Month: April 2014

Lots of folks are creating incredible Glass apps for physicians, especially to supplement, or even replace, EHR user interfaces. But no one, to my knowledge, is working on a Glass task management system for cleaning and stocking hospital rooms. While this aspect of environmental services has special wrinkles, such as dealing with isolation rooms where extraordinary measures must be taken, there’s also a lot to take for granted. Much patient experience depends on (at least) clean and well-stocked patient rooms. So I thought — patients checking in and out, peripatetic housekeepers, peripatetic supervisors, checklists — hey what about Glass!

Now, I’ve programmed in lots of languages, and I knew one thing, I didn’t want to write a lot of buggy, unmaintainable code… I wanted this Glassware built the modern way, on a BPM platform. BPM stands for Business Process Management. What’s cool about BPM is that you can draw a workflow and a workflow engine can execute it.

It just so happened, about this stage in my thinking, I had a Twitter conversation with (Malcolm Ross, VP, Product, )

nice article on glass. Devices like Glass is why Appian is all-in on mobile workflow/BPM

— Malcolm Ross ()

One thing led to another and here I am at Appian World 2014. ( on Twitter.) I’m on a panel about BPM and mobile (representing Google Glass). And I’m helping demo … well, it doesn’t even have a name. It’s a proof-of-concept integration between Appian’s BPM Software Suite and Glass, and the use case is, wait for it, hospital environmental services task management. At least that’s the way I think of it. It could also be used in hotels and institutional living venues.

The rest of this blog post is about the process by which, the, uh, shoot, let’s call it “Glass House”, came to be and how it works on Glass. I’m going to skip over important work without which this app would not be possible, creating the drag-and-drop smart adapters real programmers had to write to connect Appian BPM Software Suite to Glass. Once these adapters were created, Malcolm Ross picked my brain for about an hour and created the following drawing of Glass House workflow….

… and created the following process model in Appian Process Modeler.

Then Malcolm demoed Glass House for me.

The rest of screen shots are from the Glass House demo here at Appian World 2014.

We’ll explore Glass House top-down.

The house keeping supervisor steps of the elevator and snaps a photo of the floor’s QR code.

Glass House retrieves the following dashboard.

Tapping the dashboard retrieves specific room-level information.

Alternatively, the supervisor pauses before a room, snaps that QR code…

… and reviews that room’s cleaning history.

The supervisor can leave a comment (posting to a secure Twitter-like activity stream shared by environment services staff).

Mark the room unclean.

Request clean.

Now, suppose the super bumps into a housekeeper. The housekeeper’s photo retrieves name, employment history, ….

(The background of the following screenshot is the photo of myself I took with Glass. Appian matched it against a database and retrieved my list of tasks.)

… and open tasks.

That’s the core of Glass House. There are other options, such as Report Incident, that’d feed a potential incident reporting system. One could imagine adding more functionality, such as different kinds of checklists for different kinds of room. Retrieving videos of how to clean and maintain a room. Recording video of how the room is services for quality assurance purposes.

This was just the Glass portion of the app. During process model execution, data flows to and fro, to fully-featured cross-platform apps on smartphone and tablet apps, as well as to the desktop app. These apps have more functionality, such as looking up open tasks assigned to you and various status and productivity reports, all created automatically by the underlying BPM platform.

Important to note: Appian BPM Software Suite has hundreds of adapters and can talk to other information systems. It’s a full-fledged SMAC BPM platform. SMAC stands for Social, Mobile, Analytics, and Cloud. Is Glass House missing something? Add it. Use the same process modeling process used to so quickly create Glass House in the first place. Add external and internal (secure) social media functionality. Add other device platforms, as Appian makes them available, without having to change the process model. Leverage workflow analytics to find and eliminate bottlenecks. Add steps to insure compliance with new regulatory requirements. Run it in the cloud. All of which are exactly where health IT needs to go.

