The #HIMSS13 Stock Report: Meaningful Use Down, Usability Sideways, SMACWL Up, Social Through Roof

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This is not an objective account of last week’s #HIMSS13 conference in New Orleans It is quite, quite subjective. As long as you keep that in mind, I hope you find it interesting and useful.

So you can cut to whatever interests you most (and so you can tweet links to individual segments), here’s a table of contents with links to anchors.

Meaningful Use, #HIMSS13, and #EHRbacklash

First, the elephant. The phrases “Meaningful Use” and “Meaningful [X]” were everywhere. Before #HIMSS13 I searched the HIMSS conference website and counted over 40 presentations with the word “meaningful” someplace in their title or abstract. Over a hundred exhibitors self-selected the meaningful use category of product or service, second only to the HIE category.

Recently, in the non-health IT media and social media, Meaningful Use has been pilloried. See my blog posts:

In return, the pillorers have been pilloried by some in health IT media and social media.

Meaningful Use at #HIMSS13 was mostly about cheerful progress and a rosy future. But there was some defensiveness too.

That second part of the tweet, “until HIT…”, that’s me editorializing, not abstracting from the news article.

As noted, on the surface, (almost) all was cheerful and rosy. Under the surface: psychic turbulence. Private conversation with front-line physician users of EHRs and health IT technical professionals were full of concern, exasperation, mixed feelings and “We can’t go back to paper!” On the #HIMSS13 Twitter hashtag I saw declarations (for example, embedded below) about what Meaningful Use should be (or should have been from the beginning), such a Meaningful Interoperability or Meaningfully Present.

The media has been criticized for not being evidence-based in its assessment of HIT and EHR success or lack of success. But there was actual data at #HIMSS13 about declining user satisfaction with EHR usability since 2010. I tweeted the following summary slide from a survey of 4,279 physicians.

This survey received considerable play in health IT media and social media during and after #HIMSS13. Since this blog focuses on EHR and HIT workflow, I’ll quote that portion of a blog post about the survey.

“With Meaningful Use, users may have lost some of their workarounds or have new ones that they have to do, e.g. clinical visit summary that now takes 10 clicks; as a result, workflow may feel more cumbersome.”

Government and vendor reps point fingers at each other. Pundits blame, in no particular order, rapacious vendors, micro-managing bureaucrats, oblivious patients, and Luddite physicians.

That last one really rankles. It’s classic blaming the victim, in my view. And it displays remarkable misunderstanding of both Luddites and physicians. The Luddites disliked automated looms because they were *too* efficient. Automated looms increased efficiency, reduced the amount of work to be done and therefore the number of humans to be employed. In contrast, in many physicians’ view, many EHRs or *not* efficient enough. They create more work for already overworked physicians. Furthermore, the Luddites lashed out at automated looms due to their working conditions, not because of hate of technology. Ironic it is, that these automated looms, especially the famous Jacquard loom, were forerunners of modern digital computers, and therefor EHRs too!

There’s even a new hashtag, #EHRbacklash. (Click the link to search recent tweets for this hashtag.)

#EHRbacklash has been fascinating to watch since it appeared in early February. It’s worth reading The Hashtag Economy, particularly about hashtags as forms of self-expression, and reflecting on tweets search for #EHRbacklash dredges up.

Frankly, I don’t blame any of the usual culprits. And I don’t blame broken business or incentive models. I blame the technology (Fixing Our Healthcare Mess). The problem with most EHRs and much HIT, with or without meaningful use, is workflow. If this is the case, I ask, maybe EHRs need to be built on workflow management system foundations instead of document management system foundations, as most are?

Social, Mobile, Analytics, Cloud, Workflow, and Language at #HIMSS13

On to SMACWL! You may already be familiar with SMAC, for Social, Mobile, Analytics, and Cloud. Since I blog and tweet so much about Workflow and Language Technology, I’ve taken the liberty to extend SMAC to SMACWL (rhymes with “tackle”). The SLA (Six Letter Acronym) works rather nicely.


