I’m Participating in a Panel On the Future of Mobile and BPM at Appian World

(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.

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

  • @appian Of course!
  • @DarylPlummer Daryl Plummer, Managing VP & Fellow, Gartner
  • @mrappian Malcolm Ross, VP of Product Marketing, Appian
  • @neilwd Neil Ward-Dutton, Research Director, MWD Advisors
  • @suvajitgupta Suvajit Gupta, VP of Development, Appian
  • @shrikantektare Architect, Appian
  • @eskenazi Jem Eskenazi, Director, IT, European Bank for Reconstruction & Development (EBRD)
  • @tdurso Tony Durso, VP of Solutions Consulting, Appian
  • @achalaugustine Achal Augustine, IT Manager, Flowserve
  • @wareFLO Chuck Webster, Google Glass Explorer and President EHR Workflow Inc.
  • @AppianCTO Michael Beckley, CTO & Co-Founder, Appian
  • @medhatgalal Medhat Galal, VP of Enablement, Appian
  • @BrianMatsubara Brian Matsubara, Head of Global Technology Alliances, Amazon Web Services (AWS)
  • @dalkev Kevin Dalley, Business Process and IT Director, Punch Taverns
  • @robertherjavec Shark Tank
  • @sriraj79 Sriraj Rajaram, Senior Director, Practice Lead – BPM, Cognizant Technology Solutions
  • @shomaker Brett Shomaker, Principal Program Manager, Appian
  • @jedfonner Jed Fonner, Director of Center of Excellence, Appian
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Out Of The Health IT Tar Pit: My Comments on A Robust Health Data Infrastructure

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.

Here is the proposed architecture for exchange of information.


Figure 1: JASON’s proposed software architecture
for exchange of health 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.

I’ll quote extensively from the JASON report, but I’ll relegate most of that to a later post in this series, so as to not interrupt, well, me. You’ll also find there a number of other quotes, from another paper 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 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 will 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 management 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.

The rest of the blog posts in this series will propose how to do so. I’ll also deal with some obvious, and not so obvious, objections to the simplified picture of healthcare workflow tech I’ve painted in this introductory blog post.

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Day Two of Healthcare Business Intelligence Forum: Show Me More Workflow

I’m back for day two of the Healthcare Business Intelligence Forum in Washington DC! Here’s my report from Day One. I’m looking for even more workflow tech, and I find it.

Below is the venue, from the view of the stage, about a half hour before festivities begin.

Fantastic presentation by Glenn Steele MD of Geisinger Health.

Refer to the following tweeted link for an overview.

What I want to focus on is the idea that healthcare value and cost are not necessarily positively correlated. In fact, the opposite is true. The great thing about this is that it brings physicians on board relative to reducing cost as a path to increase value to patients.

So, how is it possible to reduce cost to increase value? Value Reengineering and then scaling and generalizing.

So, where’s the workflow tech? It’s under the hood. In fact, I happen to have a slide from a presentation given by the CIO (I believe) from Geisinger Health two years ago a National Library of Medicine. (It was sitting in a draft blog post I didn’t finish).

For me, the two best presentations were this one from Glenn Steele, MD and from Ray Hess yesterday. In both cases, the results of applying business intelligence to healthcare workflows were remarkable. And in both cases I happen to know they’re workflow automation, AKA BPM (Business Process Management) under the hood!

I enjoyed this presentation about the need to decrease healthcare data Semantic Incongruity — especially since it was an excuse to tweet a link to my From Syntactic & Semantic To Pragmatic Interoperability In Healthcare. My general point is basically that workflow tech can compensate for problems at the syntactic (transport) and semantic (meaning) layers. Workflow, or pragmatic, interoperability is the degree to which actual effect of a message matches its intended effect.

Issues regarding cost accounting systems have came up frequently. And here it is again. Activity-based costing is a form of micro-costing that can more accurately assign costs to specific healthcare workflows, such as an appendectomy. For a variety of technical reasons I won’t go in here (except to note I’m the only premed-accy major I’ve ever heard of) there’s a really great fit between ABC and workflow tech. In fact, I’d go as far as to say ABC won’t be practical without workflow tech. But that’s another blog post.

Now, finally, back to a bit of humor. Gus Venditto, emceeing the Healthcare BI Forum, mentioned me as a “Twitter Celebrity” so I just had to capture the moment using Google Glass. I grabbed 9 seconds and uploaded it on the spot.