Glass House is a proof-of-concept Glass app. Glass isn’t even available for purchase, except through various special programs intended to improve it. However, Appian BPM Software Suite was easily integrated with Glass, and once done so, was easily used to create the respectable bare bones of an environmental services task management app.

Speaking strictly for myself, I do hope (and expect, but again, I am not privy to any special knowledge) that Appian builds on the work of its smart developers (and process modelers). I’d love to see more Appian-style BPM in healthcare.

I just sat through an Xcellent webinar about CareXcell from Siemens Healthcare Its title was Population Health Management: One Person At A Time. Talk about tackling the right healthcare problems with the right technology! As soon as a link to the recorded webinar is available, I’ll post it here. In the meantime I’d like to post their definition of Population Health, one of the best I’ve seen, as well as highlight Business Process Management tech (BPM) specific content.

I’ve written before about how important workflow technology is to closing the loop within health population management. I’ve written before about healthcare BPM at Siemens, plus how Siemens was one the first healthcare IT vendors to exploit process-aware information systems. The next couple slide fragments reveal BPM’s critical role to making population health management software flexible and scalable.

There are lots of folks collecting and analyzing patient data. What makes BPM-enabled health IT population health solutions different is that they go beyond static reporting, to drive real-time support at the point of care. No matter how clever and sophisticated your analytics are, if you can’t close that loop flexibly (so you can change with the times) and scalable (so you can deal with potentially millions of patients) you’re not going to succeed. This is what workflow tech gives you, both flexibility and scalability of closed-loop, systematically improvable, population health management.

Another reference to business process management.

By the way, Siemens Health IT uses TIBCO business process management. Siemens gathers patient data from disparate systems, normalizes it so it can be combined for analysis, and generates evidence-based guidelines. These guidelines are implemented as workflows that are automatically executed. Regulations change? Medical best practice changes? Change the workflow definitions being automatically executed!

When workflows engines execute workflow definitions, tasks are automatically pushed to the right people at the right time. Then they are tracked and escalated if not performed. BPM is like your mother, who you could count on to never, ever, let you oversleep for school. (Well maybe once in a while, just to teach you a lesson.) So, above you see a Transition Management: Self Care/Safety Management task assigned to a Mr. Fisher. It has a date, a priority, and a status, in this case “In Progress.” If it isn’t completed by April 20, 2014, someone is going to come looking to find out why not. If the task is complete, the outcome is recorded: successful versus unsuccessful and why. And this data goes right back into the analytics to systematically improve population health intervention effectiveness and efficiency.

Beautiful!

I’ve also written about the importance of workflow technology to patient engagement. Here the workflow system knows all kinds of things, such as what is the best way to contact the patient, as well as what information or tasks to push to them. The patient is another member of the healthcare team, to whom can be assigned tasks, which if not accomplished are tracked, escalated, studied, etc., just like for other members of the healthcare team.

I’ve been writing and presenting about workflow technology in healthcare for over a decade. And I am so delighted to see it finally getting the place in the health IT sun it so much deserves.

Kudos (again) to Siemens Health IT for helping bring true workflow automation healthcare.

(Like the title says) I’m participating in a panel on the future of mobile and BPM at Appian World Thursday, May 1st here in Washington, DC.

• Chuck Webster, Google Glass Explorer and President EHR Workflow
• James Woods, Business Analyst, Bank of Tennessee
• Sergo Grigalashvili, VP, Information & Communication Technology, Crawford & Company
• Michael Beckley, CTO & Co-Founder, Appian

“Join Appian’s CTO and a panel of customers, partners, and futurists to discuss the challenges and opportunities for mobile BPM. Hear how the “internet of things,” connected devices, consumer wearables, and other emerging technologies will impact your business. Get ahead of the mobile revolution and the transformation it delivers.”

I think it would be fair to say I am a prolific tweeter so if you can’t attend, I hope you’ll monitor the #appian14 hashtag during the conference from April 30th to May 2nd. Here’s one of my many (like a 100!) tweets from last year.