To me the single most encouraging development at this year’s HIMSS conference was an interesting reversal of fortune. In past years, educational presentations were more exciting than vendor exhibits. This year the exhibit floor was more exciting than the presentation podium. Many of these companies leverage various combinations of the SMACWL technologies. Relative to the Workflow and Language tack-ons, I walked the HIMSS13 exhibit floor with a “HatCam” clicked to a ball cap while talking to myself about workflow and language technology.

For higher resolution, but shorter videos, visit HatCam Tour 2013: I Walk The #HIMSS13 Exhibitor Hall Talking To Myself About Workflow.

Much is made of Social, Mobile, Analytics, and Cloud and their potential to disrupt and transform. It is their combination that makes them most potent. Think of the synergy between ubiquitous smartphone video cameras with ubiquitous online video services such as YouTube. Now think not just two, but four, technologies coming together in creative and seductive ways. Social, Mobile, Analytics, and Cloud aren’t just platforms, they are becoming “the” platform. This platform is giant ramjet gathering people and resources, searching for innovation, delivering it, and then releasing people and resources for more progress.

People become aware of new ideas, technologies, and initiatives through social media (forming/orientation). They sound out potential partners through debate and agreement (storming/conflict and norming/cohesion). They move from superficial activity streams (Twitter, LinkedIn, even FaceBook) to email, forums, and task/case management systems (groupware and case management). Finally, for the data and workflow that’s worth it, tasks are performed while maximizing heads-down productivity.

At each stage of the funnel, some return to earlier stages, either because they’ve achieved what they sought or because they determine achievement is not possible for a given level of personal commitment of time, money, and resources. Finally, when workflows and processes are worked out, debugged so to speak, they are institutionalized in software and hardware, becoming an invisible and taken-for-granted ambient context of support and enablement.

Unstructured data (word, tweets, sentences) and unstructured workflow (do what you want when you want) gradually compile down to more structured data (database entries and tagged textual data) and structured workflows (executed by process-aware information systems). The unstructured to structured data relies on natural language processing. The unstructured to structured workflow business process management, workflow engine, and case management systems.

The SMACWL funnel is the big-picture platform condensing out of our social, technological, and economic ether. It’s bit further along in other industries, but healthcare is not immune from its operation. I saw lots of HIMSS13 exhibit vendors who combined two, three, four, or more of these six digital enabling technologies.

From my workflow- and language-centric point of view, SMAC is much like an epidemiological “vector”, bringing language-tech (particularly the machine learning aspects of natural language processing) and workflow technology (of special interest to me) into healthcare.

#HIMSS13 Social Media Through the Roof

#HIMSS12 to #HIMSS13 Twitter statistics are impressive. If they didn’t go through the roof, they at least went through the ceiling.


Especially impressive is the almost doubling of number of actual tweeters using the #HIMSS13 hashtag, since conference attendance dipped from around 37,000 to 35,000. I think this qualifies for “going through the roof” proportionally. Then there is this interesting visual, in which I overlay tweet volume from 8AM on Monday to 2PM on Thursday.


I think the folks on social media and the folks not on social media experience different conferences. I know that as my involvement with Twitter at HIMSS has increased (now pretty much all in!), my experience has changed dramatically. It’s easy to explain to others on Twitter. All you have to say is “You know what I mean,” much harder to otherwise explain.

For me, the major change between pre-Twitter and post-Twitter HIMSS conferences is that post-Twitter HIMSS seems smaller, much more intimate and personal, like HIMSS conferences used to be. Perhaps this is because the 3,000 odd tweeters operate as a conference with a conference. The massive receptions and exhibit hall can seem so large, with familiar faces so sparse, that they can be intimidating and exhausting. In contrast, Twitter plays matchmaker (delighted to meet you, how did I miss you, follow, follow, follow…), sidewalk entertainer (I wish I has smarts/wits/speed to have tweeted that!), and real-time location system (where are you, where are the presentations, where are the products and service you’re interested in?).

