for improvement now, because critical controls built into current processes may be overlooked.
  5. Validate maps to ensure they reflect current processes, all variations, and all the information needed. This is the time to be candid about how processes and workflow really occurs in the current state, including workarounds, so that the new HIT-supported processes can be developed in ways that are most productive and helpful.
  6. Collect all forms and reports that are part of processes to be automated through HIT.

Obtain benchmark data to define expectations for change and for use in benefits realization studies.

3.2.3.5 Workflow and Process Redesign

Map how the workflows and processes will be performed with HIT. Identify potential problems in current workflows and processes and determine their root cause. Things to look for include bottlenecks, sources of delay, rework due to errors, role ambiguity, unnecessary duplications, unnecessary steps, long cycle time, lack of adherence to standards, lack of information and lack of quality controls.

[end of quote]

The reason there is so much emphasis on getting workflow right before implementing EHRs and health IT systems is that it is so doggone hard to change the workflow after implementing these systems. My question is this, if workflow is so hard to change, and this requires so much time and energy and cost getting it right, and most of the time organizations get it wrong, and then are stuck with relatively unchangeable and unimprovable workflows, why not use a different technology, one in which changing and improving workflow is easy, not hard, to do?

In fact, just think how much easier to do all the above, supremely rational, steps to improve workflow (what I call meta-workflow), if only the EHR or health IT system used workflow technology. Workflows could be not just diagramed, but executed too (What’s So Special about EHR Workflow Management Systems?). Data to improve workflow would not have to be collected or made up, but come directly from the workflow log (Clinical & Business Intelligence, Meet Process Mining).

The second to last session was called Talking EHR with the Nurse Executive Council and the CIO Consortium. The presentation, itself, was short. Most of it was given over to taking questions and comments from the audience. And guess what? Most of the questions revolved around workflow. The vendors don’t understand my workflow (often true). EHRs often disrupt my workflow (unfortunately true). Are there alternatives to EHRs? (I’d argue that EHR workflow systems are the best alternative, at least with respect to workflow issues with current workflow-oblivious EHRs.)

I got up, three times, and made the following comments. (Yes, word for word, this is what I said.)

Comment 1:

Regarding workflow, there are such things as workflow systems, workflow management systems, business process management systems and dynamic and adaptive case management systems. They’re very popular in other industries. So, the question I have, is, if workflow is such a big problem, and I hear it mentioned frequently in presentations and in the hallway, why not use workflow technology to help solve it?

Comment 2:

The basic problem is that electronic health records, as they are now constructed, is they are not malleable. You can’t change them easily after you implement them. You have to go back to the C# or Java programmer back at the vendor. They are not instrumented, so you have analytics so you can improve cycle time, throughput, and consistency. And they do not have a means of systematically improving those statistics. All those things that I just described are classic attributes of software called workflow management systems, business process management suites and dynamic or adaptive case management systems. These systems are based on structured workflows that can be easily changed and easily improved. Current EHRs are based on structured documents. They force the user to be the workflow engine because there is no workflow engine in the EHR. If you want a workflow engine in your EHR you need to use a workflow management system. There are two ways of doing that. You can reengineer and retrofit that EHR or you can build it on top of workflow management system, with good workflows, workflows you can change and adapt to users’ needs and preferences.

Comment 3:

I read the white paper. It’s fantastic. From my perspective, coming from workflow management and business process management in healthcare, you’ve nailed it.

[end of my comments from the audience]

Yes, Electronic Health Record (EHR) Solutions LTPAC Providers Need Today (the second whitepaper I referred to earlier) did indeed nail it.

First of all, the word “workflow” appears 36 times in a 27-page paper (with lots of diagrams and white space!).

Here’s the concordance plot. You see that ‘workflow’ is mentioned mostly toward the end, in the concluding remarks.


visualize-workflow-mentionsN. of Hits = 36, File Length (in chars) = 65109

Let’s pull out all of the instances of ‘workflow’, sorted alphabetically on the next word after ‘workflow’. Take a look at the phrase “workflow platform”, which occurs seven times. You’ll need to scroll a ways. Be sure to checkout some of the other interesting contexts in which “workflow” occurs.