Photo of auditorium. Waiting for keynote on social . Listening to great jazz. Thanks !

— Charles Webster, MD ()

Here are all the Twitter handles of all the speakers I could find.

• Of course!
• Daryl Plummer, Managing VP & Fellow, Gartner
• Malcolm Ross, VP of Product Marketing, Appian
• Neil Ward-Dutton, Research Director, MWD Advisors
• Suvajit Gupta, VP of Development, Appian
• Architect, Appian
• Jem Eskenazi, Director, IT, European Bank for Reconstruction & Development (EBRD)
• Tony Durso, VP of Solutions Consulting, Appian
• Achal Augustine, IT Manager, Flowserve
• Chuck Webster, Google Glass Explorer and President EHR Workflow Inc.
• Michael Beckley, CTO & Co-Founder, Appian
• Medhat Galal, VP of Enablement, Appian
• Brian Matsubara, Head of Global Technology Alliances, Amazon Web Services (AWS)
• Kevin Dalley, Business Process and IT Director, Punch Taverns
• Shark Tank
• Sriraj Rajaram, Senior Director, Practice Lead – BPM, Cognizant Technology Solutions
• Brett Shomaker, Principal Program Manager, Appian
• Jed Fonner, Director of Center of Excellence, Appian

A Robust Health Data Infrastructure is an HHS report addressing why Meaningful Use has, so far, failed to deliver on early promises to dramatically improve healthcare while reducing cost. At its core is a proposed architecture to facilitate more interoperable EHRs and health IT systems. Since I also recently weighed in on why interoperability has eluded us (Pragmatic Interoperability), I thought I’d compare A Robust Health Data Infrastructure to my own views on healthcare workflow and health IT workflow technology.

Thru JASON Robust Health Data Infrastructure report twice: workflow tech angles > complexity, state, control, code volume, cost, privacy, UX

— Charles Webster, MD ()

Here is the proposed architecture for exchange of information.

The report’s authors are collectively referred to as JASON. I’ve not been about to find out what this acronym stands for, but it sounds like JSON (JavaScript Object Notation) a popular lightweight data-interchange Web format.

This architecture is, essentially, a marketecture, a “one page, typically informal depiction of the system’s structure and interactions. It shows the major components, their relationships and has a few well-chosen labels and text boxes that portray the design philosophies embodied in the architecture. A marketecture is an excellent vehicle for facilitating discussion by stakeholders during design, build, review, and of course the sales process. It’s easy to understand and explain, and serves as a starting point for deeper analysis.”

Marketecture is a portmanteau of “marketing” and “architecture”. Besides the above more technical meaning, marketecture is “used by a vendor to place itself in such a way as to promote all their strongest abilities whilst simultaneously masking their weaknesses.” I think it’s fair to say the proposed JASON diagram serves both the purposes of education and marketing, education about what will be necessary to create truly interoperable health IT software systems and marketing its adoption by a variety of healthcare and health IT stakeholders.

The JASON report prompted me to reread: Out Of The Tar Pit. You’ll see the connection in a moment.

Out Of The Tar Pit is about why software is so difficult. Software is difficult because it is complex, by which the authors mean it is difficult to understand (not the more formal concept of computational complexity). They list reasons — state, control, and code volume — to which I will return.

Why did I think of Out Of The Tar Pit when I read the JASON report? Because software architectures are about managing, attempting to reduce by design, complexity, to get to more understandable and reliable software systems. Divide and conquer: if we can reduce a software system into understandable components, and understand their interactions, we can hope to understand the whole, and make it do what we wish more reliably.

So far, so good. The JASON-suggested software architecture for healthcare information exchange is a valiant effort. It’s only missing one key ingredient: process-aware information systems. Now, the architecture is, indeed, intended to be agnostic about what specific software platforms should be used to implement it. I, however, am not agnostic. I believe, without a doubt, that many of health IT’s problems regarding usability, interoperability, and cost, are due to not using technologies that have been prevalent in other industries for years, in some cases, even decades. These are the workflow technologies, including workflow management systems, business process management, and dynamic and case management systems.

