I gave the following presentation, Digitizing Healthcare: Business Process Management’s Unique Contribution, at two back-to-back Business Process Management (BPM) conferences. This post consolidates a video of that presentation, plus slides and transcript. The two BPM conferences were…
Here’s my abstract…
— Charles Webster MD ⎌ (@wareFLO) June 21, 2016
I’m combining content related to both conferences into this single post since it is essentially the same presentation. However, I have 15 extra minutes at the Summit, so there will be more time for questions and discussion there. During the Summit, I’ll tweet out this post and video on the summit hashtag, #BPMCM16.
The first presentation was virtual (in Portugal), so I uploaded a special presentation to Youtube. The complete 30-minute transcript is a postscript to this post.
The plan was to deliver via Skype, but fall back on the Youtube presentation if Skype was iffy, which was exactly what happened. However, Skype worked well enough immediately afterwards to take a question.
Question? How to Encourage BPM Adoption at Our Hospital?
Digitizing Healthcare: Business Process Management’s Unique Contribution (45 minutes, Washington, DC)
Perhaps, related content to come!
And here it is! Trip Report: Day 1 BPM & Case Management Global Summit.
The following are the slides delivered at the BPM and Case Management Global Summit, in Washington, DC. The transcript is from the BPM Conference in Portugal (word-for-word informality and occasional typos due to mis-transcription, but, all-in-all, in my opinion, quite readable!):
I’m delighted to be able to speak to the
Portugal BPM (BPM and Case Management Global Summit) conference. I’m going to be talking about digitizing health care, business process management’s unique contribution. I kind of nicknamed this talk, healthcare’s workflow singularity. My name is Charles or Chuck Webster. I am president of EHR Workflow inc. I am very active on twitter where I am wareFLO, no ‘w’ at the end. There is my email. Feel free to use the #healthos at any time during this presentation.
I have been a proponent of workflow technology or business process management even before it was called BPM in healthcare for over two decades. You can think of me as Dr. Workflow on health IT social media. Blogging, twitter, youtube, blab, periscope, and I’m not above using humor. These are various characters that I play. People at Workflow and Dr. Workflow and so forth and so on. The Workflow king.
Health care has hit what I call, the workflow wall. There are many discontents in healthcare and they are discontented with invisible, inflexible, ineffective, inefficient workflow. If you as business process management professionals say, “Well wait a minute, we provide transparent, flexible, effective, and efficient workflow.” Well yes, there’s a great fit between healthcare’s workflow problems and BPM’s workflow solutions.
This is actually a quote from a blog post I wrote in 2009. Picture a graph that depicts progress towards higher and higher levels of market understanding of, and appreciation for workflow management systems, EMR workflow systems, and business process management. EMR stands for electronic medical record. I actually did some qualitative analysis of workflow content at various conferences. The various colors represent the different conferences. This was just my attempt to show an increase over the 2000, ‘99 to 2009 decade.
I’ve continued to track this and to promote business process management in healthcare. For example I just attended the America’s health insurance plans conference. The US pays for health care differently than other countries. I’ll get to more generic health IT in a moment. My most popular tweet was this representation of the complexities of paying for health care in the US. I mentioned the need for modern business process management. Now, do I think that all the folks who re-tweeted it and favorited it understand business process management? Not necessarily, but they know that there is a problem, and the more the merrier. They’re welcome to new ideas.
More on point, the Health Information Management and Systems Society Conference is held annually. Last year, most recently in Las Vegas over 41,000 attendees. It’s the largest health IT conference in the US. For the last six years I have searched every single exhibit or website, which is about 1,350, can be like a million square feet, just an enormous exhibit hall. I look for workflow stories. Starting back six years ago, not much. Then 2%, 4%, 8%, 16%, and now somewhere close to 50% of those 1,350 vendors have some kind of health care workflow story. We fit into your workflow, we make your workflow better and so forth. Of that 1,350 I actually found 111 vendors that specifically mention workflow engine business process, for business process management.
