Just before the HIMSS16 conference John Lynn and I talked about exhibitors with great healthcare workflow stories. And a whole bunch showed up to tell their own great workflow stories, on Blab! The meeting of the minds was intense. You can listen to the original blab (848 viewers, 55 replays, as of today’s date), or, you can skim or read the complete transcript below.
John: Welcome to our series of healthcare scene interviews where we sit down with top leaders in healthcare IT. I’m John Lynn the founder of healthcarescene.com, a network of leading healthcare IT resources. I’m happy to host the king of workflow here with me today. We’re going to be talking to healthcare IT workflow, EHR workflow and in particular what’s happening at HIMSS 16 with vendors. He even has the badge, workflow king. Perfect. Now, there’s a number of people that joined specifically to talk about what they’re doing related to workflow. Before we do that, let’s welcome our special guest, the king of workflow, Dr. Charles Webster, more affectionately known as Chuck or on Twitter. Welcome, Chuck.
Chuck: Glad to be here. Thank you for having me. I’m willing to talk about workflow a lot. You’re a bully pulpit. You got a great series going here on blab.
John: Thanks. I mean, we couldn’t have Chuck on without talking workflow. I think you’ve branded yourself for good, but otherwise …
Chuck: It’s literally impossible to have me on. I think you have noticed that when the topic isn’t about workflow, I don’t try to monopolize unnecessarily the conversation.
John: That’s true. You are good on blab, even non workflow topics, that’s true. Chuck, tell us, how did you get into workflow? Why are you addicted to workflow? I’m not your counselor or psychologist, but what’s your story? Why workflow?
Chuck: Partly, it’s educational. I was pre med accounting major which is pretty darn unusual. I had to take all these really tough accounting courses and really tough pre med courses. I basically analyzed … You know in the Martian movie, where he said, “I’m going to science the heck out of this.” I had to workflow the heck out of my life in order to do well enough in order to get into medical school and do the accounting degree. Then I got to industrial engineering. Industrial engineering is all about workflow. I have a master’s in industrial engineering. If you look at the intersection of all those, I remember people going what a stupid thing to do combine an accounting degree and a medical degree. Guess what? Today people think it’s brilliant because healthcare costs are such a big issue. That’s my roots in workflow. It has to do with costs and life hacks, managing my own life in a situation where I needed to pull out all the plugs, so to speak.
John: I think you’re the only one in healthcare that might have a medical degree, an industrial engineering degree. It’s quite the combination.
Chuck: Actually, there’s a couple of people who have MDs and industrial engineering degrees. I’ve never met anybody who has an accounting degree and a medical degree.
John: Yeah. Most of the industrial engineers don’t have a medical degree as well. That’s interesting. When we talked about doing this blab, the reason I was really interested in doing it is that I know each year you go to HIMSS, you go through the vendor list and evaluate, how are they using workflow, how are they using workflow technologies, how are they working on that. I love when you have a depth of history about something. I’m interested to know, how has workflow technologies evolved at HIMSS? When did you start tracking it? I think it was 2011, was that the first year or …
Chuck: 2010 was the first year I started to systematically mine the websites of all the exhibitors. My first HIMSS was in 1995 and I presented on workflow, workflow management systems at the point of care. I just noticed there just was a dearth of knowledge and content in that area. In 2010, when I started to tweet and blog more systematically, I said, “I know what I’ll do. I’ll look at all the websites and find all the really great workflow stories and hopefully workflow technology stories.” I basically found zip. Just amazing. There was hardly any mention of even the phrase workflow weren’t anywhere on any website.
John: 2010 was right as meaningful use was starting. I guess the next year …
Chuck: The thing is workflow it’s on everybody’s mind now but people forget that we’re very data centric. It’s all about data. It’s all about giving meaningful use certified. As soon as you start talking about workflow, you get into usability and of course there’s been a push back from doctors in terms usability of these systems. To some extent the emphasis in workflow now is a backlash but that’s okay, I’m willing to … There’s also a lot of great workflow stuff going on. Now in 2011, I found about 2% of websites have interesting stories that I could tweet about and then I went 4%, 8%, 16%.
I remember thinking going into 2015, I literally go to every single website of 12 to 13 and 1400 websites. It takes a couple of weeks. I remember thinking there’s no way that it’s going to double again because it just can’t. It has to stop at some point. 2, 4, 8, 16. I basically ran out of time. There was so much great, so many people who were saying, “We improve workflow in this way” or “Here’s our workflow testimony” or “Here’s our workflow engine” or “We’re leveraging new cool technology from the workflow technology” which is called business process management. I ran out of time. I actually was a hundred vendors short. This year, I’ve used a different system. I’m still searching all of the websites. In fact, I’ve got about 107. My cutoff was January 14th, there were about a thousand vendors that registered. A couple hundred have been added since. I’m hoping to circle back and get them before HIMSS shows up.
Basically, to give you the short answer, in the last couple of years there’s just been a tremendous surge. Now, between a third and a half of all HIMSS exhibitor websites have some workflow angle. They talk about workflow, how they alleviate workflow problems, how they create workflow, how it fits seamlessly into someone’s workflow. Given that 1995 is when I started evangelizing for this stuff, obsessively perhaps, now I’m extremely excited to see this dramatic hockey stick uptake and interest in workflow and also great products that just have great workflow that are designed to create efficient, effective and satisfying workflows.
John: Can you give us some examples? What are some of the things that you look for in a website and examples of what you’d found as far how they’re applying it? Because I think there are a lot of people who can define workflow in a lot of different ways, right? What are some examples of things you look for or what are the common trends that you see on these websites? I mean, it’s incredible to think you’ve visited each one, right?
