Month: May 2014

I’m delighted to see Business Process Management (BPM) cited in the recent PCAST Systems Engineering in Health Care report Better Healthcare and Lower Costs: Accelerating Improvement Through Systems Engineering.

Systems Engineering used to be called Industrial Engineering. I have a graduate degree in IE. My old department at the University of Illinois is now called the Department of Industrial and Enterprise Systems Engineering.

In this report they write

“Successful and sustainable improvement must involve reconfiguring the workflow and overall environment in which these professionals practice, which can help to reduce the burden of work while improving the performance of the system.”

“Reconfiguring workflow”, that’s what I blog and tweet about constantly. Sometimes I wonder what people think. Chuck, workflow, workflow, workflow, blah, blah, blah… 🙂

Anyway, this post is just a squib to pull out several quotes about BPM, Human Factors (part of IE) and Systems Engineering (above).

“Business Process Management: cross-functional, iterative approach to optimize processes and knowledge transfers as changes occur in the system. Most common tools are software packages (vendors include IBM, Oracle) implemented to manage workflows, documents, and processes.”

“Human Factors: study of the cognitive and environmental influences on human performance.”

I continue to work for, and increasingly see, awareness and diffusion and adoption of workflow technology in healthcare. The PCAST Systems Engineering in Health Care Report report is just one (particularly salient) datapoint in amidst a cloud of signs and signals that healthcare is finally beginning to take workflow seriously.

Yeah!

On June 16th I’m presenting BPM and Case Management: US Healthcare Wants You, But May Not Know It, Yet at the BPM & Case Management Global Summit (archive) here in DC. I hope to meet you and talk shop! I’ll be tweeting about my presentation and the conference, so I hope we can “tweet shop” too!

P.S. An offering to the search engine gods…

BPM and Case Management: US Healthcare Wants You, But May Not Know It, Yet

Charles Webster, MD, President, EHR Workflow, Inc.

Healthcare processes are mess, no matter whether structured and repeatable or unstructured and one-of-a-kind problem solving and interaction among knowledge workers. One third of an almost three trillion dollar economy is estimated to be wasted due to inadequately managed clinical and administrative workflow and processes. How is traditional health IT failing to solve these problems? How can business process management and case management (BPM/CM) help? What are ten obstacles slowing diffusion of process-aware information system into healthcare? How can we eliminate, reduce, and circumvent these enemies of healthcare workflow progress? These and other questions will be answered, to help you, a BPM/CM vendor, gain audiences with, and prove your worth to, health IT professionals, managers, and decision-makers.

A Google Glass Explorer with degrees in Accountancy, Industrial Engineering, Artificial Intelligence, and Medicine, Dr. Webster designed the first undergraduate degree program in medical informatics and partnered with three healthcare organizations to win the first three consecutive HIMSS Davies Awards for Ambulatory Excellence, the top award in the health IT industry for electronic health records.

I see convergence between care coordination platforms and business process management tech used to implement them. The following slide crystalized this for me.

needs 1 Common 2 Data warehouse 3 Care coordination platform (IMO shld use workflow tech)

— Charles Webster, MD ()

An Accountable Care Organization, or ACO, is a virtual enterprise of primary care physicians, specialists, and hospitals that coordinate care for a population of patients and are “accountable” for both cost and outcomes. There’s much discussion of what kind of IT infrastructure is needed to create successful ACOs. The above tweeted slide is an example. That it was retweeted at least thirteen times indicates some agreement, or at least interest, in the health IT Twittersphere I inhabit online.

As an experiment I cross-indexed “care coordination” and “workflow engine” with BPM or “Business Process Management” or “Workflow Management System.” I found lots more links than I tweeted and embedded below. I arbitrarily stopped at ten or eleven. But even just those are pretty interesting. For example, I found an expected mix of academic presentations and papers, but I knew I’d find that. Researchers have zeroed in to what they called process-aware information systems (in healthcare) for over a decade. More interesting was all the vendor-related content. I’ll alternate between the two categories below.

First of all, there’s this slide from a non-academic source. It simply mentions a workflow engine being used to manage alerts and messages to providers. Workflow engines are the essential component of what used to be called workflow management systems, but now are called business process management systems or suites. Later links will explicitly invoke need to BPM tech in building care coordination platforms.

Care Coordination Software • Workflow Engine • Provider Channeling • Alerts & Messaging http://t.co/ulfuG5mH4f

— Charles Webster, MD ()

The following slide is from an academic presentation. The layers proceed in abstraction from medical guidelines based on medical experts and research, down through medical pathways based on cooperating care team members to treatment plans and processes. I really like the definition of care pathways: “Aim to model a timed process of patient-focused care, by specifying key events, clinical exams and assessments to produce the best prescribed outcomes, within the limits of the resources available, for an appropriate episode of care.”