real-time participation in care processes leveraging configurable workflow and checklists.
Sections above address the workflow and interactive decision support capabilities needed
secure cross provider workflow and passing information
through standards based document
clinical environment requires rapid innovation in design of care workflow and processes within and across changing care settings.
the existing EMR modular configuration causes disruption in workflow and results in
development of “workarounds”, thus negatively
In our post-Facebook world, the benefits of socialization of work and workflow are
becoming better understood. The ability to “share”, “like”
It requires a platform approach that ensures that all system workflow can be consistently developed, implemented, managed, and imp
variability in function specifics, process, protocol and workflow .
While workflow guide task- and process-level actions and checklists organiz
Rich extensible workflow , integration and coordination
It also delivers a
CRM aware platform with database,		 workflow , interface, portal, social, and mobility building blocks
Clinicians strive to “fit” their care delivery process or workflow into the EMR modules.
The care delivery process embedded in clinical workflow is often characterized in terms of a pattern of actions
enforce the protection of extracted information, or include the workflow necessary to make it easy for the user to add the security
source
and pre-analyze the “big data” needed to “prompt”		 workflow .
pply that expertise to the workflow “prompt” step in order to enhance workflow outcomes will be a key
differentiator of effective EHR system
Socialization adds an accelerator dimension to all aspects of the workflow platform
described above.
The same extensibility platform, our workflow platform, if you will, informs multiple dimensions of extensi
community of providers. In fact, the value enabled by
the		 workflow platform is primarily found in the network effects
exchange, or a cross-entity coordination all reflect the same basic workflow platform requirements. A core patient-centered EHR and secure
securing
compliance for complex, high impact processes. The		 workflow platform should be able to richly leverage the checklist
An effective workflow platform should be able to accommodate development and sharing
capturing of action/decision may be pertinent. The effective workflow platform
will provide rich support for developing unit proces
The “prompt” aspect of the unit workflow process brings evidence to bear on system outcomes.
Protocol-Driven and Contract-Based Workflow
The system		 workflow process should be driven from a defined and customizable set
were developed, little attention was paid to supporting
the clinical		 workflow process that guides professional clinical care within and
These
systems were not designed to support the clinical		 workflow process that guides professional clinical care.
new ways of visualizing information is a key factor in assuring that workflow processes can be defined in ways that are highly intuitive
ernal and external sources (big data)
and apply that expertise to the		 workflow “prompt” step in order to enhance workflow outcomes
Management

  • Alerts; operational + clinical
  • Event management
  • workflow
  • Remote monitoring by internal audit
  • CMS audit access
accelerate time to
market, while achieving the efficiency and		 workflow requirements outlined in the paper.
A platform approach can provide support for configurable workflow , rich data analytics and visualization,
checklists and proto
Historically, workflow systems viewed roles statically, with processes flowing in
Protocol-Driven and Contract-Based Workflow The system workflow process should be driven from a defined
Clinicians rely on clinical care delivery processes ( workflow ) to provide care (reference Appendix 2.0).
The workflow unit process described above can be oversimplified as trigger


wordle-words-workflowWords and Phrases Associated with “Workflow” at #LTPAC13

Yes, there’s “platform”. Maybe “process” and “processes” should be combined to rival “workflow.” Or, since process and workflow can be synonymous, maybe I should have deleted those too. But look at the rest of the words.

  • Configurable
  • Prompt (as in to prompt a user)
  • Checklists (a hot topic)
  • Coordination
  • Protocol-driven
  • Outcomes
  • Expertise

So, clearly, workflow is at the center of a number of extremely important health IT topics that are on lots of minds these days. And there it is: “platform”. As in “workflow platform.” Seven times!

I have, in fact, written a lot about workflow platforms. They include workflow management systems, business process management suites, and adaptive case management systems. For example, this is what I wrote about “platform” in an EHR workflow context:

An EHR workflow management system is the workflow management system used to generate a specialty-specific EMR workflow system. It is a platform for launching and managing EMR components just as an operating system is a platform for launching and managing user applications and software services. Both are “an agreement that the platform provider [gives] to the software developer that logic code will interpret consistently.”
(http://en.wikipedia.org/wiki/Computing_platform)

EMR workflow systems are extensible by virtue of being generated by EHR workflow management systems. Extensibility “means the system is designed to include hooks and mechanisms for expanding/enhancing the system with new capabilities without having to make major changes to the system infrastructure.”
(http://en.wikipedia.org/wiki/Extensibility)

An EMR “software extension is a computer program designed to be incorporated into another piece of software in order to enhance, or extend, the functionalities of the latter. On its own, the program is not useful or functional.”
(http://en.wikipedia.org/wiki/Computing_platform)

Workflow technology and extensible platforms are not only complementary, it is the workflow platform that makes extensions possible. Much of the rest of Electronic Health Record (EHR) Solutions LTPAC Providers Need Today also describes qualities the most EHRs lack, but workflow platforms do very well.