Chuck: First of all, I’ve looked at hundreds of definitions of workflow. Mine is relatively simple. It’s simply a series of steps or tasks consuming resources achieving goals. Now those steps could be activities or they could be experiences. There’s an incredibly important relationship between workflow and patient experience because you think about a series of experiences that are being driven by the IT. I guess some of the areas I’m really excited about is in structured messaging for example. There’s this wonderful phrase, my wife has worked within the luxury hotel industry for about three years, there’s this phrase, “The system behind the smiles.” Basically, half of customer experience is based on your interaction with that frontline staff, the half of that experience is based on things that that frontline staff have no control over. It’s the backend systems that have to work. That’s the workflow that has to work.
Structured messaging is an example of permissions, communicating, no tasks languishing. Even though the patient isn’t interacting with the structured messaging system, their customer experience or patient experience is benefited. Another area is in real time location services. Folks are adding workflow engines to all the sensory datas. If you think about the internet of things and wearable data, all this time stamp location data and it’s tracking not just where devices are, where [inaudible 00:10:35] are, but it’s also tracking the patients’ state. Which brings me to … There’s about a dozen other areas in which workflow technology is making it’s push such as speech recognition using specific workflow technology and the backend to turn sounds into database entries and to route that to the right person and do quality assurance. Anyway, the four things that I look for are …
John: Before you get into that Versus Tech made a good comment and said, “Yes. RTLS, the real time location system is a powerful workflow driver.” I think we’re just beginning that journey, right? We still need to install the hardware. We need to think about what’s the right way to do it. I think that’s interesting. It’s such a powerful technology but we’re still … We just landed on the moon and now we’re trying to figure out what to do with it, right?
Chuck: Yeah. I know. I’ve been feeding about the potential interaction between real time location tracking services and workflow engines for four or five years and within the last couple of years I’m seeing really interesting amalgams or mash ups of the RTLS and the workflow technology so that in real time we know where the bottleneck is, where the change and demand is and we can in real time send notifications to staff to do basically load leveling. The other thing is if you combine the RTLS and the workflow technology using dramatic reductions industrial engineers call cycle time, cycle time is the beginning to the end of a workflow. The beginning to the end of a patient encounter in an ambulatory office or the beginning to the end of a hospital stay or the beginning to the end of a check in or discharge process. I’m seeing folks that workflows that require four hours to discharge someone being dropped to half an hour combining real time LS and workflow technology.
John: Yeah. I saw this first hand at Sanford Health in Fargo, North Dakota. They built this new clinic and they just totally applied whatever technology they could find that made sense. They actually created kind of a Disney front of house, back of house which is it’s own unique experience, but they incorporated all this monitoring. The patient would actually room themselves and then as soon as the patient walks in, it would realize that the patient neared the room and it would notify the nurse that they were there. I forget exactly what their goal was but it was something like within a minute of the patient rooming themselves, the nurse would walk in and say, “Hey. Welcome for the visit” and then start it.
It tracked everything. They would know when the nurse went in, it would know when the doctor went in. I mean, it was just the most interesting and beautiful workflow. You could see it was the baseline of what was going to be possible. I’m sure some of the doctors and nurses were a little reticent at the beginning to say, “Do I want to be tracked like that?” The patients, “Do I want to be tracked?” It’s a powerful workflow solution I thought.
Chuck: There’s another example like that it’s around perioperative workflows. This company set up a dashboard that shows exactly where you are in a surgical workflow. There was a bit of data they needed to get that they couldn’t get from [inaudible 00:14:16] work or decided not to use that. They ended up putting a big red button on the wall at the swinging doors into the surgical suite and they basically just told everybody, “Okay. When you walk by there with the patient, just punch that button.” There were some resistant to that as you mentioned being tracked like that. Then other people were looking on the dashboard and they’re looking for that information and the other users in the workflow were going back and saying, “Hey. Darn it. Punch that button because we need to know that information.”
John: He didn’t do it.
Chuck: [inaudible 00:14:52] your life easier. That’s another good example.
John: That’s great. I actually just did, in my last lab I think was with SAP and they’re working the periops with stuff at Mercy and how they used analytics to improve it, right? Which that all goes back to what’s the workflow to get the data so you can improve the services? MedicaSoft LLC said, “It’s very beneficial when tracking flow through emergency departments to either discharge or hospital admission. The nice thing is the EDs want to get the workflow, right? Because they know how important that is.
Chuck: I’d like to mention, you mentioned SAP and you mentioned MedicaSoft. I want to highlight those folks at HIMSS that have interesting workflow angles. SAP uses a very advanced form of workflow called business process management or sometimes CBPM or hashtag BPM. Twenty years ago it was called the workflow management systems industry and now it’s called the BPM industry. There are a lot of BPM companies now at HIMSS. MedicaSoft has a really interesting blog post in which they talk about workflow engines and managing tasks in exactly … You’ve heard me talk about task management and workflow management and workflow engines now for four or five years and they have a blog post that I tweeted out and I said, “This is just such an excellent introduction to the potential use of workflow engines at the point of care.” That’s an area that healthcare really hasn’t taken advantage of as much yet as I think we will see in the next couple of years.
John: Interesting. I did not know that. I just want to remind people that we’re happy to add anyone on, if Versus Tech or MedicaSoft wants to hop on. I see Max is here. She said she’s shy but I’m sure she’d hop on. Jill, if you want to hop on, feel free to hop on. There’s a number of other people that have joined. I see FormFast is here. If any of you guys want to jump on, hop on, we’re happy to talk with you about your products and workflow. Otherwise, Chuck and I have no problem talking.
