The Critical Difference Between Workflow Management Versus Mere Workflow: Process-Aware HIT

The following preamble and table of contents is for surfers who randomly land here and may benefit from a bit of orientation. Skip to the content!

In 2003 and 2004, I wrote a series of white papers about workflow-centric, instead of data-centric, EHRs. It’s taken 13 years, but much of what I wrote is finally becoming true. This is one of a sequence of blog posts adapted from those white papers and (republished) during HIMSS16. Terminology has evolved, but the ideas are as relevant now, if not more so, as then. (Take me to the beginning of this series of blog posts!)

  1. EHR Workflow Management Systems: Essentials, History, Healthcare (Written In 2004!)
  2. The Critical Difference Between Workflow Management Versus Mere Workflow: Process-Aware HIT
  3. The Critical Importance of Executable Model Of EHR Workflow: Process-Aware HIT
  4. Different Versus Same Person Versus Time EHR Workflow: Process-Aware HIT
  5. Multi-Specialty, Multi-Site, Multi-Encounter Workflow Management: Process-Aware HIT
  6. A Survey of EHR Workflow Management Productivity: Process-Aware HIT
  7. EHR Productivity Survey Discussion: Process-Aware HIT
  8. Workflow Management and EHR Usability: Process-Aware HIT
  9. User-Centered, Human-Centered Process-Aware Health IT
  10. Process-Aware Workflow Management Systems With Healthcare Characteristics: Process-Aware HIT
  11. The Future of EHR Workflow Management Systems: Process-Aware HIT
  12. Interruptions and Exceptions in IT Enabled Healthcare Workflows: Process-Aware HIT
  13. Clinical and Administrative Healthcare Workflow Patterns: Process-Aware HIT
  14. Process Mining Time-Stamped Health IT Data: Process-Aware HIT
  15. Capacity Management Implications of Healthcare Workflow Technology: Process-Aware HIT
  16. The Roots of Task-Workflow Pragmatic Interoperability: Process-Aware HIT
  17. Who Or What Is The Workflow Engine: That Is The Question: Process-Aware HIT
  18. References for EHR Workflow Management Systems: Process-Aware HIT
  19. Glossary of EHR Workflow Management Systems Terminology: Process-Aware HIT

Workflow Management Versus Mere Workflow

Van der Aalst and van Hee [1] describe an evolution of information systems that can be profitably applied to the evolution of the EHR as well. First were collections of separate applications, each with its own database; then applications began to share a common database. Each application had its own user interface; then applications shared a common look and feel and, increasingly, context as well. Finally, workflow-related business logic moved into workflow management systems, which managed application workflow. In short, data, user interface, and now workflow have migrated or are migrating out of healthcare applications and into shared databases, user interface resources, and workflow management systems.

A workflow management system is a software application that stores and executes workflow or process definitions to create and manage workflow processes while facilitating interactions among users and applications [1, 2]. “Workflow” and “workflow management” (and by extension, “workflow systems” and “workflow management systems”) are frequently confused and this is naturally so. Users usually interact with workflow systems, not the workflow management systems used to implement them. However, it is the underlying workflow management system that allows a workflow system to be flexibly tailored to local processes and user preferences, and to be easily monitored and maintained.

A useful analogy can be made between a database management system and a workflow management system. A database usually comes with a database management system that is used to execute and manage it. The database management system creates, executes, monitors, and edits the database, but is not itself the database. During database execution, users and applications create, update, and delete data. Similarly, a workflow management system creates, executes, monitors, and edits a workflow system, but is not itself a workflow system. The main advantage to EHR users of getting both a workflow system and a workflow management system—together—is that they can further customize the EHR workflow system to reflect their clinical needs, personal preferences, and business requirements.

At this moment when the EHR can benefit so much from workflow management system technology, the EHR can also benefit from the model of how the workflow management system industry has developed during the past decade. In both cases, WfMSs then and EHRs today, there existed or exists a software application that had or has great potential to increase the effectiveness and efficiency of core processes as well as increase the satisfaction of those engaged in making those core processes happen. While there was and is great opportunity, there was and is uncertainty. There was no standard model of application functionality and no standard terminology for discussion, education, and planning. So, the Workflow Management Coalition helped to define a standard model of workflow management, the Workflow Reference Model [2] (Figure 1 represents relationships among important terminology).

This Workflow Reference Model described a common vocabulary about workflow, a workflow management architecture that was technology and vendor neutral, and key interfaces that required standardization.


The Workflow Reference Model is reminiscent of the electronic health record reference model being defined today. So, it is natural to connect these two efforts when presenting the concept of electronic health record workflow management systems. In fact, a recent paper examining the legacy of the original reference model concludes by saying that the core legacy may be that “it has provided a common framework for people to think about Workflow and BPM (Business Process Management) and ten years of fascinating discussions!” [3] I hope and believe the same will be true of electronic health record workflow management systems, too! (By the way, there remains a residual of terminological variation, such as process definition versus workflow definition.)

Much of what I wrote about in this 2003-2004 series of white papers is indeed coming into existence today. The basic idea of building workflow-centric health IT systems is indeed gaining steam. Many of my tweets during HIMSS16 are about companies embedding workflow engines in their products. In addition, we are seeing a surge of Business Process Management technology in healthcare and health IT. Terminology varies. Sometime they are called Healthcare or Care Management Systems. What they have in common is a “process-awareness” that has been mostly missing to day in recent medical informatics and health IT history. This new layer of cloud-based workflow engines addresses thorny issues of EHR and health IT usability, productivity, safety, and interoperability. Indeed, since my 7000-word, 5-part series, Achieving Task and Workflow Interoperability in Healthcare , was published in 2015, I’ve seen considerable progress. Also see my recent 10,000 word, 5-part series on Pragmatic Interoperability published on HL7Standards immediately before HIMSS16.

It is still useful to look back at my 2003 and 2004 series on EHR workflow management systems for seminal ideas that are only now being realized in products and driving results. In many instances, I have written considerably more material on various subtopics.

For further exploration of the difference between a workflow system and a workflow management system, see my Confusing Workflow Technology With Workflow Is Like Confusing Your Database With Your Data.

Take me to the next blog post in this series! The Critical Importance of Executable Model Of EHR Workflow: Process-Aware HIT.

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