From Ten Years Ago, Dallas HIMSS: Landmark Presentation on BPM EMR Workflow Groupware (by the way, 13 years ago the EMR/EHR was called the Computerized Patient Record, or CPR):

[begin quote]

The best way to present our own comments on the importance of modular and extensible EMR component architecture is to highlight two slides along with their slide handout notes (still available on the HIMSS website and archived here). They refer to Microsoft’s COM objects, not today’s Web services, .NET components, plugins, and so on, so I’ve supplied an updated translation. These slides are also animated, so be sure to click on them.

(I admire the WordPress plugin system that allows me to extend my blog to publish these Flash videos based on ten-year-old PowerPoint slides. The average WordPress blog has five plugins. This one has fifteen. Works great. It’s similar to the point I’m making about extensible EMRs–ironic!)

Two slides from our presentation (animated):

[kml_flashembed fversion=”8.0.0″ movie=”/video/EMR-pediatric-clinical-workflow-groupware/extend/CPRs-should-be-extensible2.swf” targetclass=”flashmovie” publishmethod=”dynamic” width=”540″ height=”418″]

Get Adobe Flash player

[/kml_flashembed]

From PowerPoint slide notes:

“Allow developers to customize the workflow-enabled CPR, since one size does not fit all. Here Microsoft’s Component Object Model (COM) is critical, since it allows a developer or VAR to add their own screens as options for selection by the workflow engine.”

Updated translation:

“Allow users and developers to customize EMR workflow groupware systems, since one size does not fit all. Here Microsoft’s .NET, Web services, plugins, and other modular means to extend EMR functionality are critical, since they allow a user, developer or reseller to add their own screens and functionality as options for selection by the workflow engine.”

[kml_flashembed fversion=”8.0.0″ movie=”/video/EMR-pediatric-clinical-workflow-groupware/architecture/component.swf” targetclass=”flashmovie” publishmethod=”dynamic” width=”540″ height=”418″]

Get Adobe Flash player

[/kml_flashembed]

From PowerPoint slide notes:

“This slide is for the programmers in the audience (please explain it to the non-programmers). Decide to work with a workflow-enabled CPR that relies on a COM architecture possessing a set of publicly accessible APIs, so you can assemble a best-of-breed component solution and customize to your users or market.”

Updated translation:

“This slide is for the programmers in the audience (please explain it to the non-programmers). Decide to work with an EMR workflow groupware system that relies on a modern modular architecture possessing a set of publicly accessible APIs (application programming interfaces, check out the WordPress plugin API), so you can assemble a component solution customized to your users and market.”

After our 2000 presentation we continued to emphasize the relationship between clinical group workflow requirements and modular componentized EMR platforms:

“Workflow management systems are usually highly componentized, in that the workflow engine does not need to know much about the applications that it executes (just the prerequisite circumstances for execution and what context information to supply). This componentization provides a route … to introduce new EHR functions or ways of accomplishing them (such as a new decision support module or data display) into work-a-day … settings.” (“EHR Workflow Management Systems: Essentials, History, Healthcare”, TEPR Conference Proceedings, 2004, Fort Lauderdale)

[end of quote]

Let’s take a look at more items on this white paper’s wish list. There’s a section, starting on page 20, titled Extensible. I already covered workflow technology’s uniquely extensible properties above. But then there is the following…

“Every unit process includes a trigger, a particular data view, a recommended action (prompt, alert, decision support, etc.), an execution-communication-documentation of action including any new data associated with that action, and an update of relevant data.”

and a diagram, from left to right…

Trigger -> Data View -> Prompt -> Action

About which they say: “The workflow unit process described above can be oversimplified as trigger-> information -> action -> information. Finding rich new ways of visualizing information is a key factor in assuring that workflow processes can be defined in ways that are highly intuitive and compel user engagement and effectiveness.”

In other words, a defined workflow is triggered and then executed while interacting with data and users, leading to an action. This is not an uncommon vision of EHRs becoming proactive members of the virtual care team. However, what has been lacking (at least within the confines of healthcare and health IT) is an effective, efficient, and flexible workflow platform for making this vision real. I argue we (healthcare and health IT) must import from, and partner with, the workflow management systems industry, now usually called the business process management industry, to finally bring this vision to reality. I wrote about this in Clinical Intelligence, Complex Event Processing and Process Mining in Process-Aware EMR / EHR BPM Systems. Here’s the outline from that presentation (on-line via the previous link).