Chuck: FormFast, fantastic. I think Max Estrada is fantastic. I’m blocking on the vendor that Max is … She’ll introduce herself.
Max: Hi, I’m Max Estrada. I’m a lead consultant with Galen Healthcare.
Chuck: Galen Health. I’ve often tweeted about you guys in workflow the last couple of years.
Max: Yeah. I’m interested, Chuck, in how you see workflow technology helping at the clinic level because I think a lot of things we get into, we’re seeing … Steve has emphasized so much over quality and we see places where providers are clicking through task lists and work lists to get them done because the goal is to get it done. Where is that intersection of getting the right workflow but also getting in the quality care and not just focus on efficiency?
Chuck: You broke up there a little bit at the beginning but I think I get the gist of your question. One of the great things about workflow technology is that the workflow engine is all models of workflow. Sometimes they’re called process mats. It can present the right springing to the right person at the right time. Right now, most EHRs don’t have that technology, therefore, the user has to search around. It used to be we had to click down these menus. Now we have lots of tabs and clicking. If the system has a better understanding of the workflows, it can present the right screen at the right time and that transforms experience in this way.
If we’ve ever installed software we can just go on next, next, next, next. You’re always getting the same thing at the same spot, where you expect it. It dramatically speeds up installing software. It dramatically reduces the complexity and probably the [inaudible 00:18:48] and all that. I think that you can achieve much of … I don’t believe that doctors are really that against data input. If the data is going to benefit the patient, they’re going to help them make a decision in the future or if they’re making an order. They’re ordering something to happen, a symbol of [inaudible 00:19:11]. Most of the clicking in current electronic health records is the navigation going to try to find the screen and scroll to find the place where you enter the data. That navigation is exactly what a good workflow engine can bring to the party. Automatic navigation.
John: Chuck, are you saying that just because you’re focusing on efficiency doesn’t mean you have a reduction of quality. I think that’s my experience is that when you implement the right workflow, it makes you more efficient and can improve your quality, right? Which I think is Max’s question, right?
Chuck: You’re right. Let’s imagine that you have a workflow that’s eight steps. It starts over here, it goes over to here. Then you eliminate the steps that aren’t value added or that aren’t purposeful. A lot of those steps are navigating in the application. If you can, let’s say, eliminate four of those steps, you can now execute that workflow twice in the same amount of time using the same amount of resources. Now you’re basically doubled that’s called [inaudible 00:20:19] by producing cycle time. Here’s the thing, when you shorten the workflow, you not only double your productivity, that workflow invariably becomes more consistent.
Also, think about the opportunity cost of the … It becomes more predictable and that means that patients don’t have to wait as long because if you know exactly when the workflow is going to start because you know when the other workflows are going to end, that means that the patient doesn’t have to wait as long. Second of all, they’re not tied up in the workflow as long when you think about the opportunity costs. There’s all these things that patients would rather be doing than waiting for workflow to start or actually being in the workflow. By dramatically making the workflow more efficient than shortening it and getting rid of those steps, you dramatically improve because the number one thing that patients usually complain about is having to wait. It’s incredibly important to patient experience.
Sandy: One of the things you mentioned earlier … This is Sandy Gary, by the way, it’s MedicaSoft. I’m [inaudible 00:21:29] working with our clinical team. We have [inaudible 00:21:32] clinic, clinicians that work directly with us. One of the things we’re currently working on that’s really interesting with workflow is how they go from working with multi patients. A lot of times we have multiple patients on the ward or ED. Again, they’re trying to, as you mentioned earlier, minimize that time through the flow of [inaudible 00:21:48] and the whole process. How do we make the software so it goes from that multiple patient, boards and on tracking flows, to single patient encounters? How can you help us with that to smooth that out? Because it’s very interruption driven. It’s working with different situations.
Chuck: John asked about what I looked for. There’s four things that I look for right now and that is … I can’t go into all of them but automaticity, transparency, flexibility and improvability are the four major workflow properties that I look at in terms of whether technology [inaudible 00:22:22] to improving workflow. Transparency, that is being able to see in single view the state of all the tasks, of all the workflow, the state of all … It’s like what aircraft control towers are doing. Aircraft control towers, they see all the planes, they know how much fuel, how long they’ve been waiting, they know where to order. Yes, the pilots and the patients are safer, they land more quickly, but what you’re talking about is in logistical picture and traffic management. Transparency, being able to track all that stuff which brings you back a little bit to the RTLS stuff, but there’s other ways to getting that information. If you can infer it from [inaudible 00:23:06] activity, if you’re doing a physical exam, even though you’re not literally physically tracking the patient, you know they’re doing a physical exam. There is a way to leverage both of those.
John: Versus said actually an interesting question. They said, “How about automated data entry?” They’ve just done an implementation that automates entering the case start and case stop times in Epic Optime. What is the balance between automation of all the data entry and workflow? What’s your approach with that, Chuck?
Chuck: I’m assuming this is the question. If we can automated the data coming, for example, from medical devices, aimed at the EHR and not require a human to enter that themselves then you save someone some labor and also potential for misentry. Also, I’ve seen systems now that are verging on ambient listening. The doctor is just talking to the patient and in the background it’s just like the old days and this is being recorded, then they have scribes that are remote. That’s actually I think I believe how Augmedix is still involved in the Google Glass work program. It’s probably going to be rebranded. I believe it replaced Google Glass.
