9.5 Theses For A New Healthcare Workflow Ecosystem

(Get my whitepaper! Why Process-Aware BPM is Key to Health Plan IT Agility, Integration, and Transparency!)

I was going to write a blog post for the upcoming AHIP Institute (June 3-5 in Nashville) titled “10 Reasons Why Health Plans Need to Double Down on Modern Business Process Management!” (and I still might!). But then this week’s #HITsm (Health IT Social Media) tweet chat topics were posted. I’d been thinking of writing a workflow version of the recent 95 Theses for a New Health Ecosystem, so I did, tho scaled down due lack of time (certainly not lack of ideas or ambition). :)


By the way, AHIP stands for America’s Health Insurance Plans. As I usually do before a conference with a substantial health IT component, I search every exhibitor website for evidence of workflow technology. The good news is that health payer IT is a hotbed for the kind of customizable workflow, process-aware BPM (Business Process Management) style tech I advocate. As healthcare increasingly integrates clinical and financial IT system, a task for which BPM is ideal, health payer IT is a major route for diffusion of workflow tech into health IT and healthcare.

1. Thou shalt not be enslaved and oppressed by your Health IT workflows.

Users of health IT, from clinical staff to patients to health plan employees, need to own their workflow. What could I possibly mean by “own workflow”? How can we make it possible that patients, physicians, the intended beneficiaries and users of these IT systems, should own their own workflows?


Use workflow technology. Draw workflows in workflow editors. The results are both executable by workflow engines and understandable by non-programmers. Some of these systems look like traditional workflow diagrams, such as produced by Visio. If you don’t think non-programming users of these systems can understand workflow diagrams (many can, in my experience), then there are systems that present simplified, but still usefully editable, workflow.

What if patients, physicians, and other health IT users don’t want to click or touch anything during design? BPM (Business Process Management) systems can be changed, even implemented, a magnitude faster than traditional health IT system. Analysts (business and clinical) can quickly iterate through a series of workflow designs, until converging on workflow satisfactory to patients, physicians, and staff. In either case, super-users creating super workflows, or healthcare organization analysts doing the same in close coordination with users — break the workflow monopoly that has been imposed on us by workflow-oblivious legacy health IT.

2. Thou shalt not force fit clinical and financial workflow into workflows dictated by workflow-oblivious health IT systems.

Most current health IT systems have relatively frozen workflows. They have no means to use workflow execution context (”enactment” in BPM parlance) to intelligently decide at run-time what and how to paint content on each screen and which screens to present in which order based on user who-what-why-when-where-how context.

Square Peg in a Round Hole_0565

Structured-workflow-based IT systems, AKA modern Business Process Management work/flow platforms have exactly this means. Combining this means with usability engineering and appropriate governance promises more systematically improvable health IT workflow and usability.

3. Thou shalt not confuse healthcare workflow with workflow technology.

You wouldn’t confuse your baseball card collection with the Microsoft Access database management system you use to manage it. Or your patients with your EHR. Or your health plan members with your membership management system. But people, especially in healthcare, confuse workflows with workflow management systems all the time.


Workflow is what actually happens when work is done. It is a series of steps, or tasks, that consume resources (money, time, effort, attention), and achieve one or more goals. Virtually all purposeful activity involves workflow.

Workflow technology, on the other hand, has some sort of model of workflow. This is model is executed or consulted, in conjunction with human users, when they do their jobs. These executable process models are at the heart of what distinguishes healthcare workflow technology from generic healthcare information technology. All information systems “affect” workflow (that is, influences workflow, for good or ill). But healthcare workflow technology “effects” workflows (that is, drives, makes it so, in the Captain Picard, Star Trek sense).

Confusing workflow with workflow technology is what gives rise to the notion that introducing process-aware information systems into healthcare and health IT is mere “tweaking” of workflow.

4. Thou shalt replace “Data Silo” with “Workflow Silo in your vocabulary.

Metaphors are not just flowery language used by poets. The metaphors and analogies we use, user-friendly (treating computers as people), data silo (farming, nuclear war), and data liquidity (flowing water), powerfully influence how we think. That is the point of Metaphors We Live By, an influential book in cognitive science.


I propose we stop talking about ‘data silos’; start talking about ‘workflow silos”. Data and workflow are related concepts, but very different ways of looking at healthcare. In fact, almost everywhere you see ‘data’ (especially in a headline), just replace it with ‘workflow.’ You’ll be pleasantly surprised by the innovative ideas that just seem to begin to, well, flow

5. Thou shalt use workflow technology to create true workflow interoperability.

“WFM/BPM systems are often the “spider in the web” connecting different technologies. For example, the BPM system invokes applications to execute particular tasks, stores process-related information in a database, and integrates different legacy and web-based systems….