Malleable and systematically improvable workflows, mediating the trigger to action loop, will be necessary to realize the vision described by this white paper. And the best representatives today of workflow platforms with malleable and systematically improvable workflow are called business process management systems or suite. See my EMRs and EHRs Need to Solve “The BPM Problem”: Why Not Use BPM to Help Do So? in this regard.

Later on the same page, in the section titled Checklists & Protocols is this…

“Increasingly in the healthcare world checklists are being seen as a strategy for defining and securing compliance for complex, high impact processes. The workflow platform should be able to richly leverage the checklist pattern both for development and for implicit user experience.”

I write about precisely this in response to recent call from Atul Gawande (a famous checklist proponent) at the recent Health Datapalooza in DC. See My Second Blog Post Inspired by Health Datapalooza: Workflow, Communication, Tasks, and BPM.

About which I write:

I agree!

If EHRs and health IT systems need

  • workflow,
  • communication,
  • task management,

where can we find the technology to provide this functionality?

And then I simply search in Google for workflow+communication+task+management. The ten links I get back are all workflow management systems related, so take them one at a time. I pull out the abstract or intro that seems most relevant to Atul Gawande’s call to action. He’s calling for the same thing that Electronic Health Record (EHR) Solutions LTPAC Providers Need Today calls for: True EMR and EHR workflow platforms.

Finally, on the next page, in a section title Social Collaboration is this …

“In our post-Facebook world, the benefits of socialization of work and workflow are becoming better understood. The ability to “share”, “like”, “follow”, “group chat” people, tasks, events, objects, records, and documents can significantly enhance any work team’s cohesiveness, effectiveness and productivity. While there are particular security concerns that need to be accommodated, care teams are no exception. Socialization adds an accelerator dimension to all aspects of the workflow platform”

Again, BPM has what healthcare and health IT needs: the “Simple, no-training social interface.” From one of my trip reports to a BPM vendor’s conference…

The “no-training social interface” referred to is the now almost classic activity stream. Folks are used to Facebook, LinkedIn, and Twitter, why not use a similar user interface? It takes less training and is naturally social to boot. Since each platform doesn’t require a programmer to create a different program, and therefore different user interface, consistency across platforms is achieved. So, not only does previous user experience with social media transfer to the EHR, training on one EHR platform (say, desktop Web) transfers to another (say, mobile, or, increasingly, from mobile to Web and desktop)

Essentially, what Electronic Health Record (EHR) Solutions LTPAC Providers Need Today describes are EMRs and EHRs implemented on a modern workflow platforms commonly called business process management suites.

Earlier is a section titled Call to Action for Software Providers and the following …

“This EHR whitepaper proposes a vision for the delivery and use of an integrated, secure and optimized on-line system for the LTPAC care team, care delivery and interaction with the patient. This on-line system does not exist today.”

No, it does not. But it can, if we combine the clinical content and functionality associated with traditional EMRs and EHRs with the context-aware, effective, efficient and flexible workflow of modern, extensible, BPM suites, especially as they add social workflow, move to the cloud, and deploy to a variety of devices without having to write a separate app for each mobile platform.

So? What are we waiting for?

Google Glass Welcomed to the HatCam Family and

Saturday I took the train to New York to pick up my , as part of the program. Back in February I’d tweeted … got a reply in March.

Then I got a DM a couple weeks ago. Around health IT conferences I’m the “HatCam Guy.” So I’m already used to walking around with a camera or two on my head. I wonder if that had anything to do with getting into the Glass Explorers program, but if it did, I’m sure glad for it.

Here are my HatCams rolling out the red carpet, welcoming Google Glass to the family.

welcome-google-glass

I need a couple weeks living with Glass before I can give it an adequate assessment (but so far, very good!). Look for my detailed reaction here or on my blog at HIMSSFutureCare.com.

Let me say now, from what I have come to understand about Glass from reading hundreds of blog posts, news articles, tweets, and technical documentation, Glass has big workflow implications for healthcare. I’ll not steal my own thunder regarding that, so stay tuned. But the thunder will likely be good, since I was prompted to change my Twitter account name from to . I also created a new website to put up future content about Google Glass and related technologies. Nothing much there yet, but keep an “eye” on it!



wareflo

I’ve been thinking of changing my Twitter handle away from the EHR part of for quite a while. I focused on the topic for years, given lots of presentations, written lots of blog posts, and tweeted lots of tweets. But the healthcare workflow “action” is gradually moved out of the EHR and into a host of technologies that interact with EHRs, or go around them altogether. I scratched that surface in my post The Power of Process and the Future of Health IT.