The idea is is that there it’s not automated data entry in the sense that it’s computer software, but rather what you’re doing is you’re offloading the expense of data entry from the highly expensive positioning to the less expensive scribe, but you’re using technology to do that. Those systems, the medical scribe systems, also often use sophisticated workflow management. In fact, what scribes do is way more than simply enter data. What they also do is a lot of intelligent task management. One of the things that medical scribes are doing is creating workflow management systems that are almost in a cognitive symbiosis with the medical scribes. There’s a great deal of value to that for such things as care coordination and coordinating across, continue with care, having that human in them in that manner.
John: [inaudible 00:25:39]. Max, as a consultant, you’ve probably seen a lot of different workflow technologies and we’d love to hear more from MedicaSoft. What’s your experience with workflow?
Max: I think for me it’s not as much the experiencing the technology pieces of it but more really often the disconnect between how the software was designed and what’s actually happening in clinics and how people actually work, what they need the software to do compared to what the software is designed to do. That’s where we come in a lot of times and say, “Let’s mold the software to do what you need it to do” or switch it around to make it more efficient. Some of our optimization projects, we’re looking at how long is it taking doctors to sign notes and why, how many tasks are needlessly generated when you have something already documented in the system somewhere else.
A lot of that … It’s something that it feels like we really need to pick a part of a human level sometimes because of things are done with implementation and training. Then they’re gone and you just have the help desk and people change the way they do things over time. One of the things that I’ve been thinking about a lot lately is how do we almost like a quality approach to a tier two support and maintain a connection with the clinics and ongoing training, and making sure that people understand the software is there to work for them. We want to make their lives easier not harder. We want to make the data available to accentuate patient care.
Chuck: John can attest to the fact I have talked about customizable workflow in years. That is people say we need to involve clinicians into [inaudible 00:27:43] EHR at a local system before we implement. Guess what? That system needs to be customizable in ways after it is implemented because the program is not known to workflows and that’s one of the benefits of workflow technology is that you can change the workflows and you can customize that interaction without having to send it back and getting something like Java or C sharp or Mumps program, [inaudible 00:28:07] or whatever, train people. That’s one of the values in workflow technology is that it can be customized after it’s implemented to increase usability. That was improvability in that list of four that I mentioned.
Sandy: That’s definitely some of the things that we’ve seen is to be able to customize it when you actually know what the workflow at the facility is. There’s the addition of what you see in the screen and the timing of it but also the fact that clinicians want to be able to enter that data in the context of once they’re doing the actions. While they’re in the process and in their thought process, their cognitive process, rather than having to try to document and or do it later. When you work that cognitive processing and why they’re making a decision, to be able to record why they’re making those decisions at the point they do it versus some of the older type EHRs where it’s very structured now that documentation has to be done afterwards or it drives your workflow. Those are the type of things that we’re trying to get.
Chuck: I have what I call the litmus test for frozen EHR workflow. The litmus test is that you put that little eye dropper and you drop something into the beaker in the clinical lab and it goes from red to blue. It tells you exactly the acidity level, litmus test. Of course, litmus test is just a [inaudible 00:29:22] metaphorically. Litmus test is like a single checkbox and say you got to past this test. When you are looking at the workflow of an electronic healthcare, there are some other health IT systems that clinicians have been using.
Say, “Okay. Show me your demo.” They’ll show you a sequence of screens and behavior. Then you say, “Okay. Now, I want you to change the workflow. I want you to show me the workflow editor. I want you to show me the screen that allows you so that … ” There’s this one step that we don’t do in our clinic, let’s get rid of that step. Now, if they say, “Oh, I’m sorry. We cant do that. We have to go back to the programmers.” Guess what? There’s no workflow handed. The workflow isn’t customizable. If they say, “Oh, no problem” and they can fix it on the spot, there’s a good bet that that is based on workflow technology.
Sandy: Then you need to provide the tools that allow people to do that so they can easily see that and understand it as well. That it’s not hearing in some kind of foreign language but it’s actually something that an front end user can understand and see and be able to modify.
John: I think that’s one of the biggest weaknesses I’ve seen in a lot of the healthcare IT implementations. You hear all these people complaining that it’s so awful but they haven’t invested the time it takes to customize the workflow or customize the software to meet their needs. I’m sure, Max, when they’re consulting those, all about that, is they’re probably at the breaking point when they finally come to you and say, “I need to fix this workflow.” It’s just like they’re happy to fork over a check for a bunch of money but if you say, “Hey. Spend a couple hours figuring out your workflow.” Most of them would be like, “No. That seems a bit too much.” It’s an interesting balance. No doubt consultants will have a long life in healthcare to come.
Sandy: The other part that’s interesting with that is also the maintenance of the workflow because you don’t want it to be overwhelming because it does change all the time and so it needs to be something that’s easy to change because if it’s cumbersome to make those changes and maintain it, that’s a problem as well.
John: Having a process where you actually review it regularly. There’s a post coming out on Hospital EMR and EHR about this. It’s a new series we’re doing called the Healthcare Optimization Scenes, how do you optimize your EMR, your ERP. He made some interesting points about the [inaudible 00:31:46] that people feel like that’s the end of the project when in reality it’s the middle of the project, right? You might even argue that it’s before that but it’s somewhere in the middle, right? All of the optimization of your workflow and of your processes is what you have do after the fact to get value out of the software. It looks like there’s a number of other people and they want to hop on. Out of Max or MedicaSoft, you want to switch out? We can certainly rotate people though. For example, let’s see, there’s a few questions too. Khal Rai said, “What’s your take on the role of AI in streaming workflows?” Any thoughts on AI in workflow, Chuck?
