Top Ten Reasons EHR-BPM Tech Is Not (Yet) Widely Deployed in Healthcare

Why haven’t process-aware technologies, such as business process management (BPM), diffused faster into electronic health records (EHR) and health information technology in general?

  1. Not Invented Here-ism: Most academic and commercial BPM activity occurred, and continues to occur, outside the US, mostly in Europe.
  2. Complexity: Complicated data structures and simple workflow is complicated. Simple data structures and complicated workflow is complicated. Complicated data structures and complicated workflow (such as in EHRs) is hypercomplicated.
  3. Paradigm Shift: You pick a paradigm and then you stick with it unless you’re forced to change. Health IT initially picked a different paradigm.
  4. Lack of Competition: In other industries, where cost competition is fierce, companies are forced to adopt workflow technology to minimize cost while maximizing flexibility.
  5. Meaningful Use: EHR vendors are stretched thin addressing Meaningful Use requirements.
  6. Screens vs. Workflow: It’s easier for users to appreciate good-looking EHR screens (layout of data and controls over space) than good workflow functionality (sequences of events over time).
  7. Self-interest: Switching to new platforms is risky and threatens current revenue streams.
  8. Billing Emphases: As long as the right codes are generated to maximize revenue, nothing else matters.
  9. Skeuomorphism: Misguided attempts to model EHR user interfaces on paper medical record forms.
  10. STP (Straight-Through Processing): Traditional workflow management systems and business process management systems outside of healthcare once emphasized automating human users out of processes. They required modification to work in healthcare. (Current workflow management systems, BPM suites, and adaptive case management systems are much better in this regard).
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  1. Posted October 30, 2012 at 7:57 pm | Permalink

    Wow! This is a great summary, and all too true. Items 1, 3, 6, and 9 are probably 80% of the problem. Lately, I am beginning to think that 9 alone accounts for 30%.

    Excellent list!

  2. chuckwebster
    Posted October 30, 2012 at 8:07 pm | Permalink

    Thank you Dr. Carter.

    And for asking me the question prompting this post!



  3. Posted January 25, 2013 at 1:52 am | Permalink

    #8 (billing) = 100% of the problem.

    The systems we have were all designed around CPT and ICD-N codes.

    Even the current incentives to implement EHR’s (like much of our healthcare itself) is aligned around a poor attempt at behavioral econsomics (pay docs to use crap).

    Performance is a characteristic of a system. We have the system we built - and it is performing as built (not well - and VERY expensive).

    We can “improve” our way of this mess - but improvement is a system science - not an economic one. Like much of American logic - we’re trying to apply economic science to fix that which is broken. I wrote about this recently here:

  4. chuckwebster
    Posted January 26, 2013 at 10:21 am | Permalink

    Thank you Dan!

    “#8 (billing) = 100% of the problem.”?

    Fixing Our Health IT Mess: Are Business Models or Technology Models to Blame?

  5. Posted February 10, 2013 at 9:24 am | Permalink

    This list is pretty similar to the list of EHR issues I have been compiling although yours is more extensive.

    One more to add: conflicting needs for discrete data points (good for billing, yes, but also good for querying later to spot patient or even population-based trends) versus need for analog narrative (the way humans actually work/communicate). Current trends seem to favor the former over the latter. Can the discrete data objects be “hyperlinked” or “hash tagged” into a narrative?

  6. chuckwebster
    Posted February 10, 2013 at 10:19 am | Permalink

    Thank you VERY much for your comment, Don!

    I’d argue that the structured data (discrete) vs unstructured (analog) tension belongs under #2 in the above list.

    1) Complexity: Complicated data structures and simple workflow is complicated. Simple data structures and complicated workflow is complicated. Complicated data structures and complicated workflow (such as in EHRs) is hypercomplicated.

    It’s no coincidence that the first workflow management systems were also document image management systems. Both pictures of documents and recordings of voice are analogue in the sense you mean. Because they were “analog” BLOBs (undifferentiated bits), they were simpler to deal with, so automated workflows could be more complex. Traditional EHRs started at the other end, with complicated data structures. Therefore automated workflow was, and is, rudimentary — forcing physicians to assume the unwanted role of workflow engine. That’s what most of the clicking is, which EHR users complain about, it’s the work necessary to drag an structured document management through a series of workflow steps.

    Modern workflow management systems such as business process management suites and dynamic, or adaptive, case management systems, can do both: structured data and structured workflow. We need to migrate, invent, reinvent, rip-and-replace, workaround, etc. the current generation of structured document management systems (AKA EHRs). The better, more usable and more useful process-aware technologies are already embedded in many of the cloud-backend/mobile-frontend enterprise stacks that are the newest, new wave in the business process management industry. We need to marry the complex domain knowledge in current EHRs (both passive content and active content such as representations of workflow) with these modern technologies. And, by the way, these platforms have all kinds of social and data tech hooks that it will take traditional health IT literally decades to replicate (MUMPS anyone?).

    And yes, I’ve seen EHRs that link from generated narrative or patient reports back to the underlying data objects contributing to the narratives and reports.


    PS By the way, Don tweets at @donpancoe.

    We need to encourage Don to tweet more!

  7. Ramayya
    Posted April 8, 2015 at 4:08 pm | Permalink

    Healthcare systems are Socio-Technical Systems and not pure Business Systems as the current Economic Theories expect them to be. Hence, all the current Economy/Business-based approaches to developing EHR Systems will always kill the Quality that is paramount in Health Care.

    Further, healthcare has multiple facets- Quality, Regulations, new Knowledge that impacts the healthcare delivery, the location of the healthcare services, the locations and conditions of the healthcare receivers, etc.

    In addition, there are many primary players (patient, physician, pharmacist, lab-technician, pathologist, surgeon, nurse etc.) in the healthcare delivery workflow. The operation of the workflow is what that determines the Quality of Care and Legal/Regulatory Requirements/Specifications that these players have to conform to, not the economic/business needs that the current EMR/EHR Systems try to satisfy.

    Flying a commercial airplane full of people or conducting war are not businesses, just as Healthcare is not a business and can not be modeled using current production-oriented economic theories. Perhaps one should look at some of the EU Countries, specially Scandinavian Countries are approaching the development and implementation of EMR/EHR Systems, and the EU is pouring research funds into developing technologies and standards to support the development of these systems.

    May I therefore suggest that Concept Map of Healthcare Landscape first developed before architecting a EMR/EHR System.

    The following website is a mother load of Concept Map Information and also has a FREE Tool to develop Concept Maps–

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