“wareFLO” is both a portmanteau and a pun. A portmanteau combines meanings from different words. wareFLO could mean “software workflow”, software that implements workflow or workflow between and among software applications (getting at both interoperability and usability). It’s a pun for “wearFLO” as in wearable workflow tech. It can mean “Glassware workflow”. Google Glass software has a very interesting architecture from a workflow technology perspective. Then there’s flow as in Mihaly Csikszentmihalyi’s optimal psychological flow (BTW, I used to hang out with one of his grad students!). Finally, (or maybe not finally, if I think of any other associations) there’s “Where flow?” the question. Where do you want to go, or flow, in general and right now?

But I won’t wait to tweet, a lot, about Google Glass, and various and sundry idiosyncratic passions, from my newly renamed Twitter account:


The Power of Process and the Future of Health IT

[I’m reposted this from my blog post by the same name on HIMSS Future Care.]

I’ve read that 500 words is the optimal length for a blog post (Search Engine Optimization? Least Publishable Unit? Human attention span?) Easy! I’ve written lots of 5,000 word blog posts. All I have to do is multiply by 120 percent and divide by 12! (And I’m already 20 percent there.) [Hmm. I think someone may have edited this post, because this first paragraph surely can’t be 20 percent of it!]

A bit more about The Power of Process, the title of my entire monthly blog series… If you look up the definition and synonyms for “powerful” you find “mighty”, “strong”, and “energetic.” I hope I can live up to those wonderful words. But I think you’ll find even more interesting the words associated with “powerful”: effective, efficient, fast, connected, and secure. Wow! You can’t get more relevant to today’s health IT headlines and issues that those adjectives.

Let’s get with it, this, my first blog post on Future Care…

Health IT is like China in the 90s, where I used to visit. China was (and obviously still is) big, insulated from rest of the IT world, but also opening up to it. Healthcare, also, is big, historically insulated, but becoming less so.

twitter-profile-smacwl

What are the technologies spreading into health IT? I’ll focus on the following six [represented above, on my Twitter profile], because, while each is a platform, of sorts, they are coming together to create a meta-platform, a platform of platforms.

  • Social Tech
  • Mobile Tech
  • Analytics Tech (including “Big Data”)
  • Cloud Tech
  • Workflow Tech
  • Language Tech

The technologies, like weather, respect no borders. They blow where they will. They are transforming every industry; healthcare and health IT are not immune.

The first four technologies even have an acronym: SMAC. Think of it as an adverb, as in the abruptness of “I ran smack into the future!” To SMAC I add W and L for workflow and language tech. Sometimes I even use the #SMACWL hashtag (rhymes with “spackle” or “grackle”, if you’ve heard of those).

If you’ve read me before, you know I blog (200+ posts) and tweet (20,000 tweets) about workflow. And the great thing about workflow is that I can pivot anywhere from it. Workflow is a series of steps, consuming resources, achieving a goal. Workflow is everywhere. That is why process-aware technology (that’s what academics call workflow technology) is so profound but also hard to understand and appreciate.

All of the other techs – social, mobile, analytics, cloud, and language – increasingly rely on workflow technology to manage interactions among software systems and with human users. As they infiltrate, diffuse, and “infect” healthcare, they are vectors carrying into healthcare sophisticated workflow technologies.

How important is workflow to the future of health IT and transforming healthcare? It is the glue, the context, the coordinating substrate for combining all of the other technologies we see every day in the headlines.

My Second Blog Post Inspired by Health Datapalooza: Workflow, Communication, Tasks, and Business Process Management

  1. Why is Health IT behind in workflow-friendly technology and process awareness? How do we fix?
  2. Health Datapalooza? Good. Health Workflowpalooza? Even better!

Yesterday’s blog post Health Datapalooza? Good. Health Workflowpalooza? Even better! had a bunch of tweets containing the #HDPalooza hashtag and “workflow,” but I missed the following tweet.

(I missed the tweet because “workflow” doesn’t match “providers–workflow”)

Using “workflow, communication, task management” to “take work back from the providers” will lead to “sudden adoption.”

I agree!