…Different components may fail resulting in loss of data and parts of the systems that are out of sync. Ideally, the so-called ACID properties (Atomicity, Consistency, Isolation, and Durability) are ensured by the WFM/BPM system; atomicity: an activity is either successfully completed in full (commit) or restarted from the very beginning (rollback), consistency: the result of an activity leads to a consistent state, isolation: if several tasks are carried out simultaneously, the result is the same as if they had been carried out entirely separately, and durability: once a task is successfully completed, the result must be saved persistently to ensure that work cannot be lost. In the second half of the nineties many database researchers worked on the so-called workflow transactions, that is, long-running transactions ensuring the ACID properties at a business process level [40, 109–113]. Business processes need to be executed in a partly uncontrollable environment where people and organizations may deviate and software components and communication infrastructures may malfunction. Therefore, the BPM system needs to be able to deal with failures and missing data. Research on workflow transactions [40, 109–113] aims to gracefully handle exceptions and maintain system integrity at all times.”


6. Thou shalt build your next great health workflow app on a true work/flow platform.

If you can’t find any health IT applications that fit your needs and workflows, and you don’t want to create such health IT applications from scratch (meaning hiring programmers to write code) consider a “low code” approach.


  • Design your app on a modern platform.
  • Draw workflows in a editor without coding.
  • Design forms with point-and clicks.
  • Use the completed application over the Web.

Then push a button to generate intelligent workflow apps natively running on multiple mobile devices without doing any additional building or testing.

7. Thou shalt use intelligent workflow to create engaging patient experience.

The intelligent workflows behind engaging patient experience… what do I mean by that? Well, I mean something similar to “the systems behind the smiles”, i.e. the “robust systems and processes” employees need to simply assume exist, so their minds are free to extend fantastic service. Healthcare needs both, great people and great workflow. I tend to focus on the workflow tech necessary to deliver great workflow, but first I must acknowledge healthcare’s great people.

We’re moving from Systems For Transactions to Systems for Engagement. Systems For Engagement focus on delivering adaptive user experience. They’re idea for fast-paced change. And they support new work patterns, such as embracing mobile and social.

Workflow tech continues to diffuse into healthcare and health IT, especially with its maturing hooks into social, mobile, analytics, cloud, and even Internet of Things and wearable technology. As a result, health IT, and even EHRs, are becoming more effective, efficient, flexible, and relevant to the patients who encounter it when they have to, and the providers who use it daily.

The end result will be more intelligent workflows, better patient experience, and more engaged and healthier patients.

8. Thou shalt use modern Business Process Management for Population Health Management.

The best technology on which, from which, to create care coordination platforms is workflow technology, AKA business process management and adaptive/dynamic case management software. In fact, when I drill down on most sophisticated, scalable population health management and care coordination solutions, I usually find a combination of a couple things. Either the health IT organization or vendor is, in essence, reinventing the workflow tech wheel, or they embed or build on third-party BPM technology.

Seven advantages of BPM-based care coordination technology. It…

  1. More granularly distinguishes workflow steps
  2. Captures more meaningful time-stamped task data
  3. More actively influences point-of-care workflow
  4. Helps model and understand workflow
  5. Better coordinates patient care task handoffs
  6. Monitors patient care task execution in real-time
  7. Systematically improves workflow effectiveness & efficiency

9. Thou shalt carry the message of usable, agile, interoperable, and transparent workflow far and wide!

I’ve been quizzed: What, exactly, are you trying to accomplish?

My answer is always the same: Change health IT. I say this without hubris (well, maybe a little) because I’m not the only one. Mine is increasingly becoming a group effort, and social media has been essential to creating a ragtag band of Workflowistas. I, we, are gradually seeing light bulbs gradually appearing over the heads of thousands of health IT professionals.

Join us!

9.5/10. Thou shalt not feel constrained by cute blog post titles as to content in your blog post.

My blog post title has been riff on the recent 95 Theses for a New Health Ecosystem (scaled down due lack of time, certainly not lack of ideas or ambition). Health IT reminds me of that old poem line, “Water, water, everywhere, Nor any drop to drink”, except in this case it’s “Data, data, everywhere Nor any workflow to connect, to accomplish, to measure, to track, to harness”.

Let’s change this!

Fellow workflowists, viva la workflow!


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  1. AdamG
    Posted May 29, 2015 at 12:23 pm | Permalink

    I’m a guy who works in a hospital IT department who wears a bunch of hats, uses a lot of skills, and can describe himself with a cadre of impressive-sounding acronyms and titles (business process reingineer, project manager, solution architect, business analyst, etc.). However it all boils down to me needing to get something done with the constraints of time, resources and quality in a changing political climate.

    In my specific case I need to install a new EMR in our cancer center while trying to improve the backward paper processes by making things more interoperable and reducing the time they take to accomplish. Very specifically I’m working through how to build a better “front desk” process, where a patient is assigned a medical record #, encounter number, their insurance information is collected and entered, they agree to payment and HIPAA policies, etc.