The evolution of workflow technology in healthcare is similar to the evolution in other industries, it’s just a lot slower. If you’ve been around for a couple of decades, you know that at one time, data, and business logic, and user interface code were all mixed together in applications. Then we pulled the data out into databases and we manipulate or access that data through data base engines. Then we pull the user interface out. It used to be people drew from x1, y1, to x2, y2, a button. Now you just hand that off to the operating system and say, draw a button. Now we are in the process of taking workflow and business logic out of these applications and storing them in databases and using workflow engines and decision engines to interpret them.
Other industries are further along than healthcare. Obviously, business process management over there on the right is the most process aware industry. That’s because that’s what it has to sell. Many other industries are crossing a kind of singularity. They are widely implementing declarative representations of workflow and work, and along with the workflow engines and other kinds of interpreting engines to make work more efficient and flexible. However, health IT is still just beginning to appreciate the need for workflow technology. It’s kind of moving from a workflow obliviousness to a kind of a dim awareness of the potential. It knows that there’s a problem with workflow, not yet sure what to do, but open to suggestions. That’s a good thing.
I sometimes refer to that healthcare workflow wall as a workflow singularity. A singularity is, most folks today popularly today associate it with the idea that when self improving artificial intelligence comes along, then there’ll be an explosion of technological innovation. Then these AI’s will run away and become really smart, and people are debating about whether that’s a good or a bad thing. I refer to something called the workflow singularity. The workflow singularity will occur when a sufficient amount of our infrastructure and applications are based on re-representations of work and workflow that can be executed automatically, and which can be instrumented, so as to provide the workflow analytics to feed back into and to more systematically improve those workflows. Specifically, this singularity is pivoting on an emphasis almost solely on clinical data to a more equal emphasis on clinical data and clinical events driving workflows. Representing those events, representing those workflows and harnessing those representations. Literally representing them in the computer to drive and to systematically improve a [variety 00:07:59] of through put, reduce medical errors, improve user satisfaction with the systems, including patients.
What’s happening now, is we have basically boiled the ocean in terms of capturing data. We have more data than we know what to do with, but this data is in silos and in databases. We are laying down on top of that, a new workflow layer. Some of that workflow layer is health IT kind of re-inventing the wheel and some of that workflow area is based on workflow technology, and business process management, orchestration technology such as is present in the modern BPM industry. Just because the workflow layer is being laid down on the data layer, doesn’t mean that the data is the platform. The data is being consumed by the platform, and what’s going to happen is that this new layer that’s coming down on top. That is going to become the platform, on which a variety of workflow savvy applications that are interoperable, that are safer, that are more usable and provide patients with a better experience with the health care system.
Predicting BPM’s health care future. I’ve been tracking this for over two decades. I can say with great certainty that we’ll continue to see growing workflow and workflow type thinking. People in health IT and healthcare will think about workflow similar to the way that health workflow technology, and business process management, and adaptive and dynamic case management of professionals and vendors think about it. You will see, we have an incredible installed base of traditional health IT, database, data centric databases with thin layers of user interface slapped on top. They will retrofit workflow technology they will add rudimentary workflow engines. They’ll also leverage third party workflow technology.
At the same time this is happening, we will see the so called SMAC technology social mobile analytics in cloud serve as vectors. A vector is an agent that brings an infection into a community. Social mobile analytics in cloud, startups, and initiatives from other enterprises, increasingly are created through low code application assembly techniques in the cloud, running on mobile without you having to write a lot of objective C java code and often, increasingly often, these have workflow engines. Representations of workflow and this workflow interacting with the business or the clinical logic. We are essentially head for what I call, “Full-stack” healthcare interoperability. Full-stack refers to developers. Someone who can install the operating system and run the databases and design the database models on the back end, on the front end create the mobile applications and the code running in the browsers as well as understanding the user and the design.
