My Foreword and Chapter in Business Process Management in Healthcare, Second Edition

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(Excuse my mug! It’s my current @wareFLO Twitter avatar.)

Foreword

I am delighted to write the foreword to BPM in Healthcare. Forewords traditionally deal with genesis and scope. I’ll tell you why I, an emissary from the medical informatics and health IT community, traveled to another land, that of Business Process Management (BPM). I hope to convince you that the sky is the limit when it comes to the potential scope of BPM in healthcare. And, finally, I assure you this is the right book to start you on your own exciting path to healthcare workflow technology self-discovery.

I first wrote about “Business Process Management” (BPM) in a 2004 health IT conference proceedings paper entitled EHR Workflow Management Systems: Essentials, History, Healthcare. But I’d been writing about workflow systems in healthcare since 1995. From the Journal of Subacute Care:

subacute

In 2004 I applied the Workflow Management Coalition’s (WfMC.org) Workflow Reference Model terminology to an Electronic Health Record (EHR) ambulatory patient encounter. (The Workflow Reference Model itself dates from 1994.)

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I attended my first BPM conference in 2010 (BPM in Government, which had a healthcare track). At that and many subsequent BPM (and Case Management) conferences I met many of the BPM experts and workflow professionals who co-authored many of the Future Strategies’ publications currently sitting on my own bookshelf. In particular, I’d like to thank Keith Swenson, (My Sandbox, Your Sandbox, in this volume) for answering my incessant questions and welcoming health IT colleagues to BPM venues over the years. Eventually I even became a judge in the annual BPM and Case Management excellence awards.

That’s where BPM in Healthcare comes from in my personal journey. But where is BPM in Healthcare going? The biggest big picture within which to appraise the potential for BPM to transform healthcare is The Fourth Industrial Revolution2. The Fourth Industrial Revolution (also known as Industry 4.0) is not about any individual technology, such as steam power, electrification, or computing (the first three industrial revolutions). The Fourth Industrial Revolution is not even about the Internet of Things (IoT), 3D printing, self-driving cars, artificial intelligence, or big data. It is about the interaction among all these technologies. In other words, The Fourth Industrial Revolution is not about innovative technologies, but innovative systems of technologies. It is about multiple, different, complementary, interlocking, and rapidly evolving technology sub-systems becoming part of an even larger, and way more complex, super-system, a system of systems. Wearing my systems engineering hat, I will argue that the Fourth Industrial Revolution is therefore about processes and workflows.

How do systems engineers manage system complexity? With models. Systems engineers gather data and optimize these models. These optimized models then drive system behavior. Then more data is used to optimize, and so on. In the old days, systems engineers sometimes gathered data with stopwatches and clipboards. I did exactly this, when I built simulation models of patient flow. Today, the Internet of Things and Machine Learning are reducing time scales to collect and process data down to mere seconds. And today, process-aware systems, such as BPM suites, orchestrate and choreograph system processes and workflows, potentially in seconds.

What are “process-aware” systems? These are information systems that explicitly represent, in database format, models of processes and workflows. The models are continually informed by data. The models are continually consulted when deciding what to do, say, or steer next. While process-aware systems “introspect,” they are not “aware” in a conscious sense, but rather in the sense that they can reason with these models; in real-time, in response to their environment and to exhibit intelligent behaviors that would not otherwise be possible.

Currently the industry most adept at representing work, workflow, and process explicitly, in a database, and using this data to drive, monitor, and improve process and workflow is called the Business Process Management industry. Why is BPM so relevant to creating and managing effective, efficient, flexible, and satisfying systems or systems? Because, as Wil van der Aalst, a leading BPM researcher writes, “WFM/BPM systems are often the ’spider in the web’ connecting different technologies” (and therefore different technology systems).

BPM, while not a direct descendent of early artificial intelligence research, inherits important similar characteristics. First, both distinguish between domain knowledge that is acted upon and various kinds of engines that act on, and are driven by, changing domain knowledge. Workflow engines are like expert systems specializing in workflow (warning, a very loose analogy!). Just as expert systems have reasoning engines, workflow systems have workflow engines.

Second, artificial intelligence (AI) and machine learning (ML) are critically about knowledge representation. Early AI used logic; current ML uses neural network connection strengths.

Finally, many AI systems, especially in the areas of natural language processing and computational linguistics, communicate with human users. When I say “communicate” I don’t just mean data goes in and comes out. I mean they communicate in a psychological and cognitive sense. Just as humans use language to achieve goals, so do some AI systems. Communication between humans and workflow systems is rudimentary, but real. Workflow systems represent the same kinds of things human leverage during communication: goals, intentions, plans, workflows, tasks and actions. These representations are, essentially, the user interface in many workflow systems.