Workflow tech is used by, embedded in, a wide variety of social, mobile, analytics and cloud platforms. From speech recognition and natural language processing systems to “big data” and machine learning workflows, executable process models are helping to manage software complexity, increase understandability and reliability. I might visit some of the boxes of this architecture in a later post: stovepipe legacy systems, UI apps, middleware apps, semantics and language translation, as well as privacy services. However, before I do so we need to review the major sources of software complexity the JASON architecture seeks to tame.

Out Of The Tar Pit blames software complexity on

• state (data values)
• control (order of execution) and
• code volume (lines of text).

Out Of The Tar Pit suggests programmers think more declaratively about what the software does, not how it is accomplished. This would go a long way to reduce software complexity. In other words, if health IT could better manage software state, control, and code volume, this would go a long way toward accomplishing the same higher-level goal that motivates the JASON architecture.

The better health IT manages state, control, and code volume, the more it will reduce complexity and achieve goals motivating the JASON architecture. On all three points, workflow technology contributes. Let’s take an extremely simplified patient encounter workflow.

A more realistic representation of healthcare workflow would be a magnitude more complex than this example. However, it would not be more complex than the software code necessary to support users in during interacting with patients, users, and data partners. This simplified workflow is sufficient, though, to illustrate how workflow technology manages state, control, and code.

First of all, the above network is what is called a state transition network, or STN. Each of the numbered nodes is a patient encounter state. “S” is the start state. Circled nodes are end states. Arrows between states represent state transitions. For example, to get from “S” to “1” (vitals) the task of taking vitals must be recorded as having been accomplished. And so on. “S” and “1” and so on represent state just as much as variables in a computer program represent state. However, these states are at a level high enough a human familiar with patient encounter workflow can understand the “program” (the STN) but low enough that a workflow engine can execute the program, perhaps by putting a task in a user’s worklist and checking it off when completed, or recognizing from other data when the vitals task has been accomplished.

Workflow systems still have a lot of variables, most pertaining to patient state stored in databases, but also entered or calculated during a patient encounter. However, by explicitly representing workflow states, and connections among them, in a declarative manner (think of declaring a variable, assigning a type, and a value) at a level that makes sense to both humans and machines, a significant portion of EHR software complexity is more understandably managed.

What about control, the order of task execution? Arrows among states represent this. Instead of confusing if-then and case statements where commas matter, not to mention executing chunks of software in parallel and not knowing in what order they will complete, sequence order is represented a level of abstraction understandable by human but executable by engines. Workflow technology has a natural means to represent and automatically execute representations of state and order missing in traditional health IT systems not using workflow engines and executable process definitions.

Finally, there is code volume. Many workflow technology vendors bend the truth a bit and boast about “no code” development. However, dragging, dropping, and double-clicking on Visio-style icons can indeed be “substantially less code” development. Properly trained business and clinical analysts, who don’t know how to program but do understand healthcare workflow, can create applications that would otherwise require teams of programs a magnitude or more longer to create.

To close the loop between my workflow discussion and my JASON architecture discussion, both seek to manage software complexity in different, but complementary ways. So, why not use both? Use workflow tech to implement the JASON architecture.

Siemens Healthcare was and is a pioneer in use of business process management software at or near the point of care. I’ve written about them frequently and even more.

As a educator about process-aware tech in healthcare (workflow management systems, business process management, and dynamic/knowledge-based/adaptive case management software), I keep an eye on Siemens workflow-related white papers, product brochures, YouTube videos, conference presentations, and webinars.