Chuck: I need to know a bit more about what he means by streaming workflows. Actually, my master’s is in artificial intelligence. I didn’t mention, I have got four degrees. In my mind, the connection is … Here, Khal Rai is coming on. Do folks remember expert systems? Expert systems, you could put a bunch of rules in it and then they would do infectious disease diagnosis. The way you customize the expertise of the expert system is by changing rules. That’s exactly the same way that workflow systems work. Workflow systems, the rules are about workflow instead of about clinical diagnosis. Two areas where you’re seeing, someone mentioned Watson here, by the way, I’m swooned with the scientist behind Watson, IBM Watson. Watson takes that data, that means the question, it breaks it apart, it combines it with a bunch of data sources and then generates a reply through a series of steps also leveraging workflow technology is based on workflow and open source workflow managing system which the name escapes me right now.
Then finally, to get back to Khal Rai’s point that asked about streaming, what I’m reminded of is Google Maps. Google now, if anybody’s on Android, and you have that turned on, it’s trying to predict what you’re going to do next and then do something useful. Focusing using machine learning in order to actually learn using deep learning. You’ve probably heard of that. They’re trying to learn the workflows and then use that learning in order to do something useful. Just like earlier I was talking about users being to be able to customize their workflow, so that the electronic health record did the right thing at the right time. Google is working on machine learning technology that makes your smartphone do the right thing at the right time. In one case, a human is editing the workflow and in the other case it’s being learned through deep learning and machine learning.
John: Yeah. I think it’s an interesting question. IBM Watson could certainly help with the workflow in business process management, but it’s so immature right now. It’ll be interesting to see how that evolves over time. That’s true for all the AI technologies out there.
Chuck: Here’s an interesting question from [inaudible 00:34:55]. A great guy [inaudible 00:34:58], thank you very much. How can we make workflow a good to have feature to go to a must have feature [inaudible 00:35:04]? I do not think so. I will give you an interesting angle on uniquely using workflow and workflow technology. I was the lead on the project for our electronic record to become CCHIT certified in 2006. It marks the first of 18. In 2004, the planning started. The early list of requirements to be a CCHIT certified included workflow engines, customizable workflow, transparent workflow and then it got eliminated for some reason.
I have mixed feelings about that because I have mixed feelings about meaningful use which it evolved out of, it competed for and it replaced CCHIT. Now I will tell you this, that is one of the reasons federal health IT panel briefly in discussions. They actually discussed adding workflow engine as a meaningful use requirement. The problem is I think they’d screw it up. I’d rather the market whether you buy a system with a meaningful workflow engine or not. Then if there are multiple systems and they used different workflow engines and they work in different ways, I would love to market to pick and move and choose the users. I don’t want to see meaningful use do the same things workflow that they already did to …
John: Yeah. There’s a huge risk in that. When I wrote about meaningful use being replaced or whatever, I said it could get worse, right? Be careful what you wish for. I think going back to that question though is should the government need to stimulate workflow technologies, my answer is no. One because how would they even define workflow technology, it’s such an impossible task. Two, if the technologies are that good, they should be good on their own. They should provide the efficiencies that you need. If they provide those efficiencies then you should want to implement them. It shouldn’t take a government incentive to actually want to improve your software technology. In fact, I am excited for the period of non meaningful use where software vendors are actually catering to the customers and implementing technologies including workflow technologies. It does benefit the patient and benefit the doctor.
Chuck: I see [inaudible 00:37:40] working on SRSsoft. In fact, I believe that’s a restaurant started out using a workflow engine on a document imaging platform. That would have been 10, 15 years ago. Now I know that you’ve mentioned that they’re introducing a new workflow engine. I’m seeing workflow engines sprouting like mushrooms in the spring and that’s a fantastic thing.
Khal: John?
John: I think we can actually hear Khal. Khal, are you there?
Khal: Can you hear me?
John: Yes. We can’t see you but we can hear you. Good enough. I mean, no one wants to see our pretty faces anyway.
Khal: You guys look awesome to me.
John: We’ll pay you later. We’ll pay you at HIMSS. Khal, you’re from SRSsoft, tell us about what you guys have been doing with workflow.
Khal: To set the context, we are in a specialty ambulatory, high volume, high transaction space. That’s what we focus on. One of the things we’ve been talking to our customers about and the market about is how do we change the dialogue on workflow? For the past 10 years we’ve been trying to automate and digitize workflow that started on paper and now it’s in digital. Now what we’re saying is what can you do in an electronic environment, in a digital environment, that you couldn’t otherwise have done when you started in paper? One of the things what we were doing now and this is something that we’re doing gradually, we’re actually working on something called smart workflow.
Essentially what it is is we know who he people are who’s using the software, we know the role that we’re dealing with and we know what kind of patient they see. What we’re trying to do is seed the system with certain protocols. Let’s say you’re seeing, I don’t know, you’re someone who does hip replacement. We setup the protocol and say here’s what you typically do when you do a hip. Guess what? If you see a patient that is in certain demographic, maybe they have diabetes, maybe they have some other conditions, you tend to change your workflow as you do that and the system adapt to you. We come back and say, “Hey listen. Every time you do hip you do that except when you see these conditions.” Should that be a workflow that the system should adapt to you?
By doing that, we’re essentially taking waste out of the system and really streamlining the way … Almost kind of the comment, the question we had, not necessarily streaming, but streamlining the way you run patients through the system by moving the provider upstream in the equation. You’re documenting as you go rather than through the process of seeing a patient, doing some clicks, doing some collection and then going and finishing up the encounter. That’s true, there’s a [inaudible 00:40:32] to get to the stage where we’re predicting the next step or two and adapting the workflow based on the patient you see and the role that you play in the encounter.
