Four Benefits Of Structured Workflow and Messaging: Patient Experience

Skip the preamble and take me to the slides and speaker notes!

Thank you to TelmedIQ (HIMSS16 booth 12110) for sponsoring the webinar transcribed below.

Structured messaging is an example of the structured workflow for which I have been an evangelist for decades. Structured healthcare data is important, yes, Everyone acknowledges this. However, healthcare and health IT are just beginning to wrap their collective minds around the idea of structured workflow. Recently TelmedIQ (HIMSS16 booth 12110) sponsored my webinar, Wellness Through Workflow. (Thank you!). Over-and-above secure structured messaging, which is itself so relevant to care team coordination and consequent patient experience, the webinar is also a great introduction to structured healthcare workflow and workflow technology in general. Here are my slides and speaker notes from that webinar. Please excuse occasional transcription typos!

  1. Better Patient Experience Through Structured Messaging and Workflow Technology
  2. The Systems Behind The Smiles: Patient Experience
  3. The Workflow Behind The Smiles: Patient Experience
  4. Health Information Technology’s “Workflow Wall”: Patient Experience
  5. The Workflow Technology Prescription: Patient Experience
  6. Four Benefits Of Structured Workflow and Messaging: Patient Experience
  7. What If We Had Automated Workflow Before Data? Patient Experience
  8. Workflow Engineering Patient Experience & Engagement
  9. Re-Integrating Healthcare Data and Healthcare Workflow: Patient Experience


What is structured messaging, which is an example of workflow technology? You pre-build these message structures, and you can think of these message structures as kind of like simplified forms, that folks are very familiar with in healthcare. You send that securely over the internet, and these messages can occur in strings, back and forth, conversations. These are the workflows, these are the steps, tasks, activities.

Because you are using the same set of structures over and over again, same message types, over and over again, folks become familiar with them. When it arrives, they know exactly where to look to find the information they need, if the workflows and the forms are designed correctly. They can be, because you can change them, even after you’ve implemented.

All of this familiarity leads to both speed and accuracy. Speed is important because the faster you interact, the more throughput you can get. For example, if it takes, instead of four hours, from beginning to end of a workflow, from beginning to end of a case, if you move that to two hours, you’ve effectively doubled your capacity. Accuracy, it’s more consistent, and because you can track the task status, you can make sure that nothing languishes, or fails to be done. This combination of structured data and structured workflow facilitates automation through workflow technology.

The three major components, pieces, of structured messaging, in a calendar model, are forms, these are the forms that I just talked about. You’re sending these out, and instead of people having to type a lot of text, and then to remember what it is they need to type, and then they have to look at it and they have to interpret it, because it is structured, you have what’s called recognition memory instead of retrieval memory. Retrieval memory, you have to remember what to create. In recognition memory, you have an enumerated list of possibilities, and you choose whichever one you recognize to be correct, it might be yes, no, please ask me again when I get back to the office, that sort of thing.

Then you have the calendar. Shared mental models are so important for team behavior. If you’ve ever talked to someone about your calendar, even though there’s no calendar in front of them and there’s no calendar in front of you, there’s calendars in both of your heads, they’re like virtual calendars, and you’re using it as a shared mental model, to talk about whether you can meet up or not. Shared mental models need to be shared, not just among the humans, they also need to be shared with the software. It needs to be at high enough level that the humans can understand it, but low enough level that the workflow engine can consult it, and a calendar is an ideal model for that.

Then you’re got the rules. The rules are proactively watching for certain conditions to happen. Someone needs some care, and you check in the calendar, you see who’s available, if they’re not available, you use a rule to route it to the back-up, and then you check later to see if they answered, and if not, you escalate, those are the rules. Forms, calendars and rules.

This is kind of a pictorial representation of that. On the left we’ve got the calendar. This is the shared mental machine model. On the right we have these forms, and these forms aren’t just about text, they can also contain images, audio. These rules and these forms, the user interface and the workflow, is softcoded, so that means that once you implement it, folks who aren’t programmers can change the workflow behaviors.

What are the major benefits of structured workflow? Number one, automaticity. Because you have a workflow engine, and it’s in the software, instead of a human workflow engine, it’s a software workflow engine. It can recognize and be triggered, and do things without manual human intervention, although this can be overwritten. If the workflow engine consults a rule and sends you something, and maybe someone didn’t code something right, you can always say, “Well, no, that doesn’t apply to me.” If you don’t, then there are fallback rules in this logic.

Then you have transparency. Because every task goes through the workflow engine, that means the task is both time-stamped, and the workflow engine keeps track of the status. “Is it pending? Is it in process? Has it been completed? Is it languishing? Has it been forwarded to someone else? Has it errored out? Has it been cancelled?” All this information is available, and it can be viewed by the members of the team, that can see, “Okay, I see this task in our group, and Joe, who usually does it, didn’t do it, so I guess I’ll have to do it.” The workflow status can be viewed in reports by the supervisor, so they can say, “Show me all the outstanding tasks that have languished more than five minutes,” and they can be seen by the administrators, who are keeping the system running well.

It is this task transparency that allows you to compensate for interruptions. Instead of a human saying, “Oh, I need to do this later,” and they forget, the workflow engine knows that you haven’t done it, and it can remind you.

Flexible. Workflow engines don’t just do what workflow engines do, they consult these workflow rules. These workflow rules are out there in the environment. They can be changed by the administrators and the supervisors. They tell the workflow engine what to do, they are softcoded. Therefore, when you change them, the workflows change.

When you put together transparency and flexibility, you arrive at improvability, because you’ve got this time-stamped task data out there, you can use it, using a variety of tools, to find and eliminate bottlenecks, rework or redundancies, doing things over and over again. This can be used both to improve cycle time, reduce the workflow from four hours to two hours and double your capacity, and increase consistency, that is vastly increase the likelihood that the task will eventually be accomplished within a certain window of time.

Those are kind of essential aspects of architecture, but you also have to be concerned about these sort of value added ons. It’s not just text in the form, you also have voice, images, radiology images, for example. Then you need to able to convert, so if you try one channel, by voice, and they don’t respond, well, maybe you need to text them.

As is the case with many add-ons today, you’ve got to integrate with EHR, that’s happening. Particularly, tasks that happen in the EHR may need to cause things to propagate up through the structured messaging system.

Of course you need HIPAA compliance. Then, there’s cross-platform. Because these systems are sending data to either Android, or iOS, or to the desktop, you have the option to use your own device, that’s the bring your own device phenomenon.

Finally, this may seem redundant, so why am I mentioned intelligent message routing and escalation again? Well, you want content. Just like picklists of drugs and codes are content, workflows are content, too. When you get that structured messaging system, you want to have a set of routing and escalation workflows already, sort of … Other people have been using them, and they work great, and then they work great for you, you don’t have to create them from scratch, and you can tweak them further.

Take me to the next post in this series: What If We Had Automated Workflow Before Data? Patient Experience.

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