To sum up, The Fourth Industrial Revolution is not about any one product, technology, or even system. It is about innovation in how multiple systems of technology come together. Process-aware technology, such as business process management, will play a key role in gluing together these systems, so they can be fast, accurate, and flexible, at scale.

You could go off and read a bunch of books about BPM. There are many excellent tomes. Then figure out how BPM and healthcare fit together. Or just keep reading this Second Edition of BPM in Healthcare.

If you are a healthcare or health IT professional interesting in healthcare workflow and BPM/workflow technology, you could start here:

References

Aalst, W. Business Process Management: A Comprehensive Survey, ISRN Software Engineering, Volume 2013 (2013), Article ID 507984, 37 pages.

Webster, C. Prepare for a Computer-Based Patient Record That Makes a Difference, Journal of Subacute Care, Vol. 1(3), 12-15, 1995. (http://ehr.bz/subacute1995)

Webster, C. EHR Workflow Management Systems: Essentials, History, Healthcare, TEPR Conference, May 19, 2004, Fort Lauderdale. (http://ehr.bz/tepr2004)

Terminology and Glossary. Winchester (UK): Workflow Management Coalition; 1994 Feb. Document No. WFMC-TC- 1011. BPM in Healthcare (2012) Future Strategies Inc., Lighthouse Point, FL. http://bpm-books.com/products/ebook-series-bpm-in-healthcare

Case Management in Industry 4.0: ACM and IoT – see chapter by Nathaniel Palmer” “http://bpm-books.com/products/best-practices-to-support-knowledge-workers-print


Free! My Book Chapter:

Marketing Intelligent BPM to Healthcare Intelligently!


@wareFLO On Periscope!

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Communication Ethics in Healthcare and Health IT

WHAT TO SAY WHEN THE WRONG THING WAS SAID

Today’s #HCLDR (Healthcare Leadership) tweetchat topic, What to Say When the Wrong Thing Was Said, hosted by @researchmatters, reminds me of a paper I wrote and presented over two decades ago (in Hong Kong!): Communication Ethics and Human-Computer Cognitive Systems. I discuss communication ethics and its relevance to designing intimate human-technology interfaces. My paper is mostly about humans using and communicating with intelligent tools, from intelligent prostheses to smart robots. In this post I retrieve some of those ideas and apply them to ethical human-to-human communication.

Communication Ethics

“Communication ethics, traditionally, involves the nature of the speaker (such as their character, good or bad), the quality of their arguments (for example, logical versus emotional appeals), and the manner in which presentation contributes to long term goals (of the individual, the community, society, religious deities, etc.) (Anderson, 1991 [in Conversations on Communication Ethics]). These dimensions interact in complex ways”

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“Consider Habermas’s (1984) ideal speech…. Communication acts within and among cognitive systems should be comprehensible (a criteria violated by intimidating technical jargon), true (violated by sincerely offered misinformation), justified (for example, not lacking proper authority or fearing repercussion), and sincere (speakers must believe their own statements). These principles can conflict, as when an utterance about a technical subject is simplified to the point of containing a degree of untruth in order to be made comprehensible to a lay person. Thus, they exist in a kind of equilibrium with each other, with circumstances attenuating the degree to which each principle is satisfied.”

Medical Ethics

“Four principles—observed during ethically convicted decision making—have been influential during the last decade in theorizing about medical ethics (Beauchamp & Childress, 1994): beneficence (provide benefits while weighing the risks), non-maleficence (avoid unnecessary harm), self-autonomy (respect the client’s wishes), and justice (such as fairly distribution benefits and burdens, respect individual rights, and adherence to morally acceptable laws). People from different cultures and religions will usually agree that these principles are to be generally respected, although different people (from different cultures or ethical traditions) will often attach different relative importance to them.”

Pragmatic Interoperability

In another series of posts (five parts! 10,000 words!) I wrote about the concept Pragmatic Interoperability. Key to pragmatic interoperability is understanding goals and actions in context, and then communicating in a cooperative fashion. Healthcare professionals are ethically required to cooperate with patients. Implicature part of the linguistic science of cooperative communication.

“We’ll start with implicature’s core principle and its four maxims.

The principle is:

“Be cooperative.”