Recently I attending a webinar sponsored by Siemens: How can Complex Event Processing, Business Process Management, and SWIM Help to Improve Performance, Quality, and Efficiency of Patient Care? SWIM stands for SWIM Workflow Initiative in Medicine — yes, a recursive acronym! 🙂 At about the same time I discovered some wonderful new (to me, but seem very recent) product brochures and case studies.

I’ll summarize this content here, but I should mention I have no financial relationship with Siemens Healthcare. I just think that a rising healthcare BPM tide raises all boats, so to speak. By boats I mean People and Organizations improving Workflow with Health Information Technology. I even have a directory of #POWHIT profiles in where I award web badges!

Healthcare BPM > CareXcell workflow (engine-based) management booth 3165

— Charles Webster, MD ()

“dynamic care plans, integrated within the embedded business process management technology, deliver patient-specific messages for evidence-based interventions at every point in the care workflow. An underlying workflow engine monitors the care plan activities for completion or deviations, triggering timely patient-specific interventions and event-based alerts, as well as escalating missed tasks to a specified care team member.” (ref)

Note the important role BPM and workflow engines play!

I’ll start with a couple slides and then an outline of the entire webinar. After that I highly workflow tech-related material from the recent brochures and use cases. Please, by all means, view a video of the webinar: It’s free!

The webinar included two presenters on related topics. Bradley Erickson, MD, PhD, of Mayo presented “SIIM Workflow Initiative in Medicine (SWIM) Lexicon: Measuring and Improving Workflow.” Marc Overhage, MD, PhD, presented on Business Process Improvement and Directions.

Nice overview of BPM benefits for healthcare workflow!

So true! It is finally begin to happen though, I’m happy to report.

And here is my distilled outline of the entire 50 minute presentation.

• How to Improve Workflow
• How to describe workflow
  • Steps
  • KPIs
• Standard for collecting/accessing workflow events
• Time, EventID, SystemID, Additional info
• Future
  • Collect workflow data from population
  • Determine optimal workflows by department
  • Use workflow engines to support optimal workflows
• Workflow Engine for brain tumor protocol
• We need event data
  • What exists
  • What doesn’t but is needed
  • “Harmonization” (match ids, sync times)
• “Workflow engines are widely used outside of medicine. We need to catch up.”
• Business Process Management Technology
  • Manage clinical processes from beginning to end
  • Identify clinical workflow problems
  • Monitor clinical workflow execution
  • Calculate effectiveness & efficiency measures
• “Process = series of actions performed to achieve an intended result”
• “Workflow = In healthcare, either a sub-process performed by a single individual or a process”
• Simple processes
  • Linear
  • Predictable
  • Short
  • Departmental
  • Static
• Complex Processes
  • Predictable & unpredictable
  • Many steps
  • Multiple paths
  • Nested processes
  • Many participants
  • Many interfaces
  • Interdepartmental
  • Change frequently
• Stroke Process Example
• Process Types
  • Process vs Knowledge Workers
  • Simple vs Complex Processes
  • BPM -> CEP/BPM -> “Contextualization”
• Care Teams Need
  • Reliable
  • Flexible
  • Efficient
  • Satisfying
• Contextualizing a model process
  • Tweak executing BPM process every time one of the following changes
    • Patient
    • Time
    • Setting
• Process monitoring prompts “re-contextualization”

The following is supplementary material I’ve been able to find in a series of product brochures and case studies. Again, I embolden specific references to workflow tech.

Workflow Technology: The Right Information at the Right Time

“the Soarian® system’s embedded workflow technology is critical in supporting improved care delivery and team collaboration. Any care delivery process includes many steps, creating multiple opportunities for variability and potential human error. The workflow engine helps the care team eliminate process variability, which in turn supports patient safety and positive outcomes. EMH also leverages the workflow technology to guide clinicians in addressing or completing time-sensitive care interventions. “The workflow engine works behind the scenes to gently remind and guide our teams to care for patients in a manner consistent with the evidence.”