If EHRs and health IT systems need

  • workflow,
  • communication,
  • task management,

where can we find the technology to provide this functionality?

Well, the first place I go to find things, these days, is Google. Below is a screen capture of just the first page of over 12 million hits returned by workflow, communication, task, and management. After the screen capture I pull out some quotes. Reading them is a good introduction to workflow technology.

I hope you’ll actually go through the search results and read extracts from them about workflow, communications, tasks, and management. But, if you must, you go proceed directly to my conclusion.

google-search-workflow-communicaton-task-management

Since Google constantly tweaks its algorithms, the following is a list of links based on the first page of search results for workflow + communication + task + management.

First there’s the scholarly links. All of them are almost 20 years old (and one is 21 years old!). One of papers has almost 1900 citations. It is widely known. I read it years ago. For each I pull out a bit of relevant content, which, if you read, is not a bad introduction to workflow management technology.

An Overview of Workflow Management: From Process Modeling to Workflow Automation Infrastructure (1995)

Abstract

Today’s business enterprises must deal with global competition, reduce the cost of doing business, and rapidly develop new services and products. To address these requirements enterprises must constantly reconsider and optimize the way they do business and change their information systems and applications to support evolving business processes. Workflow technology facilitates these by providing methodologies and software to support (i) business process modeling to capture business processes as workflow specifications, (ii) business process reengineering to optimize specified processes, and (iii) workflow automation to generate workflow implementations from workflow specifications. This paper provides a high-level overview of the current workflow management methodologies and software products. In addition, we discuss the infrastructure technologies that can address the limitations of current commercial workflow technology and extend the scope and mission of workflow management systems to support increased workflow automation in complex real-world environments involving heterogeneous, autonomous, and distributed information systems. In particular, we discuss how distributed object management and customized transaction management can support further advances in the commercial state of the art in this area.

The action workflow approach to workflow management technology (1992)

Abstract

This paper describes ActionWorkflowTM approach to workflow management technology: a design methodology and associated computer software for the support of work in organizations. The approach is based on theories of communicative activity as language faction and has been developed in a series of systems for coordination among users of networked computers. This paper describes the approach, gives an example of its application, and shows the architecture of a workflow management system based on it.

CORBA-Based Run-Time Architectures for Workflow Management Systems (1996)

Abstract

This paper presents ve run-time architectures for implementing a Workflow Management System (WFMS). The architectures range from highly centralized to fully distributed. Two of the architectures have been implemented at the Large Scale Distributed Information Systems (LSDIS) Lab at The University of Georgia. All the WFMS architectures are designed on top of a Common Object Request Broker Architecture (CORBA) implementation. The paper also discusses the advantages and disadvantages of the architectures and the suitability of CORBA as a communication infrastructure. A minor extension to CORBA’s Interface Denition Language (IDL) is proposed to provide an alternative means of specifying workflows. Simplied examples from the healthcare domain are given to illustrate our technology.

That last line? Healthcare examples!

Let’s look at the rest of search results.

Task handling in workflow management systems

Abstract

Workow management systems aim to automate the execution of business processes. One of the objectives of the workow systems is to include the already existing applications such as legacy applications as well as new applications which are termed as tasks into the system and provide synchronized execution among them. To achieve this a mechanism is necessary to support the communication between the tasks and the system. The communication mechanism should handle the transfer of data necessary for the execution of the tasks and for the scheduling of the tasks. Another point to be noted is the necessity of the handling user tasks that have to be performed by the users of the workow system. Since the trend is toward distributed execution to avoid the bottlenecks due to the nature of central systems we considered these issues in a distributed execution environment. Therefore in this paper task handling in a truely distributed workow management system that is being developed at METU namely METUFlow is described. Yet the techniques described are general enough to be applicable to any workflow management system.

Workflow Management

Introduction

Workflow management software is a set of tools that manages the process of collaboration of certain recurring enterprise projects or day-to-day workflows. Generally in companies of any size, there are many types of work that require collaboration among people within the company. Without the help of workflow management solution, collaboration among employees becomes extremely difficult with majority of the communication among members done in manual fashion. DigiCentury provides workflow management solutions customized to any situation.

Collaborative workflow (Wikipedia)

Workflow

Workflow is a set of activities (service requests, tasks) and the rules that govern their behavior as they move from one service provider to the next until a project is completed.

Collaboration Objects

Collaboration objects include web-based meetings, instant messaging, knowledge management wikis, documents (ECM), and shared calendars.