John: Are you pushing that down the stack as well to the nurses? I mean, I’ve heard a lot of people doing that, right? Where they have these nursing staff which can be facilitated dramatically in a much better way. It sounds like your [inaudible 00:40:55] technology would work well with nurses if you predict what the doctor’s going to choose so the nurses can prep those things before the doctor even arrives. Are you doing that direction as well?
Khal: You got it, John. That’s what I mean by [inaudible 00:41:06], it’s potentially what we do. Not only we are able to do that, push it downstream to the nurse or the MA, but as the different roles come in out of the equation, you almost have a calendar or summary on your right hand on your side of the screen that’s telling you what happened around you. If you come in at it from a nurse perspective, you are able to see what the front desk person’s already done or if you come in from a provider perspective, it tells you what other roles have done with their encounter and it fits what you should do next based on that equation. It’s all about what we do is we use services and the cloud on machine learning where we actually see the system with some assumptions and the system evolves and learns from it as you use it. It’s pretty fascinating. It’s very early in the process. We have some really great souls who are with us but it’s just going to change the way we do medicine.
Chuck: I got to brag. HIMSS 00, 16 years ago, I gave the first presentation on an electronic health record built on a workflow management system. There’s the link, right there. There’s the link that describes it. Everything Khal was talking about, exactly, task, tracking the task, work plans, a dashboard, an office view that you will see all of those tasks status at the same time. That technology not applied to health care has been lightly prevalent in other industries for over two decades. It is only now beginning to be used into healthcare.
I’m just so delighted and I think there is almost a pent up, a deluge, happening and that is health IT and medical informatics about 20 years ago, they came to a fork in the road and they said data is complicated and workflow is complicated, we can’t tackle both so we’re going to tackle data. A lot of what’s happening in the last two decades has become from this extremely … I mean, data is really, really important, trying to collect all this data, but really, workflow is more important. You need to figure out what your goals are, figure out what the steps in the workflow are and then figure out the data, the feedback. If all what you’re doing is collecting a bunch of data, now you have to reverse engineer the system in order to add that workflow layer.
Khal: I think you got it, John.
John: I remember some early discussions with Evan Steele, the former CEO of SRSsoft. Kind of complaining, you said, “Yeah. We’ll do [inaudible 00:43:43], because we know we have to as an EHR vendor.” You could tell it was against the principles of what he wanted to accomplish. It’s interesting that now meaningful use is matured to a point that SRSsoft could do these. I think you call them smart workflows, right Khal?
Khal: Yeah, you got it. You know what? I think now that we’re doing meaningful use and we’re collecting data, I think the fact that we’re able to exchange data in a somewhat standard way, although we’re not 100% standard. I think that’s going to elevate the discussion to having the ability to run these workflows and workflow engines that Chuck are talking about outside of your ecosystem. You don’t have to be inherently having a workflow engine that’s built on Epic or Cerner or anybody else. You can run workflows agnostic to the datas at.
Chuck: Exactly. Six months ago, I wrote 7,000 words, five part series in Healthcare IT News called Achieving Task and Workflow Interoperability in Healthcare and it’s all about how we are laying down a layer of process where workflow engine coordinated there in the cloud on top of all of these database like electronic health records. Absolutely that’s exactly what’s going to happen.
John: Welcome, FormFast. What’s your name? What do you do at FormFast?
Aaron: My name is Aaron Vaught. I’m the director of marketing here.
John: Excellent. Welcome to the conversation. Anything you want to add? Any questions you want to offer? That’s the [inaudible 00:45:22].
Aaron: I just wanted to comment that what we see a huge potential for workflow across the entire healthcare enterprise not just on the clinical side but on the administrative side as well. We offer solutions for HR, risk management, purchasing and seeing the increased adoption for those solutions as hospitals are looking for greater efficiency across the entire enterprise really. We’re really excited about the potential for workflow to transform healthcare.
Chuck: I did a webinar with you guys about three years ago, four years ago, called The Power of Process. It’s 45 minutes long. It’s on YouTube. I’ll post it in a moment. Everything he talked about because not just the clinical workflows have a tremendous impact on patient experience, these administrative workflows happen in the background, if staff can’t count on them working perfectly, then the staff is going to be mad and they’re not going to be able to do what they need to do. There are all going to be kinds of workarounds. The kind of stuff that FormFast does at the enterprise level for administrative workflows is absolutely critical for patient experience.
Aaron: Absolutely. We’re finding that as well that the way that the technology helps users adopt those workflows, the workflow technology to improve their processes, we’re finding that with our eForms capabilities that we’re mostly known as the leader in eForms. That’s a great way to start collecting data that can drive workflow with our workflow engine. It’s a familiar interface that users can use to start to improve processes.
John: Excellent. There’s a number of people that are online. There’s an open seat if you want to join. I see Michelle from Qinec. I see Mach7’s here. Experian just hopped on. There’s an extra seat if you want to hop on to ask any questions or Max, or FormFast, FormFast is on, Versus Tech, feel free to hop on. How have you seen the evolution of your technology because you really did start as the paper rolled with the forms? Where are you seeing all of your technology going in the future?
Aaron: The evolution for us was starting off with forms automation that we’re moving documents around, printing them and printing them with patient information. Our customers came to us and wanted to see if we could also automate those administrative processes with workflows. We developed a workflow engine. We developed tools to make it easy for them to design their workflow. We have a visual workflow designer, drag and drop, so that you can visualize what the workflow process is much like what Chuck was talking about before. If you can visualize, you can understand it, it’s going to be easier to see where the process can be improved. For us, it’s about finding new ways to make it easier to design the workflow, to automate the process and provide data that hospital leaders are looking for.