By the way, from opening #HIMSS13 bell Monday at 8AM New Orleans time to closing bell Thursday at 2PM, I was the top #HIMSS13 tweeter, if you don’t count @HIMSS13 which simply retweeted tweets containing the #HIMSS13 hashtag. I barked with the big dawgs! (Tweeted with the big birds!)

I’m @EHRworkflow in the following tweets.

Qualitatively, what I wrote in #HIMSS10 Best Ever: Due in Large Part to Social Media also applies to #HIMSS13. Except for the red rose in my lapel, now I wear a camera on my head. Quantitatively? Multiple by ten! (Hmm. I wonder if that is literally true, tweet-wise.)

EHR and HIT Workflow and Usability at #HIMSS13

At every HIMSS conference I focus on workflow and usability. This year I looked at every vendors website (1200+!) and searched for and read about workflow and usability. Sometimes I found interesting material among technical documentation, such as how to edit a process definition. Sometimes it was the marketing message fascinating (”Your Workflow, Only Better!”). Then I created an entire new website to highlight and showcase the #HIMSS13 vendors who, in my view, are going in the right workflow and usability directions.

Less than ten percent of the #HIMSS13 exhibitors qualified for a POW!HIT! Profile. POW!HIT! stands for People and Organizations improving Workflow with Health Information Technology. (Yes, it intentionally evokes the POW! and HIT! during the campy Batman TV series fight scenes.) Walking the exhibit hall I stumbled across a half-a-dozen more I need to add.

I managed to attend several #HIMSS13 presentations that impressed me.

Let’s review some tweeted slides from the Care Process Management presentation first.

Take a look at the title of this blog: EHR Workflow Management Systems. Now take a look at the following slide:

The slide came from a talk about Care Process Management, which is basically a rebranding of Business Process Management in respect for clinical sensibilities.

The following is a complicated slide that you won’t be able to make out unless you click the following link to see the originally uploaded photo. I also follow with an outline based on the slide.

Above is a business slide and the pink background of the Care Process Management Layer (AKA Business Process Management Layer) doesn’t help. The originally uploaded photo is clearer. Clearer yet is the following outline of layers:

Enterprise Process Architecture and Key Components

  • Users
    • Nurse
    • Physician
    • Health Professional
  • Web/Mobile User Interfaces
    • PC
    • iPhone
    • iPad
    • Portal
    • RFID
    • Whiteboard
  • Care Process Management Capabilities
    • Business Process Management Suite (BPMS)
    • Rules/Event Engine
    • Business Intelligence (BI) Tools
    • Collaboration Messaging
    • Notifications
  • Enterprise Service Bus/Integration Engine
    • HL7 Messaging
    • Database Management
    • Entitlement
    • Real-Time Location System (RTLS)
  • Application Layer
    • Patient Registration
    • Scheduling
    • Operating Room (OR) Management
    • Electronic Medical Record (EMR)
    • Communications

Note the prominent and important presence of a Business Process Management Suite in one of the middle layers of the architectures. Also notice that a process engine (slide below) is different from an interface engine (slide above). Though they increasingly share some functionality. I talk about this during my 25 minute HatCam walk of the exhibit floor.

It was a great presentation. I encourage you to watch it online on the HIMSS website.

On to usability!

I’ve been somewhat disappointed and frustrated many discussions and debates about EHR usability. (My two masters degrees, in Industrial Engineering and Intelligent Systems, included healthcare workflow, aviation human factors, cognitive science and artificial intelligence.) This presentation about usability myths was a pleasant surprise.

The following slide, about disillusionment and frustration among users is consistent with the previously tweeted slide about user satisfaction and EHR usability ratings dropping across specialties and vendors.