Definition of Collaborative Workflow

Collaborative workflow is the convergence of social software with service management (workflow) software.

As the definition implies, collaborative workflow is derived from both workflow software and social software such as chat, instant messaging, and document collaboration.

The goal of collaborative workflow is to provide synergetic efficiency gains to its constituents (social communication and service management) by:

  • Improving effectiveness on joint tasks by removing the communication barriers between team members
  • Minimizing organizational boundaries and information silos
  • Allowing online social interaction to be goal oriented, structured, and measured

Ideally, collaborative workflow is a collection of parallel and sequential tasks that rely on communication and coordination to achieve a desired outcome.

TrakSYS for Workflow and Task Management

Workflow and Task Management

  • Automate the flow of information throughout the enterprise
  • Communicate tasks and instructions to personnel
  • Reduce wait and wasted time
  • Eliminate non-productive activities
  • Reduce waste and rework by improving quality and productivity
  • Reduce production cost
  • Improve customer satisfaction

(Could EHRs and health IT systems use workflow/task management? You bet!)

An Overview of Workflow Management: From Process Modeling to Workflow Automation Infrastructure

This is the same paper, by the same name, as one of the links listed in the scholarly links section of this blog post.

Catalog and Archive Workflow Management Component

The critical objects managed by the Workflow Manager include:

  • Events – are what trigger Workflows to be executed. Events are named, and contain dynamic Metadata information, passed in by the user.
  • Metadata – a dynamic set of properties, and values, provided to a Workflow Instance via a user-triggered Event.
  • Workflow – a description of both the control flow, and data flow of a sequence of tasks (or stages that must be executed in some order.
  • Workflow Instance – an instance of a Workflow, typically containing additional runtime descriptive information, such as start time, end time, task wall clock time, etc. A Workflow Instance also contains a shared Metadata context, passed in by the user who triggered the Workflow. This context can be read/written to by the underlying WorkflowTasks, present in a Workflow.
  • Workflow Tasks – descriptions of data flow, and an underlying process, or stage, that is part of a Workflow.
  • Workflow Task Instances – the actual executing code, or process, that performs the work in the Workflow Task.
  • Workflow Task Configuration – static configuration properties, that configure a WorkflowTask.
  • Workflow Conditions – any pre (or post) conditions on the execution of a WorkflowTask.
  • Workflow Condition Instances – the actual executing code, or process, that performs the work in the Workflow Condition.

Mediware Workflow Manager

(Cool! A link from home health made it into the first page of results returned by Google.)

  • Workflow Manager generates notifications automatically, enabling instant, efficient communication.
  • Use the built-in Workflow Manager to enable efficient communication among team members, including clinicians connected through portable devices in the field.
  • View your notifications immediately upon logging in and use the Workflow Manager to track completion of related tasks.
  • Generate communications on-demand or automatically based on important events, such as a patient referral, an adverse event or updates to a medication profile Use rules to define who gets notified of what and when.
  • Define priority events that pop up a message to affected users as soon as they occur.
  • Jump from a task directly to the patient or claim that needs action.
  • Track ownership and assign tasks to other users.

Exploring Human Workflow Architectures

Summary

Human workflow systems and some of the most representative patterns of human-to-business processes interactions break down into two major components. The first is human workflow systems and the interactions among them as they are implemented in integration platforms. The second component is human workflow interaction design patterns and how they are implemented using interactions among the human workflow systems. This discussion will take a close look at these processes.

[End of list of links and extracted material]

Conclusion

I’ve written about many of the above topics in this blog (200+ posts) and I’ve tweeted about them from (20,000+ tweets). I could provide links from some of this material to specific posts. Sometimes I do exactly this, write a post and link back to lots of other posts. This time I’ll not, because I don’t want to break up the material or to lead readers out of this post. I’d rather you make it this far without distraction. But, I do hope you’ll take a look at the long list of blog post links on the right side of this blog. Also, my Electronic Medical Record Workflow Management: The Workflow of Workflow has been at the top of Google for EMR + workflow and EHR + workflow for a decade.

The workflow management systems industry has moved on and terminology has changed. Most workflow management systems are called business process management systems or suites. “Suites” refers to the wide assortment of wonderful tools that workflow engines and executable process models make possible and benefit from. One way to calculate this overlap is to conduct one more Google search. It is the same search as above (workflow + communication + task + management), with one addition: BPM.

Wow! Over two million hits!

Sounds like another blog post.