“The fundamental advantage of the workflow engine over a rules engine is the level of sophistication. Being able to support a highly complex clinical process, monitor patient progression across the continuum of care, notify the appropriate clinician(s), and escalate if needed not only drives out variability in care but improves patient outcomes. The workflow engine is really helping us transform the way we care for patients at EMH.”

“EMH plans to use Soarian and its workflow capabilities to address future challenges and opportunities. “With healthcare reform, there are growing requirements for transparency and accountability,” says Wray. “We are highly focused on getting our IT solutions in place and optimized to support these changes.”

Physician Engagement Supports Workflow Efficiencies

“Like most community-based facilities, PVHMC physicians are independent. It was, therefore, imperative to align with the workflow demands of those who practice at different facilities with different EHRs and other systems.”

“I believe Soarian has much less ‘clutter’ on the screens, making the physician experience more streamlined and simpler,”

“Soarian’s clinical summary [as a rounding tool] allows us to view the most pertinent information in one location without having to search throughout the patient record. The way orders are set up not only makes it quick and easy to identify orders and results but to see if they have been completed or not.”

“The care team also uses Soarian’s embedded workflow engine capabilities to prompt clinicians about care interventions that are due or overdue. For example, nurses and clinicians receive real-time alerts when a patient has a documented risk of falling (via use of screening/risk assessment tools). Depending on the patient’s level of risk, the appropriate interventions populate the clinician’s worklist, further supporting documentation completion. Having optimized processes in place and information readily available helps the care team respond quickly, which can lead to more positive patient outcomes. “The prompts the workflow engine provides to staff, as well as the actionable worklists, contribute to timely execution of patient care interventions,” says Pam Crawford, PhD, MSN, RN, vice president of nursing and chief nursing officer. “The workflow engine is like a ‘helper’ for the nurses, ensuring those time-sensitive activities are completed.”

“Physician Affinity

“The Soarian system helps physicians streamline their work by providing anytime, anywhere access to a patient’s complete medical history. “The ability of physicians to check their results, receive alerts via the workflow engine, and use CPOE capabilities all support physician affinity,”

How It Works.The Soarian workflow process.

“The Soarian system offers an embedded workflow engine that helps your organization coordinate and manage processes as well as clinical data from beginning to end—across departments, disciplines, and care settings—to help improve operational efficiencies and quality of care. From acute myocardial infarction to infection control management, care processes become more manageable with a solution that helps synchronize and automate activities. As illustrated in the MRSA example below, the workflow engine simultaneously manages numerous handoffs, notifications, and next steps to ensure the right person is performing the right task at the right time. You can further improve outcomes and care delivery by adapting and optimizing your own processes with the workflow engine in Soarian, using parameters that match the unique needs and goals of your organization. Parameters can include clinical roles, care protocols, quality benchmarks, and timing of notifications and escalations.”

“It leverages existing Soarian capabilities such as embedded workflow technology, a flexible service-oriented architecture, a superior user interface, and powerful analytics. Soarian Ambulatory supports cross-continuum capabilities like clinical worklisting and interdisciplinary plans of care to help synchronize care activities.”

“Embedded workflow engine helps synchronize clinical activities, supporting greater transparency, accountability, and adherence to evidence-based practices.”

“ Soarian workflows have become an essential part of how we provide care at Lake Health. Our end users, managers, and Quality department not only depend on them but are routinely thinking of new uses for the workflow functionality.”

“ The use of Soarian and the workflows has helped us address our patient safety initiatives and quality of care we deliver. We now have the data to support our decisions and the communication among care providers is improved.”

Connecting people to connect care: Soarian Clinicals

Soarian for Clinical Care: Connecting people to connect care.

Conclusion

Siemens Healthcare was and is a pioneer in use of business process management software at or near the point of care. Siemens’ workflow-related white papers, product brochures, YouTube videos, conference presentations, and webinars play an important role in educating the health IT industry about enormous potential for business process management systems in healthcare.

Thank you Siemens Healthcare!