    Since I’m the IT guy, I’m expected to solve all of the problems with data. Enter it once in a particular system, and it, in theory, can go everywhere. My reality is much more complicated since I’m working with several disparate business units, closed systems from multiple vendors, and different depatments who wish to work in their preferred systems only.

    Working within my constraints I can design a data-centric workflow that is complicated (expensive to build), prone to break (expensive to maintain), and I believe will not best serve the needs of everyone.

    As someone who advocates that we think beyond data, can you recommend a reliable approach / framework for identifying where and when to insert people processes instead of data ones?

    What factors can I use to make a tradeoff between ‘throw another body at it’ (or ‘just enter it twice in two systems’) versus ‘it’s just software, program it’? My expertise is in making tradeoffs between how to program data solutions, not how to weigh them against people processes.

    Thank you
    Adam in CT

  2. chuckwebster
    Posted May 29, 2015 at 12:44 pm | Permalink

    What a wonderful question! (In the sense that it so eloquently paints a word picture of hospital health IT today!)

    I feel for you… (having worked in a community hospital MIS department, supporting literally 100s of applications)

    If you don’t mind, I’m gonna try to outsource this one :) (ie send it to people I admire, who are smarter than me, and experts on processes and process technologies…)

    I imagine there are a variety of potential answers, depending on whether one takes a short (short-term work arounds) or a long view (infrastructure, platforms).

    (I’d put an irritating animated gif here of someone frantically looking through a book for an answer, but that would be indeed be irritating of me, so I won’t.)

    Thank you so much for such a realistic portrayal of what it’s like to work in a hospital MIS (that acronym still around?) department these days!


  3. Posted May 29, 2015 at 1:16 pm | Permalink


    Like Chuck, I feel for you. I cannot offer you a way to decide between extra resources or automating tasks, but I can point you to a list of redesign heuristics. Most of these do not involve any technology. Browsing them may give you an idea of alternative ways of improving process performance.

    Here’s a blog about these heuristics by someone I presented to: http://www.ny-central.org/process/process-redesign-heuristics/

    In this paper, you will find the original list: http://www.win.tue.nl/~hreijers/H.A.%20Reijers%20Bestanden/BPRpractices.pdf (read Section 4)

    Here is an evaluation of these heuristics and their extension for healthcare: http://alexandria.tue.nl/openaccess/Metis237259.pdf

    Hope it helps.


  4. chuckwebster
    Posted May 29, 2015 at 1:22 pm | Permalink

    TX Hajo!

    By the way, I’ve followed @profBPM on Twitter from my very earliest days on the social network.

    Excellent resource. Tho he’s now a professor, I believe he had extensive experience in industry before that.


  5. Posted May 29, 2015 at 2:05 pm | Permalink

    Adam- you certainly have quite the quandary. I’m not sure there are any really useful frameworks for the people vs. data problem (especially if you view the system with complexity science, as I do), as the chaos (of chaos theory, not chaos ED) makes it nearly impossible to effectively model. Generally, these type of decisions are simply reduced to costs (as best as can be accounted for) and judged accordingly.

    I think part of the particular challenges you’re facing, too, are caused by the organization thinking that tech is the solution to all problems (at least how I read your description above). In this vein, I think Chuck’s point #4 above is perhaps the most insightful; some of the challenges (front desk organization and process), might be better solved through a standardized process assessment (such as value stream mapping) to separate out tech factors from human factors from system/ design factors.

    From a practical perspective with regard to your own work, I’d focus on the paper and/ or people-based processes that are high failure or high cost when they fail (FMEA is ideal for prioritizing in this situation), and focus on workflow tech solutions at those points. Chuck’s point #6 is particularly useful in these contexts to design a workflow-based solution and get the data in a usable format to move on to less flexible (but perhaps needed) systems, like the EHR.

  6. chuckwebster
    Posted May 29, 2015 at 2:25 pm | Permalink

    TX Sean! (Told ya I knew some smart peeps!)

    BTW, Sean is @esseeconsulting on Twitter.

    The reason I keep mentioning Twitter is its growing contingent of healthcare workflow and workflow tech people. We’re still definitely in the health IT minority, but we make up for that with spunk and grit.

    I also know some potentially vendors, but don’t want to turn this thread into a commercial. However, it does seem to me there is a growing role for workflow tech to, essentially, compensate for workflow-oblivious EHR and HIT tech. So if anyone had specific technical advice or relevant success stories, I certainly wouldn’t complain!

    Many thanks to Hajo and Sean!


  7. David Claire
    Posted January 5, 2016 at 7:54 am | Permalink

    Adam - How did things ever turn out with your project of building a better “front desk” process and working through the people vs technology-based process tradeoffs?

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