Meaningful Use, Workflow Burdens, and the “Broken Iron Triangle” Software Development Anti-Pattern

Process-aware information systemsworkflow management systems, business process management, and adaptive case management — are relevant to meaningful use. The relevance deserves a longer blog post than this. But I can’t resist reposting a Google Plus comment I made to Brian Ahier’s G+ post What It Will Take To Achieve The As-Yet-Unfulfilled Promises Of Health Information Technology about a Health Affairs article of the same name.



I usually tweet links to comments, but cannot, for the life of me, figure out how to tweet a link to a Google Plus comment. Apparently, unlike tweets, they cannot be embedded elsewhere (yet), such as in a blog. Here’s an example of an embedded tweet. In fact, thank you to Vince for tweeting it in the first place, otherwise I would not have known about the Google Plus post and its several dozen comments.

So I took a look and was impressed by Dr. Stanley’s and Dr. Vaughn’s comments. I Googled around and found the quote (below) about effects of “poor planning” and “meaningful use” on “software tweaks” and “workflow burden”. Since this blog is, substantially, about eliminating workflow burdens via tweaking software (editing workflow definitions executed by workflow engines), well, I could no longer resist Google Plus.

But I’ll plagiarize myself, repost the comment here, and tweet it. (Sigh: Sometimes it seems like even my workarounds have workarounds.)

The context is this. A couple of folks from the RAND Corporation followed up a 2005 RAND study that predicted “widespread adoption of health information technology could eventually save the United States more than $81 billion annually by improving the delivery and efficiency of health care.”

From Brian’s excellent summary:

“‘The failure of health information technology to quickly deliver on its promise is not caused by its lack of potential, but rather because of the shortcomings in the design of the IT systems that are currently in place,’ said Dr. Art Kellermann, the study’s senior author and the Paul O’Neill Alcoa Chair in Policy Analysis at RAND, a nonprofit research organization.

‘We believe the productivity gains of health information technology are being delayed by the slow pace of adoption and the failure of many providers to make the process changes needed to realize the potential,’ Kellermann said.”


  • Predicted savings of $81 billion
  • “shortcomings in the design of the IT systems that are currently in place”
  • “failure of many providers to make the process changes needed”

Elsewhere I have argued that current structured-document-based EHRs aren’t up to the task of creating the natural, consistent, supportive, relevant, and flexible workflows we need to transform healthcare (on the scale addressed by RAND’s 2005 report). I could include a few more links here, but, actually, you can chose a blog post at random from the right side of this blog, under “EHR Workflow” (well, maybe not The Twelve Days of EMR Beta Testing, gotta recategorize that!). Instead, we need structured-workflow-based EHRs, built on modern workflow management systems, business process management suites, and adaptive case management foundations. (Natural language processing too! There are fascinating connections between workflow and language.)

Anyway, here’s my Google Plus comment (my first ever, by the way):

“What should be a robust market for reducing administrative costs, the authors write, has been skewed a bit by poor planning in the rush to meet federal meaningful use deadlines, resulting in the need for repeated investment in software tweaks and workflow burdens for some doctors and nurses.”

A long list of features + a series of hard deadlines = recipe for unstable, difficult to use and maintain software. It’s the Iron Triangle anti-pattern of software development. (and lots of hits elsewhere)

This part of the RAND report, albeit reported second hand, rings true to me. The only part I disagree with: “a bit.”

Platitudes? Agreed with by everyone in health IT, even on the outskirts? Not this part. (Are we even talking about the same report?)

Some of the other comments about the 2013 RAND report indicate it just restates the obvious. As you can tell from the last line in my comment, I disagree. At least the paragraph “What should be a robust market…” (admittedly second-hand and somewhat out of context) touches on a real problem. There is no “robust market for reducing administrative costs” and “poor planning” and “meaningful use” are part of the problem.

I don’t think this is a widely held view in health IT (though I think it is gaining mindshare). So the recent RAND report is tacking into a multibillion-dollar headwind to make this argument. For that, I congratulate Kellermann and O’Neill for their effort.

I might have to actually walk a couple blocks, to the Library of Congress, and read it!

Addendum (1/10/13)

Check out tomorrow’s New York Times article on this subject.

Addendum (1/22/13)

My blog post: Twitter Reacts to New York Times’ “In Second Look, Few Savings From Digital Health Records”: An Informal Sentiment Analysis

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