"process-aware" > Personalized Care Pathways using & Artificial Intelligence http://t.co/wzkL7msj6T

— Charles Webster, MD ()

What we need are models, executable models, at a variety of levels of abstraction, but consistent with each other, of both what we need to do and how much it will cost. And our healthcare information systems need to represent, reason about, and systematically improve these models. What was the above presentation called? “Personalized Care Pathways using Business Process Management & Artificial Intelligence.”

Process Contextualization slide (see my Tackles Population Health Management blog post)

— Charles Webster, MD ()

I am also reminded of a recent webinar given by Siemens Health IT discussing “contextualized” and “re-contextualized” process models. Above is a slide from that presentation. Adapt a process model to the patient and setting, tell a Business Process Management system to execute it. If the patient and setting changes in important ways, re-adapt the process model and continue with execution by the BPM system.

Care Coordination Platform workflow engine closed-loop task execution escalation rerouting reprioritization

— Charles Webster, MD ()

“Workflow engine closed-loop task execution escalation rerouting reprioritization” … exactly what I wrote about in my 2010 MedInfo paper, “Clinical Intelligence, Complex Event Processing and Process Mining in Process-Aware EMR / EHR BPM Systems.”

The future > Care coordination workflow engine "forms invisible layer between user interface & underlying HISs used" http://t.co/OTeVUIAT4m

— Charles Webster, MD ()

The above tweet links to a chapter in a book of research papers. The cool thing is I can actually embed the page from that chapter in that book from which I quoted. So, here it is.

This “invisible layer” between user interfaces and health information systems? This is the workflow technology that makes care coordination possible, that is, both flexible (by tweaking executable process models) and scalable (through their execution). I’ve written about the need for this layer of workflow interoperability and usability in my blog post, “From Syntactic & Semantic To Pragmatic Interoperability In Healthcare.”

Mapping Integrated Care Pathway into 4 Health Case Management teamwork, collaboration coordination

— Charles Webster, MD ()

The phrase “teamwork, collaboration, coordination” occurs in the abstract from this paper, which asserts Business Process Management software will be necessary to achieve those three necessary elements of care coordination. Elsewhere I’ve written about the science and technology of coordination, another name for BPM and related technologies.

"Care process management is application of business process management methodology to clinical processes"

— Charles Webster, MD ()

Above, the authors explicitly define Care Process Management as using Business Process Management to manage clinical processes. Vendors often rebrand BPM because sometimes they feel the word “Business” has negative connotations to clinicians. You’ll also sometimes see Healthcare Process Management for the same reason. However, if you poke around in the footnotes, you’ll usually see some sort of reference to BPM. Even if “Business” is suspect, the allure of “[Something] Process Management” is irresistible. Interestingly, I’ve seen vendor phraseology evolve away and then back to the B in BPM. BPM has a several decade-old track record, going back to workflow management systems. It’s a track record vendors can point to harness some of that credibility.

The next few tweeted quotes, paraphrases, and links, just round out my sample of results returned by Google. Feel free to jump to my conclusion.

CMS-aligned data, workflow engine, care coordination , reporting &communications via Altruista Health

— Charles Webster, MD ()

Accountable Care "care coordination workflow engine translates rules into follow-up actions for members of care team

— Charles Webster, MD ()

"care coordination workflow engine is cornerstone tool" Successful Care Coordination: Accountable Care IT Foundation

— Charles Webster, MD ()

Workflow engine converts clinical protocols to To-Dos for members of patient’s care team & tracks care coordination http://t.co/KUVNYFTwHc

— Charles Webster, MD ()

Real-time Patient Flow Management using Business Process Management, Location Tags & Complex Event Processing

— Charles Webster, MD ()

The above tweet is actually to a published research paper. I include it here because it evinces another interesting trend I’m observing. Folks who sell real-time location tech, to track people and equipment, are developing their systems into complete workflow solutions. I see the same thing happening with nurse call systems. When you are a necessary piece of the workflow, the next value-added strategic step is to begin to manage more-and-more of end-to-end workflow. We’ll see these and similar vendors (such as in Enterprise Content Management) both develop proprietary workflow solutions and embed or talk to third-party business process management suite vendors.

I’ve been tracking diffusion of workflow tech into healthcare for over two decades. I find it absolutely fascinating, the end-run about electronic health records. At one time, about a decade ago, I was sure that EHRs would evolve into true EHR workflow systems. Instead, EHR feature sets were “pinned” by Meaningful Use. As a result, EHRs are increasingly viewed as a necessary evil, to get data from the point of care. Once you get that data, the only way to create population health management systems that can affect clinician and patient behavior at the point-of-care *and* do flexibly and scalable, is to leverage workflow technologies such as workflow management systems and Business Process Management systems and suites.