The maxims are:

  • Be truthful/don’t say what you lack evidence for
  • Don’t say more or less than what is required
  • Be relevant
  • Avoid obscurity & ambiguity, be brief and orderly”

I think most, or all, of the above ideas are relevant to figuring out that to say next, when the wrong thing was said. I will be looking for examples during the Healthcare Leadership tweetchat.

Healthcare Leadership Tweetchat Topics

T1 Beyond classical adverse events like wrong-site surgery or incorrect medication dose, adverse communication events can also occur in healthcare. What types of troubling or harmful communication issues have you experienced that affected your care?

T2 Perceptions vary. Patients may perceive something as a problem, whereas the healthcare team just sees business as usual. How can patients help clinicians understand that perceived problems are as important as actual problems?

T3 What steps can help (quickly) establish rapport between health care practitioners and patients so that if communication goes off-track, each is better equipped to address the problem or perceived problem?

T4 If nurses or other care team members observe poor communication between a physician and patient, what is their obligation–how should they attempt to address the situation?

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Health 2.0 Fall Conference Sponsors Using Business Process Management and Workflow Engines

I searched every website of every Health 2.0 Fall Conference sponsor, 87 in all. I found three companies that emphasize Business Process Management (BPM) and/or workflow engine technology. As I am always trying to encourage more use of workflow tech in healthcare and health IT, I am writing this post to highlight these progressive Health 2.0 sponsors.

The three progressive bringers of workflow technology to healthcare and health IT are…

From the Kainos Evolve website:

(about use of Alfresco Business Process Management software: very complimentary!)

“When we set out to design our Mobile-Enabled Healthcare Platform one of the biggest decisions we made was to use Alfresco for our Business Process Management (BPM) and Electronic Content Management (ECM) services. This decision had a major impact on our product, and we’re convinced we made the right choice, so I wanted to walk you through how we made it.”

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“Workflow processes are a fundamental part of our platform. We have a number of core principles that we use to help guide us when we build product. Firstly, everything we build must be driven by the user need and all our applications must be mobile first, interoperable and extensible. eForms and Workflow is one way we make our platform extensible. We want our customers to use our tools to quickly build forms and model entire care pathways. We want them to do this independently without having to wait on features to be added to a product roadmap. But in a modern healthcare environment, traditional BPM is not enough. We need tools that are simple and easy to use, yet flexible.

customerdefined

Clinician’s behavior can not always be mapped using rigid processes. We need modern tools enabling ad-hoc tasks to be generated, dynamic processes to be modelled, simple collaboration between care providers and care recipients and analytics to measure and report on outcomes.”

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ECM and BPM are traditionally two very distinct things. When we embarked on this journey we had a very clear vision to select the best tools for the job. This meant we wanted the best ECM product and the best BPM product from the best vendor in each space. We performed two separate and distinct evaluation exercises and I fully expected to be working with two products from different vendors. But midway through our journey it became clear that Alfresco offered something unique that didn’t exist anywhere else on the market. Yes, they have two separate products – Alfresco One for ECM and Alfresco Activiti for BPM, but in combination what they have created is something greater than the sum of its parts and so unique that I don’t really recognise it as either ECM or BPM. In fact, these terms describe something that I don’t really relate with. When I see the words ECM and (especially) BPM I think complex, heavy-weight, closed. Stale. Alfresco have created something different – something simple, something light-weight, something open. Something fresh. I don’t know what the term is to describe this. It’s not ECM and its not BPM, but its definitely the future.

From the Axway website:

Axway ProcessManager Key Capabilities

Use the BPMN-based graphical modeling environment to design processes and specify attributes

ProcessManager’s graphical modeling environment is based on the Business Process Management Notation (BPMN) 1.1 standard, which allows business analysts to represent business process logic and patterns by drawing a diagram.

Business analysts can then specify the attributes for the process objects, such as:

  • Relevant communication service (e.g., OFTP 2) for an incoming order
  • Back-end integration service for processing the order in the ERP system
  • Transformation service for converting the file (e.g., EDIFACT or XML)
  • Routing mechanism

The modeled process can then be tested and refined before it is put into production.”

And from BPM Visibility Paves the Road to Operational Excellence:

Business Process Management Systems (BPMSs) are extremely powerful, as they allow process automation and offer visibility on how an organization performs in its overall value creation network.

In fact, BPMSs can also provide visibility without automating anything, simply by consolidating flows of events. For instance, probes can be used to fetch information from legacy applications and generate events, which are consolidated by a BPMS providing visibility on parts of process instances about which one has very little information. Another important usage of non-automated processes is the control of events coming from business partners, ensuring that every collaboration’s participant provides the appropriate information at the right time (and in the right format) as defined per the service level agreement.