Health Datapalooza? Good. Health Workflowpalooza? Even better!

Related:

  1. Why is Health IT behind in workflow-friendly technology and process awareness? How do we fix?
  2. Workflow, Communication, Tasks, and Business Process Management

I had a blast, monitoring the torrent of twending tweets containing #HDPalooza, from the Health Datapalooza conference. As usual, whenever I monitor a health IT-related conference hashtag, I search for tweets containing the conference hashtag and “workflow.” I appended those tweets to the end of this post.

slide0007

Hey! What about workflow?

Coincidently I just finished a chapter on healthcare workflow technology for book on business process management. I say coincidently because there’s a paragraph about emphasis on data versus workflow. Before you read it I absolutely must emphasize I agree with the goal of freeing health data to be all it can be. It’s just that, unless we increase emphasis on the workflows along which that data flows, we won’t save money or make users happy.

(Excuse me for a moment while I don my flameproof suit…)

“Health IT focuses on representing data and manipulating data, leading to emphasis on meta-data, data about data. This is fine, as far as it goes. It’s just that it doesn’t go far enough and it is not sufficient to address healthcare’s thorny problems of (lack of) productivity, inflexible workflows, and unhappy users. The only way to systemically improve workflow is to represent workflow, and then think hard about steps to improve workflow. Just as data about data is meta-data and thinking about thinking is meta-cognition, workflow of workflow is meta-workflow. And thinking about meta-workflow in healthcare, health IT and medical informatics is sorely deficient.”

I in no way wish to diminish how hard we must think about health data. I just feel we need to think a little harder about healthcare workflow.

Anyway, I do listen and wait for openings to present themselves. I’m especially alert to opportunities to pivot from data to workflow. When defining healthcare processes came up, I couldn’t resist relating it to the workflow improvement life cycle.

Here’s the exchange (photoshopped into the order it occurred, original tweets are at the end of this post).

tweets-bpm-life-cycle

Here’s a slide from a recent webinar.

slide0023

The slide represents the business process management life cycle: design, model, execute, monitor, and optimize. The slide also relates the BPM life cycle to the PDCA (plan-do-check-act) process improvement cycle that healthcare process improvement folks know well.

Do you see the connection between reengineering healthcare processes and defining, executing, monitoring, and optimizing them? OK. Do you see the connection between defining, executing, monitoring, and optimizing on hand and the BPM life cycle on the other? OK. Then do you see the connection between reengineering healthcare processes and the BPM life cycle? Good. I do too. I even started the Healthcare Business Process Management Blog because of the connection.

I think the following tweet (after the RT) refers to a historical under investment by healthcare in information technology relative to other industries.

By “ROI explanation?” I mean that current, relatively workflow-oblivious, health information technologies might not have the kind of return on investment necessary to quickly propel adoption, absent subsidies and penalties.

I’ve argued for a long time (200+ blog posts, 20,000+ tweets) the single most important route to more effective, efficient, and flexible health IT is to incorporate more elements of workflow technology. These systems used to be called workflow management systems (and sometimes still are). Many are now called business process management (BPM) systems or suites. There are also offshoots such as dynamic or adaptive case management.

Academics refer to these kinds of systems “process-aware” information systems, because they represent, execute, reason about and improve models of processes, or workflows. In healthcare, these models may be highly detailed, incorporating clinical reasoning. They also be more general, about high-level goals; what needs to be achieved but not exactly how. Healthcare will require some combination of these technologies to help manage healthcare’s chaotic and wasteful workflows.

As well put in the previous tweet, why invest in HIT if it can’t create savings or revenue? Make the goal of HIT to reduce waste and unit costs.

Exactly!

That said, I do see signs more process-aware technologies are making their ways into healthcare. Many of the social, mobile, analytics, cloud, and natural language processing platforms, used by startups and companies bent on disrupting older healthcare business models, include process-aware elements in their architectures. I suspect and hope next year’s #HDPalooza will have even more tweets containing “workflow”, reflecting even more mentions of workflow in presentations. After all, workflow is data too! (Check out my blog post on this topic: Clinical & Business Intelligence, Meet Process Mining (Submitted to #HIMSS13 Blog Carnival)

Maybe, just maybe, there’ll be a workflow-oriented track at next year’s #HDPalooza? I’ve even got a good hashtag:

#HWfPalooza.


Appendix (tweets containing #HDPalooza and “workflow”)

(Original tweets about defining, executing, monitoring, and optimizing processes.)