Chuck: This is such an incredible … I love everything, everybody said about workflow. Thank you, John, for provoking this blab on this subject at this time.
John: Definitely. It’s interesting, like you said, to see the explosion of it. I think it’s interesting FormFast perspective saying, “Okay. Let’s do more than the clinical.” I’ve heard that more and more from vendors. They’re like, “Okay. It’s nice to do the clinical. It’s nice to do the reimbursement, but there’s a whole lot more to running a healthcare organization than just that.” Sometimes I think the CIOs of healthcare organizations and then doctors, practice managers and the smaller practices, sometimes forget that technology can benefit them in more than just an EHR, PM and HIS. It’s interesting.
Aaron: We’re definitely seeing that. Of course, I’d be amiss if I didn’t plug our presence at HIMSS being in marketing, so we encourage everyone to stop by our booth at 48,49 and have a conversation with us about what your challenges are, where you’d like to see your processes automated and let us fill you in on how we can help you.
John: That’s true. I think everyone’s going to be at HIMSS, right? It seems like. That’s great. I think Chuck will be covering the workflow solutions. He’s got his hat on so he’s going to be doing one minute hat cams. I don’t know if that’s all workflow focused or are you going to go to each one, say show me your workflow the one minute or are you …
Chuck: The hat cam, what he’s talking about is every year, for the last four or five years, I use a different camera and I actually clip it to my visor and I walk around, I do one minute interviews. I ask you one question, whatever question you want. I try to find the workflow people. The only problem is when I’m walking along, people run up after me and they beg me to participate and then I have to ask them a question about the [inaudible 00:50:44] about workflow. I’ll take off my hat sometimes to avoid that. There is a question MedicaSoft asked about workflow analytics.
Sandy: That was interesting. One of the things we see is the ability to collect analytics and data as you’re doing workflows and the timing in that. I’m just wondering how much you went into that, how many products you see processing those type of things [inaudible 00:51:08] processes.
John: Looks like we lost Chuck.
Sandy: Lost him. Who’s going to answer my question?
John: When you ask hard questions, he dips and that’s just going to happen.
Chuck: You got seven minutes left here. I’ll just take two of them and I’ll answer what I think the question is and yes I am seeing workflow and I’m seeing time stamp data, just the time stamp data and electronic health record, but also coming off [inaudible 00:51:36] things and wearable devices in order to reconstruct the entire process maps. In fact, last February I gave the keynote at the Society for Health Systems Healthcare Systems Process Improvement Conference in Orlando and it was exactly about this idea of taking this time-, and it’s called process mining.
Process mining used to be called workflow mining, you can take a million data points and all you need to do is an ID for the workflow. The workflow would be a patient enters and then they leave a hospital or a clinic or whatever, then you have a series of tasks and the tasks might be check the medication or take them to surgery. Then you need a time stamp, you need a time and a date. Those three things. Then you can add other information like what the diagnosis is, demographic information, [inaudible 00:52:33]. Run that through a process mining system and you get these beautiful flowcharts that show you the bottlenecks and the rework. In fact, I’ll put a link in here at 2012.
Most of that is happening now in the medical informatics research world. If you go to med info, at AMIA, American Medical Informatics Association, the last couple of years they’re starting to see that. Although I did it first in 2012 based on internal projects in 2008. It’s coming into the health IT HIMSS side and that’s one of the areas I’m going to be looking for this year at HIMSS. Thank you for asking that question.
Sandy: Sure, thanks. Chuck, thanks.
John: Chuck, [inaudible 00:53:21] asked a question, “[inaudible 00:53:25] patient flow can healthcare benefit from workflow tech?” actually answered and he said, “We see benefits across HR, IS and supply chain workflows. All areas are making user workflow technology getting the way from manual disconnected usually paper process into a truly electronic world.” Any other areas you’d add?
Chuck: Let me … He’s jumping on. Cool. Folks have to understand is that health IT is about a quarter of the way through a fundamental architectural shift. An architecture is what, how an application is built. If you go back over the last three or four decades, a long time ago, everything was all mixed together, business logic, data, the application, didn’t talk to anything. Then they took the data out into the database. The database is living outside of the application. Then they eventually started taking out the UI. When you click on a button, that button’s not generated by the application, that’s generated by the operating system. As this happens, the application code becomes simpler and simpler and less and less.
What’s left right now inside most health IT applications is the workflow code. The workflow code is basically the if end statements, the case statements, in Mumps, in Java and there’s all these semicolons and brackets. It’s implicit in the code as opposed to explicit and outside of the application. Most industries right now, the description with the workflow, a sequence of steps in the business roles is actually represented in a database someplace. As the application runs, just like an expert in the old days, it consults this representation of workflow that allows the users to change that representation of workflow outside of the application and changes workflow behavior without having to go back and rewrite and recompile that application. That is going to alleviate so many usability, productivity, safety and interoperability problems when a program can finally make the shift from workflow oblivious, it’s going to process [inaudible 00:55:36].
John: Interesting. Max, did you have something you want to join and say or you just missed being on camera?
Max: No. You know I don’t like being on camera. When Chuck was talking, the thing that struck me is that a lot of the software systems that we’re working in today, it’s really just a replication of paperwork flow in a electronic format. I think there is, as you’re talking about a dynamic shift, I’m really curious about what would happen if providers said forget everything you know about paper and how you used to practice medicine on paper. If you want to practice medicine, what are the things you need and how do you want to do it and take that paper process out because we have different technology now?