This year’s Healthcare Business Intelligence Forum was a great conference!

I’ll be back!

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Day One of Healthcare Business Intelligence Forum: Show Me The Workflow

I am delighted to be attending the Healthcare Business Intelligence Forum here in DC. As usual, Industrial Engineer/MD that I am, I looked for workflow tech.

That’s an old tweet, from the recent HIMSS14 conference. But it’s a fitting start of this blog post.

I’ve written a lot about the workflow technologies necessary to support care coordination, so my ears perked up at the above reference to secret sauce.

If care coordination is the secret sauce of population health management and if (as I argue) workflow automation is the secret sauce of care coordination, then isn’t workflow automation the secret sauce of the secret sauce of health population management? I certainly believe it is.

Above reminds me of a complaint about EHRs. They have the data but they don’t help users do what they need to do NEXT. Managing population health means taking that data and turning it into actions at the point of care. And that’s what workflow tech does.

More examples of workflow automation style task management: populating work lists and alerting users to actions needing to be taken.

Now what I find so interesting about this slide is the way in which “care coordination” clearly occurs outside of the EHR. This too bad, but unfortunately it’s the situation today. I read recently that almost a half a billion of investment money has gone into care coordination companies during the last couple years. Some are leveraging the kind of workflow management tech I’m looking for evidence of here at the conference.

Again this tweet echoes the previous one about NOW, NEXT, LATER. Workflow tech reminds you to do something you told it to remind you about a month ago. Actually, if you set up the workflow definitions right, it can figure out what it needs to remind you about when and where without you explicitly telling it to do so! Saves a lot of work that way.

BREAKING: workflow! :)

I walk around with Google Glass at health IT conferences and conduct what I call One-Minute Interviews. There’s just one question and I upload and tweet on the conference hashtag literally on the spot.

In the following video Christina remarks that one of the presentations emphasized that traditional business intelligence (dashboards, reports) is not enough. Business intelligence has to reflect, and in turn drive, actual, executable workflows. This approach is called Business Process Management, or BPM (though in a medical context, search engines sometimes think it means Beats Per Minute). I maintain an entire blog on Healthcare BPM.

It’s great to see a rep from a BPM vendor, especially Appian, at a health IT conference!

This tweet also echoes an earlier one about not knowing the true cost of healthcare. Which is another way of saying we don’t know the true cost of healthcare workflows. Well, healthcare workflow is made up of tasks. The most expensive resources to accomplish these tasks are people. And we don’t know how long which people spend on which tasks (see, I told you I’m an Industrial Engineer). And (I know, that’s the second “and”), I don’t think we’ll be able estimate the costs of these workflows without workflow technology to automatically measure these durations. Healthcare cost accounting systems are hobbled by lack of input from time stamped data about resources used to accomplish specific workflow tasks. See: Show me the workflow tech!

Rogers Diffusion of Innovation Curve was used to explain adoption of EHR tech. But I include it here because it also describes diffusion of workflow tech into healthcare.

By the way, the rest of the tweeted slides in this blog post are quite geeky. You have been warned.

Interesting: Core Applications and Workflow/Automation…

If you look up what this means (in the small print on the next slide), it “orchestrates execution of the activities of care coordination.” Wow! That sounds pretty important. In fact, this is the secret sauce of the secret sauce angle I riffed on earlier.

The above “marketecture” is sufficiently important that I’m not satisfied with its resolution (in other words, I can’t read the small print!). So here is the original photo. There are five main components.

  1. Connectivity, Security and Interoperability (dark blue line)
  2. Data Integration and Management in purple (including a Natural Language Processing inset in red)
  3. Data Analytics and Content in yellow
  4. Core Applications and Workflow/Automation in green
  5. Physician/Patient Engagement in red

My point here is to highlight the importance of workflow automation to the entire scheme. If you look up #4, here is what the small print says: Core Applications and Workflow/Automation: Orchestrates the execution of activities that constitute the care continuum, gathering contextual information from the transactional systems as well as the data warehouse.

Anyway, the first day of the Healthcare Business Intelligence Forum was just great. I’m seeing exactly what I hoped to see: workflow automation closing the loop from clinical and financial data back to executable workflows at the point of care. Exactly where is should be.

I’m looking forward to more of the same tomorrow, the second and closing day of the Healthcare Business Intelligence Forum!

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Complex Event Processing, Business Intelligence, and Business Process Management From Siemens Healthcare

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 tweeted about them 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!

“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.


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!

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