BPMSs make many aspects visible, most notably these two: the proper state of process instances and the different variables associated with each step, such as its cost or completion time. Hence, BPMSs can help predict the future state of an organization based on its current situation. For instance, BPMSs can help identify a potential bottleneck before it arises, and can easily correct it through something called “dynamic resource re-affectation.” BPMSs can also provide real-time visibility on specific customer cases and answer important questions (e.g., “Where is my order?”), ease human work and interactions, and identify who is responsible for what and who did what. A BPMS is simultaneously the rearview mirror allowing you to understand what happened, the windshield through which you view what is about to happen, and the steering wheel empowering you to modify and adapt your course of action.”

From a review of CareCloud:

“CareCloud has an innovative workflow engine and systems architecture”

“automatic notifications when anything takes place in your medical practice with a live feed. In real time you will know when charges are posted, when a patient checks in, or if an appointment gets rescheduled”

From the CareCloud website:

Accounts Receivable Best Practices: Automated Workflow Engine

By way of context, every year for the past 6 years I have searched every single HIMSS conference exhibitor website (1400+!) for “workflow engine” or “Business Process Management” (15% in 2016!). Health IT is gradually, but ever more quickly, moving from a purely data-centric orientation to a more balanced emphasis on both data and workflow. The primary area in which this trend manifests itself is in software architecture. The best known specific terms-of-art associated with workflow technology are workflow engine, workflow management, business process management, process orchestration, and process-aware (academia), to name a few. As workflow engines and BPM become better known in healthcare and health IT, the increasing presence of these phrases on health IT conference websites is but one harbinger of a much needed transition from data-only, to data-and-workflow, emphases.

Note, workflow tech diffusion into health IT is still a bit under the radar, so to speak. Other Health 2.0 sponsors likely leverage proprietary or third-party workflow engine and process-aware technology. It just isn’t on their website! This will also change, as the sterling qualities of workflow tech — automaticity, transparent, flexibility, and improvability — increasingly become valuable competitive marketing collateral.


@wareFLO On Periscope!

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Care Innovations on Workflow Management and Telehealth

Telehealth and telemedicine have many implications and great potential for healthcare workflow management. In preparation for today’s #HITsm tweetchat, Remote Patient Monitoring: Opportunities & Challenges, hosted by Marcus Grindstaff (@magrinds), COO of Care Innovations, I looked back over that past four years and picked the juiciest tweets from @CareInnovations to highlight here. Enjoy!

Links tweeted:

The tweets themselves!

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What Is The Purpose of A Bee? Preserving Purpose In Medicine


When I heard @StorkBrian and @Paddy_Barrett were co-hosting the #HITsm tweetchat on the topic of Preserving Purpose in Medicine, the following question came to me, unbidden:

What is the purpose of a bee?

You see, Dr. Stork is an inveterate beekeeper. I’ve watched his bees on Periscope and Vine. We’ve discussed beekeeping on Blab (now replaced by Firetalk, get a “ticket” and come to our #NHITweek Firetalk immediately after the upcoming 9/30 #HITsm chat!).

Bees, hives, and honey, constitute one of the most potent collections of metaphors in all of metaphor-dom: busy as a bee, queen bee, hive mind, swarm societies, and honey has been likened to spiritual insight harvested from the ordinary!

I could go all kinds of places with this metaphor. But I will refer you to a wonderful book about work lessons we can learn from bees, called Waggle (named after the dance bees perform to communicate):

waggle-table-of-contents-promotion-page

Check out the chapter titles. Compare to the #HITsm topics. I’m sure you’ll come up with lots of cool metaphorical ideas! See you at the tweetchat!

Here are the HITsm topics!

Topic 1: When we aim to maintain purpose (in healthcare), what is that purpose exactly? What is it you? #HITsm

Topic 2: How can we as physicians work together to build more purpose for ourselves, and work with organizations to promote it? #HITsm

Topic 3: In what ways can healthcare technology work with physicians to improve the EHR experience? What would you change? #HITsm

Topic 4: What are some strategies for preserving purpose in medicine? How can we bring more compassion and caring to healthcare? #HITsm

Topic 5: Will healthcare become less effective in treating the whole person with less in-person visits & the growth of telemedicine & virtual visits? #HITsm

P.S. More about bees and beekeeping in this wonderful video from Brian!

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