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

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You may not agree with me that Health IT is a mess. Check out my sentiment analysis of Twitter’s reaction to the New York Times coverage of the recent RAND report. You’ll at least agree that many people do agree with me.

That said, reasons offered for the mess are all over the map. You can read my summary. I’ll focus on one defense of Health IT: It’s the business model, not the technology. Sometimes it’s put differently, as in: It’s the incentive model, not the technology. But business models are all about incentives: to create a business, to sustain a business, to do business with a business.

So, to those who say it’s the business model, not the technology, I say the opposite: It is, in fact, the technology model, not the business model.


I’m a fan of business and models. I understand the importance of financial incentives to mold behavior. I have degrees in accountancy and industrial engineering, the spiritual homes of cost, revenue, and profit engineering and performance-based incentive systems.

But, no matter how much you persuade, pay, or punish frozen workflows, they won’t change. You have to unfreeze the workflows, change them, and then refreeze them. Most current EHR and health IT systems have relatively frozen workflows. They don’t have the necessary innards: workflow engines, process definitions, graphical editors, or similar means to achieve similar ends. Process-aware systems include workflow management systems, business process management and adaptive case management. Executable and malleable workflow is what these systems do. It’s the opposite state of affairs in the EHR and health IT world.

The problems of Meaningful Use are entirely predictable through the lens of the infamous Iron Triangle anti-pattern of software development. Attempting to bring too many features to market too soon usually results in unstable, less usable, and hard to maintain software.

Wait, you say. Why can’t we add resources? You can. Up to a point. At the beginning of a software project, adding the right programmer or two can be helpful. The problem is, as the number of personnel grows, you run into Fred Brooks’ most enduring law: “Adding manpower to a late software project makes it later.”

There is no way out of the Iron Triangle. You can only make it bigger. It should be renamed the Carbon Nanotube Triangle (strongest, lightest material known). You can change the triangle’s shape by shifting emphases among features, schedule, and resources. And you can change its size through technological innovation. So far we’ve been trying to do the former, mostly via stakeholders asking, begging, demanding that we slow down. Some innovators nibble at the problem, creating workarounds and crafting end-runs: EHR-lite, EHR-extenders, mEHR etc.

The only way to increase the size of the Iron Triangle (to deliver more and better features sooner) is to change what economists call the “factors of production”. In this case the factors are the software technologies we use to attempt to meet the requirements of Meaningful Use.

Most EHRs are based on structured documents represented in relational databases. What do users of Meaningful Use certified EHRs complain about? Workflow! It’s the wrong workflow. It’s laborious workflow. The workflow doesn’t fit their specialty or special needs. The workflow can’t be changed. The workflow slows them down.

Well? If the problem is workflow and we aren’t using workflow technology, maybe we should use workflow technology? This seems so obvious that one must ask: Why hasn’t it already happened? I cover that in Top Ten Reasons EHR-BPM Tech Is Not (Yet) Widely Deployed in Healthcare.

To expand the Iron Triangle we need to move from structured document management systems to structured workflow management systems. Workflow management systems have been widely used in other industries since the mid-nineties. With improvements and complementary technology (business activity monitoring, process mining, simulation, graphical editors, adaptive and adaptable workflows) workflow management became business process management and adaptive case management.

I do agree that even malleable systems won’t change and improve unless they are caused to do so by outside forces. Business and incentive models play a role here. But frozen systems won’t change even in the face of those outside forces. Our current workflows can’t change because they aren’t modeled, reasoned about, executed, tracked and improved. EHR workflows are frozen. We need to unfreeze these workflows to, if not escape from Iron Triangle, at least expand it to accommodate our goals and needs.

To those who say it’s the business model, not the technology, I say the opposite: It’s the technology model, not the business model.

It’s worth quoting from a recent interview (Could Dutch Computer Scientist Wil van der Aalst Save U.S. Healthcare 600 Billion Dollars?) with a business process management researcher.


Are there process-aware aspects of the world we take for granted in our daily lives? (products we buy made possible by process-aware factory automation, smart consumer-facing web services, stuff that happens we don’t think about until there is a glitch). Headlines are full of “mobile”, “cloud”, “social”, and “bigdata”. Does “process-awareness” not get the awareness it deserves?


“Processes are of course everywhere. When you rent a car, book a flight, buy a book, file a tax declaration, or transfer money there are process-aware information systems making this possible. Processes are as essential as data, but less tangible. Moreover, process support is much more difficult than managing data. Indeed it should get much more attention. The problem is of course that processes have always been there, while “big data”, “mobile computing” and “clouds” are perceived as something new.”

It’s a great interview. The rest of it is healthcare specific.

Process-aware information systems are widely prevalent outside healthcare. Ironically, the very cloud, mobile, social, and data technologies that health IT looks toward importing into healthcare rely on process-aware technologies. For example, when innovators look to cloud and mobile for EHR alternatives, workarounds, and wrappers, they also get the process-aware technology that makes cloud and mobile workable. Secure, flexible, scalable, context- and process-aware cloud-based backends will be key to secure, flexible, scalable, context- and process-aware front-end mobile apps used by patients and healthcare providers. There’s more about this in my Attending AWS re: Invent, Amazon Web Services’ First Global Customer and Partner Conference: What’s The Healthcare Angle? BPM vendors are further along than HIT vendors in use of cloud, mobile, and social technology. So: cloud, mobile, and social will be important “vectors” for transport of BPM’s process-aware ideas and technologies into healthcare.

Social and data tech will play supporting roles too, but that is another entire blog post. Maybe two! And language tech and workflow tech also have fascinating connections to each other.

What’s to be done?