Chuck: Relative to paper, the issue is not that we’re replicating paper processes. The issue is that once those processes are automated, we can’t change them to the way the users want them. If the users want them to replicate the use of the paper process, fine. If the users want to do something different, fine. The problem is the workflow is frozen and can’t be changed after it’s implemented. Right now, when people mirror the paper process and workflow is frozen, they blame the paper process. No, the paper process isn’t the problem. The problem is you can’t change the workflow to whatever it is that users want based on whatever workflow analytics or perhaps more informal, intuitive, let’s keep on tweaking around with this workflow until you pushing part of the system in satisfactory.
John: Excellent. I’m against the clock unfortunately, so I thought the best way to finish this since we have HIMSS just around the corner, everyone’s going to be there. If you’re interested in workflow technologies, let’s give a shout out to everyone that’s going to be at HIMSS. We’ll start with FormFast and then we’ll just rotate through. If you’re on video, you can do a video pitch. Where will we find you at HIMSS, what will they find if they come to your booth. If you don’t want to hop on video, put it in the text and I’ll read it off. Let’s start with FormFast. Where can people find you at HIMSS?
Aaron: All right. We’ll be at booth 4849. We’d like you to come by like I said and talk to us about your workflow challenges. We have a lot of fun stuff at the booths in addition to our technology, so stop by.
John: Excellent. All right, Max, is Galen Healthcare going to be at HIMSS?
Max: Absolutely. We’re going to be at booth 3273 and I’m going to be live tweeting from education sessions as well. We’re talking a lot about conversions and our new archival product and platform, so a lot more. Just follow me on Twitter and we’ll talk.
John: Yeah. This is her first HIMSS. She’s a HIMSS virgin. We’re going to make her welcome appropriately. As soon as she goes up, first tweet up and gets her first selfie, she’ll be fine. Thanks, Max. We’ll see you at HIMSS. Hey, MedicaSoft, where are we going to find you at HIMSS, what will we find?
Sandy: We will be at booth 11449. We will be showing both our electronic health record which does have a workflow engine in it as well as our personal health record. We want to see you and talk about it. Come by, drop by and see us.
John: Excellent. Thanks for joining the conversation. I appreciate it. We’ll be sure to see you at HIMSS. Looks like Mach7 joined. Looks like their camera’s not working. Does your audio work?
Mach7: Can you hear me?
John: Yup. We can hear you.
Mach7: Awesome. I don’t know why my video’s not working. I did say allow, but anyway, we’re going to be in booth 6825. I love what you said, Chuck, about the litmus test for workflow, being able to configure it and not needing an engineering degree required and that I think is really one of our strengths, our graphical user interface. Love to see you guys stop by and visit us. 6825 and see our enterprise imaging platform which includes a vendor neutral archive and workflow communication engine.
John: Nice. That’s perfect for a radiologist. I know Mach7. I spent some time with you in RSNA.
Mach7: Yeah. Absolutely.
John: Definitely. Does anyone else want to join? Versus Tech is here. I know Khal’s still here. You want to tell us where SRSsoft’s about? Let’s see. Versus Tech wrote, “Live RTS workflow demonstrations, all HIMSS long at booth number 5246.” That’s Versus Tech at booth 5246. They also have a cocktail reception Wednesday, 4 to 6pm. Come talk to patient flow with us and thanks for the great chat. Thank you. All right, anyone else who want to tell use where they’ll be at HIMSS? I see Roberta is here from HITECH Answers. She’ll be all over at HIMSS though. There’s plenty others I’m sure. Chuck, where will we find you at HIMSS?
Chuck: Everywhere. Basically, I’m probably … I have 107 companies now on my Twitter list. If you go to hit , W-A-R-E-F-L-O, no W at the end. There is a workflow HIMSS 16 Twitter list. There’s 107 member. I’m about two thirds of the way through the exhibitors. I should get through all of them. That’s probably going to be about 140. Then I’m going to sort them into priority. I will visit the ones I … MedicaSoft, I didn’t know about. I was looking at information about their workflow engine. Terrific. Mach7, love it. Radiology is one of those areas with relatively more advanced workflows. I’ll try to make it around and maybe do my one minute interviews. Periscope, maybe a product demo or two if the connectivity is up to it.
John: Excellent. Michelle Moore offered one other, , which I think must be Qinec. Qinec will be at MP65 talking about our care, pathway management and workflow. Looks like she’s from across the pond in London.
Chuck: Yes. I’d like to mention about Qinec. On their website, they are applying a longitudinal share care plan workflow management users can design the workflows. Love it. Love it. Love it. Love it.
John: Excellent. Roberta from, it used to be called HITECH Answers, sorry Roberta. I should have said, it’s Answers Media Company now. She mentioned that health IT chicks meet up Tuesday morning. It looks like it’s at 10:00, Tuesday morning’s the health IT chicks meet up. You’ll find her there. I know they have a whole [inaudible 01:02:27] hospital CIO, they have data sellers from Encore Health Resources. That’s a great meetup if you want to meet some of the most talented women in healthcare IT, that’s a great meetup as well.
I guess we’ll wrap up. I thank everyone for coming. Thanks to Chuck for facilitating this discussion and bringing so many people together. I’m actually hopping off now. I’m doing a webinar in 45 minutes. If you want to join, I think you could still sign up. It’s on the HIMSS webinar on actually why does no one notice what I’m selling at HIMSS. We’re talking about how to market at HIMSS. If that’s of interest to you, I’ll tweet it out on so you can check that out as well. We’ll be doing that webinar, Shahid and I. Thank you, Chuck, for joining us. If you want to see this video, we’ll post it on healthcarescene.com [inaudible 01:03:18] websites, find it on the Healthcare Scene YouTube channel and we’ll certainly do it again. Thanks, Chuck.
Chuck: Thank you very, very much, John.