Increasingly, the Royal Road for BPM into healthcare appears to run through care coordination, a function for which EHRs should have been ideally suited. Regardless, healthcare application architecture is finally evolving out of the dark ages into a more process-aware world. I’ll leave you with a finally tweeted slide from one of my presentations. It shows, on the right, the evolution of workflow representations, away from Java, C#, and Mumps captive in hardcoded dungeons. Instead, representations of workflow will be stored in ways that both humans and machine can understand and use in their unique and complementary ways. Human’s will create and improve workflows. Workflow engines will execute and monitor workflows. Workflow Management Systems, Business Process Management systems, and flexible Case Management (for hard to represent workflow), are finally arriving in healthcare.

. and Workflow: Are We Making Progress?

— Charles Webster, MD ()

Anyone who follows me on Twitter, or reads more than one of my blog posts, knows I’m the self-styled King Of All Workflow In Healthcare. It’s good-natured ironic puffery dedicated to a good cause. Healthcare has a workflow problem: why not use workflow technology (AKA Business Process Management, or BPM) to solve it, or at least better manage it? I’m based in Washington DC. Nearby is Reston, Virginia, where Appian is based. Appian is, according to Gartner, a respected research and advisory firm, the reigning BPM champ. (See next tweeted slide.)

2013 +82% Sales, +51% Term Revenue, Rated #1 vendor by Gartner, Largest private financing history

— Charles Webster, MD ()

Even though I’m not an Appian employee, I’ve been to all the yearly Appian Worlds. (Here’s a previous trip report.) Why? Well, if you where fascinated by BPM’s potential in healthcare, wouldn’t you go? This post is a place to collect my favorite tweets, videos, and musing re my experience at this year’s Appian World. I’ll also refer to some previous tweets and material when I think it can provide some healthcare care context and meaning to ideas at what is not a healthcare IT conference.

What was different this year was this: I was one of the speakers, on a panel about BPM and mobility. I was there representing Google Glass. In a previous post I described how I approached Appian about building a proof-of-concept integration between Glass and Appian’s BPM platform. I spoke about how I got Glass, what’s it like to walking around with Glass on, and the hospital (or hotel) environmental services task management app we created.

Hey! That's me! Second from left on that slide. I must be in right room. Having a blast as a panelist at

— Charles Webster, MD ()

You can even see and listen to my presentation, albeit from my point-of-view, recorded using Glass.

What's it like to speak at ? 5 minutes of me on integration from my POV! via

— Charles Webster, MD ()

The hospital/hotel housekeeping task management Glass app I mentioned earlier does three things. A picture of a floor’s QR code retrieves a list of uncleaned rooms. A room’s QR retrieves cleaning history, plus options to request it be recleaned or adding a comment to an activity stream (similar to Twitter or Facebook) shared by housing keeping staff. And, illustrated below, the picture of an employee retrieves name, employment history and list of open tasks (available by tapping on the Glass card below).

+ face recog. + app > Chuck Webster, 58% confidence, 5 open tasks

— Charles Webster, MD ()

Many thanks to Malcolm Ross, VP of Product Marketing at Appian, for enthusiastically facilitating this proof-of-concept integration between Google Glass and the Appian BPM software suite. Below, he traces the rise of business computing and work platforms all the way from ENIAC in 1947.

Riffing on the meaning of "Modern" at traces history of computing from ENIAC 2 cool!

— Charles Webster, MD ()

I participated in a couple interviews. This one with the Washington Post…

I'm in Washington Post! (on left, + workflow model editor) Home or Office First? http://t.co/Cd0m7qNNwt

— Charles Webster, MD ()

And this one with TV channel WUSA9 …

Check out my interview on this AM mention toward the end

— Charles Webster, MD ()

…with Mike Hydeck ….

Morning anchor trying out during our Friday interview!

— Charles Webster, MD ()

…and also with Jessica Doyle, who donned Glass to turn the tables on me!

My interview this AM w/ of re w/ mention at 0:45 cc via

— Charles Webster, MD ()

On the way out, TV reporter Nikki Burdine trying on my bright blue Glass, boy does it pop!

Honor & privilege! RT Thanks to for letting me play w/ !

— Charles Webster, MD ()

The rest of this blog post turns a bit more serious, serious about the serious benefits business process management offers for better management of complex healthcare workflows.