  1. Business process management (BPM) and adaptive case management (ACM) vendors are eager to partner with healthcare organizations and vendors. Many already do substantial healthcare business, though usually not at the point-of-care (yet).
  2. EHR users are restive, increasingly critical of the workflow-challenged systems they feel forced or bribed to use. Their professional organizations ask whether too much has been attempted too soon and with inadequate technology.
  3. Some EHR and HIT vendors have more customizable workflows than others. They may not think of themselves as EHR workflow management systems or even EHR business process management systems, but in effect they are becoming so.


  1. Educate EHR users and HIT buyers so they can recognize systems with the more customizable workflows.
  2. Find and market the EHR and HIT vendors with the right stuff: workflow engines, process definitions, graphical editors, plus other valuable BPM-like and -compatible products and services.
  3. Leverage existing business process management and adaptive case management vendor products and services.

Yes, this threatens status quo. Good. Cloud, mobile, social, and data already do. Why not add process-aware technology to the mix?

I said it before: twice. But I’ll say it again:

It’s the technology model, not the business model.

P.S. I’ll be at the upcoming HIMSS13 conference in New Orleans. I’d love to network with like-minded health IT folks about bringing more process-aware information systems to healthcare. You can contact me through this blog or tweet me at @EHRworkflow.

P.S.S. If you are interested in further related reading about the benefits of workflow technology in healthcare….

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  1. Posted February 13, 2013 at 8:22 am | Permalink

    I disagree that the problem hasn’t been caused by the totally broken incentive system in the US Healthcare market- in my opinion the main problems have been caused by the separation of the consumer/patient, the provider, and the payer, which itself is caused by government regulations and taxation (specifically the lack of taxation on employee health insurance). Specifically whose job is it to ensure the system remains “modern” and adapts to consumers changing habits and demands? Who is responsible for eliminating waste and (often life threatening) inefficiencies in the system? Once the payer and the provider are the same (or more aligned) I believe we’ll see much speedier adoption of new technologies, and thankfully that moment seems to be approaching very quickly!

    As an aside, I was in a working group at a local health IT event tasked with helping to fix a “problem” with the current system. The problem I was assigned was “churn”, which is supposedly a problem because insurers need to keep you (trap you?) as a customer for a certain number of years in order to make a profit from you. Recommendations were mostly on the government regulation side (as in: force people to stay or guarantee a certain amount of people over a period of time) As someone who comes from a non-healthcare business the entire idea of churn is a perfect illustration of how broken healthcare is: the way normal businesses prevent “churn” is by ensuring that customers are getting good service (that they actually want/need) at a reasonable price. If you can’t deliver those items, then it’s probably best for you to go work for someone else who can.

    …I’d love to meet up at HIMSS to talk tech/BPM and healthcare. You have my e-mail, let me know when a good time would be.

  2. chuckwebster
    Posted February 13, 2013 at 9:02 am | Permalink

    I agree healthcare’s incentives and business models are broken. I agree many healthcare problems are caused by broken incentives. I don’t agree that EHR and HIT are failing due to broken incentives.

    One of the advantages of process-aware business process management-style health information systems and EHRs, is they can be quickly adapted to changing incentives and regulations. If we could change healthcare’s incentives and business models tomorrow, current EHR and HIT systems could not easily adapt into newly optimized configurations and workflows. We are cementing into place frozen workflows that will resist systematic improvement for years to come.

    Even after we improve healthcare’s business models, even after we connect applications so they can speak to each other, we won’t have good ways to tell them what, when, and how. We’ve no ways to represent (and edit and improve) healthcare workflow so it can be designed and executed without need for programmers who don’t understand it. Today, ‘workflow’ is spread throughout the implementation code of every EHR and HIT application involved in this workflow. EHR and HIT-mediated interactions, inside hospitals and clinics and outside with patients and payers, are fragile, prone to ambiguity, don’t cross organizational boundaries well, and scale badly. The more we automate healthcare workflow with current non-process-aware technology and the more participants who join the fray, the more static healthcare workflow becomes and the harder it is to propagate change and new players into these workflows.

    Yes! I’ll contact you by email so we can talk shop at #HIMSS13.

  3. Posted February 20, 2013 at 11:22 am | Permalink

    I read with great interest your analysis on the sad affairs of the healthcare IT domain.
    Being involved as a physician with a degree in computer sciences with both vendors developing EHR technology and hospitals implementing it for many years I would like to add another layer on top of the famous “Iron Triangle” of project management that you have so eloquently discussed in your blog.
    Realizing clinicians and informaticists, two highly educated groups of professionals do not speak the same language, do not have a clear and proven methodology and don’t have a set of tools to help them communicate - I wrote and recently published a book on the subject: EHR Systems Analysis of the Medications Domain

    Hopefully it will clarify to both clinicians and IT: the workflows - Data in Motion as well as the structured models of Data at Rest - two crucial ingredients of any information system.

  4. chuckwebster
    Posted February 20, 2013 at 11:37 am | Permalink

    Thank you Dr. Scarlet,

    I believe I reviewed several chapters from your book last year: Excellent.

    I so liked the phrases “Data at Rest” and “Data in Motion” that I Googled it. There’s also “Data in Use”!

    Very nice!

    A common language between informatics and clinical types is an issue.

    Part of the solution will likely be more domain-specific programming languages and development environments.

    And part of the solution will be to move from “Do-by-Designing” (design a system, then use it) to “Design-by-Using” (the design of a system emerges out of use, sort of like, by analogy, universities pave the paths student create in the grass.

    There are developments in process-aware information systems research and design relevant to both of these directions.

    Thank you for your comment and I hope you come back to again!


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