The number one usability myth is that clinicians aren’t uncomfortable with technology. If you’ll excuse me, that is a complete load of tripe. Physicians aren’t Luddites. As noted earlier, Luddites disliked looms because they were so efficient. Physicians who criticize EHRs usually do so because EHRs aren’t efficient enough.

No, current HIT technology doesn’t fit the way health providers think and work. I have written extensively about this (pick a post, almost any post, on this blog). A good place to start is a blog post about my five workflow usability principles: naturalness, consistency, relevancy, supportiveness, and flexibility.

I’ve also written about the second myth, that clinicians want everything on one screen. As I discuss in The Cognitive Psychology of EHR/EMR Usability and Workflow, Fitts’ Law (larger targets are more easily, quickly, and accurately hit) and Hick’s Law (the fewer the alternatives to the correct choice, the better) dictate just a few large targets across more than one screen. Smartphones are a good example of this. They chain two or three screens in workflows that do what the user needs to do.

The presentation emphasized, on more than one slide with respect to more than on usability myth, the importance of getting workflow right. Now, I would take this observation one step further. If the problem with EHRs and HIT is workflow, why not use workflow technology? If your interest is piqued, check out Contextual Usability, My Apple iPad, and Process-Aware Clinical Groupware.

Related to the problem with trying to put too much data and order entry options on one screen, is trying to stuff an EHR with too many features and functions. These bells and whistles get in the way of ease-of-use. This is the biggest detrimental consequence of Meaningful Use on EHR design. There is nothing necessarily unnatural about a physician or other clinical staff using using an EHR. However, if there is too much data, too many order entry options on too many screens, EHR use becomes very unnatural indeed. Meaningful Use has crammed to many features and functions into EHRs too quickly for designers to figure out how to make them usable and users to train to use them. I write about this in Fixing Our Health IT Mess.

This is a very good point. Since mobile devices have smaller screens, the need to be very selective about what goes on each screen is even more important. Interestingly, the success of smartphones and tablets are influencing both website and desktop application design. I actually looked at every website of every vendor exhibiting at HIMSS, as part of creating my POW!HIT! directory (People and Organizations improving Workflow with Health Information Technology, housed at Many #HIMSS13 exhibitors has websites that looked like they fit nicely on smartphones and tablets.

It’s true that allowing clinicians to customize screens usually won’t make them happy. What they really want to customize is workflow, or at least screen flow. And you can’t do this unless you’ve got a workflow engine executing process definitions, spanning data and order entry screens, editable by a human clinician who doesn’t have to be a programmer. Check out Can Healthcare Really Have Both Consistent and Flexible Information Systems?.

I absolutely agree with this slide, except I’d replace the words “information architecture for user workflow” with “workflow management system executing process definitions based on user workflow.”

Again, I agree with the following slide. Usability is more than a subjective experience. It reflects, at the very least, the fit between EHR workflow and user workflow. And, again, if the problem is workflow, then maybe we should use workflow technology to build EHRs?

One more usability myth: Usability Stifles Innovation. I agree this is a myth. But the cause and effect is reversed. Innovation drives and creates usability, not the other way around. I write about this in Efficient and Moral Market-driven EMR and EHR Usability Innovation.

There’s a another couple usability myths, but I am running out of steam! These were a great couple of presentations. One was about workflow technology and the other was about usability and workflow. They were fascinating to attend, one right after another!

This year’s HIMSS13 conference confirms trends I’ve writing about, and tweeting about, for years, the need for, and actual diffusion of, true workflow technology into healthcare. Workflow tech professionals call this business process management, which, apparently, needs to be rebranded because “business” not a welcome word in some clinical venues. Perhaps healthcare will be more comfortable calling these case management systems, since that overlaps with BPM and even derives is name from early clinical and social case management terminology. BPM researchers call these systems “process-aware” as in process-aware information systems (PAISs). If you are interested in learning more, I’ve got a couple of excellent interviews with world experts on workflow, BPM, and process-aware tech and its relevance to healthcare. If you got this far, you might as well read them!

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