While there were no healthcare-specific presentations at this year’s Appian World, there have been at previous Appian Worlds, as I’ve discussed in previous blog posts. Nonetheless I’m intrigued to see healthcare examples on some of the most interesting slides, such as this one about Appian’s SAIL tech. SAIL stands for Self-Assembling Interface Layer. SAIL is what make is possible to generate workflow apps that will execute across multiple mobile platforms and form factors.

+1 Healthcare example at "Encrypted Text: New Patient Visit" PS SAIL "Self-Assembling Interface Layer"

— Charles Webster, MD ()

During Appian World 2014, Appian’s website moved into the first position on the first page returned by Google for “healthcare” cross-indexed with “BPM.” I’ve a half a million words on a half a dozen websites about healthcare business process management. I’ve over 42K tweets on the subject. I’ve been posting content about Appian and Appian World… I wonder if there is a connection…

Very cool to see number one on the first page of Google for "healthcare"+"bpm" during conference!

— Charles Webster, MD ()

The most relevant healthcare BPM activity and conversations occurred around Appian World exhibitor booths. Besides the Glass BPM hospital housekeeping app demoed (100 times?) at the Appian booth, Incessant Technologies showed off its own use of Appian BPM to implement clinical pathways. In the following five-minute Glass interview Vijay Poondy and Seemant Ahuja of Incessant Technologies explain how and why they’ve used Appian to implement clinical pathways on a business process management platform.

Implementing clinical pathways on BPM platform. 5 minute interview w/

— Charles Webster, MD ()

BPM, Business Process Management, has so much potential in healthcare, but it’s been slow to diffuse into healthcare. One of my most popular blog posts is the Top Ten Reasons EHR-BPM Tech Is Not (Yet) Widely Deployed in Healthcare. Fortunately I am convinced this is changing, right now, in a big way. For example, every year I search every website of every exhibitor at the HIMSS conference. That’s over 1300 exhibitors. In 2013 about eight percent had workflow-related technical and marketing material. In 2014 this rose to over sixteen percent. In other words, representation of workflow-related ideas and technologies more than doubled between HIMSS13 and HIMSS14. I think we’re looking at between 50 and 100 percent increase at HIMSS15 in Chicago.

An industrial engineer who went to medical school, I’ve advocated workflow technologies in healthcare for over two decades. Sometimes I was frustrated, because I felt progress was unreasonably slow. But I never doubted that traditional health IT would eventually hit a wall. And it has. Reasons and consequences are varied and complicated. But here I’d like to focus on several windows of opportunity that appear to be opening up.

First, several weeks ago I attended the Healthcare Business Intelligence Forum here in DC. Just as I did at Appian World, I videoed and blogged and tweeted furiously (my Day One and Day Two posts). The following tweeted slide was by far my most popular.

needs 1 Common 2 Data warehouse 3 Care coordination platform (IMO shld use workflow tech)

— Charles Webster, MD ()

ACO stands for Accountable Care Organization. The Federal Government has spent over twenty billion dollars on subsidizing Electronic Health Records. Now that a majority of physicians and hospitals have EHRs, the challenge is to use them to create ACOs. However, EHRs, alone, will be insufficient. We have to get the data back out of EHRs (that’s the “data warehouse”) in a form we can mine and learn from and use to drive clinical and administrative workflows and processes. That’s the “care coordination platform.” Use of workflow tech, AKA BPM platforms, to implement care coordination systems!

Take a look at the following diagram, from a recently released, high profile report, about the failure of traditional health IT to improve care and reduce cost. The JASON report advocates a decomposition of functionality in order to promote more interoperable health IT systems.

Participation in reinforced my belief tech is essential 2 realizing JASON report architecture

— Charles Webster, MD ()

Health IT is complicated, partly due to being a generation behind other industries in adoption of workflow technologies, and partly due to healthcare, itself, being so complicated. We can’t easily do anything about healthcare’s intrinsic complexities, but we can advocate for use of modern workflow technology to better manage modern healthcare’s complex workflows and processes. There are numerous places in the JASON architecture where workflow tech would be the ideal glue between modules as well as workflow-oriented user interfaces to those modules.

One more slide! When I say health IT is behind the times, is hitting a wall, and is literally decades behind other industries in adoption of workflow tech, I mean it.

and Workflow: Are We Making Progress Taking Business Processes Out Of Applications?

— Charles Webster, MD ()

This slide depicts generations of application architectures. Most healthcare information systems have yet to take the workflow out of applications, out into workflow platforms and services that can better manage and improve it. Let’s solve this problem. Let’s fix HIT. Let’s move current health IT failed “solutions” off workflow-oblivious platforms and to modern process-aware information systems, such as Appian BPM.