There’s all those layers. They’re all related. They’re all required to work together. This person has kind of a hands on knowledge and experience with each on those layers and how they fit together which can be enormously valuable. We need something that I call Full-stack healthcare interoperability, which I’ll discuss in just a moment.
Then business process management isn’t going to be the only new technology in healthcare. We’re going to see a variety of new technologies, and BPM will interact with those new technologies. It’s useful to think about those interactions when you’re predicting the future. These include an order of exoticness, application programming interface, the internet of things, and various kind of distributed computing including Blockchain.
What is Full-stack healthcare interoperability? Well, there are two popular terms in healthcare IT which are syntactic interoperability and semantic interoperability. Both of these terms are borrowed from linguistics, by the way I’m all but dissertation in computational linguistics. I took many courses in syntax and semantics. Syntactic interoperability is the structure of the information. It allows you to assemble it so you can serialize it, send it someplace and then [parce 00:12:50] and retrieve the contents. Semantic interoperability is the interpretation of those contents. The interpretation, the meaning must be the same in both systems. Healthcare has a variety of coding systems for diagnoses and treatments, drugs, and so forth. You rarely hear about something called pragmatic interoperability, although in the general IT and computer science community you’ll find more material about that.
Pragmatics is the next layer up in linguistics. You have syntax, the structure of sentences, semantic, the literal meaning of a sentence, and then pragmatics which is how we use words to achieve goals. That’s the non-literal interpretation. There, pragmatic interoperability is the match between the actual effect of a transmitted message and the intended effect of the transmitted message. If I say something, I have a goal that I want to achieve in the world. If that goal is achieved, then pragmatic interoperability between us two humans is achieved. Similarly, when information is sent between one organization and another, as part of a cross organization workflow, there’s a goal and if that goal is met then it’s pragmatic interoperability.
The most important context necessary to interpret these messages in context are goals, plans, workflows, tasks and activities. Which are just simply the bread and butter of the workflow technology, workflow management systems, business process management, and adaptive, and dynamic case management case software communities.
We’ll start with API. First of all, modern API’s have been around for a long time, and healthcare is only just starting to adopt them. Right now, we are creating a lot of data. Increasingly, we can move that data around and have it mean approximately the same thing. In order for this new layer of workflow interoperability to function it has to get at the data. It has to be able to pull that data. It has to be able to add to that data. That is going to be through application programming interfaces. I kind of interchangeably talk about pragmatic interoperability, data use, and workflow interoperability. Pragmatic interoperability is kind of like the linguistic theory, and task workflow interoperability is kind of the engineering.
By the way, an important API is FHIR (fast healthcare interoperability resources), but it only encompasses a small subset of clinical data that will likely increase. There are many, many other API’s that are being created using for example, a modern API generation technologies to allow this new layer of pragmatic interoperability, task workflow interoperability to be laid down on top of the data interoperability layer.
If you’d like to read more about these ideas of pragmatic interoperability and task workflow interoperability you can go to EHR.biz that’s sort of my short URL utility. EHR.biz. Pragmatic in one case and [interop 00:16:24] in the other case. Thank you very much.
Okay, now what about healthcare plus internet of things and business process management? If you cross index on Google BPM and things you’ll see a lot of interesting initiatives that is sensors are triggering state changes and little devices that are connected to the cloud. This is being transmitted to some kind of orchestration engine. Folks are creating complex interoperable internet of things platforms. You’ll typically see the ability to draw data flows and workflows, and then some kind of workflow engine. Possibly a community of workflow engines interacting with each other. Each of these little things is basically a CPU. It has some actuators, it has some sensors, and it has a way to communicate with other layers of the internet and things. BPM will play an important role in making that possible.
A big area of interest right now in health IT is getting outside of the electronic health record, and the doctors office, and the office and into the home and the lives of individuals. You’re going to see more sensors in homes and be computing wearables. The amount of data and the complexity is so great that you’re going to require workflow thinking in order to manage these systems. This is an example actually of a processed mind system of someone’s, you might call life flow or home workflow. You could easily imagine turning this into an actual executable representation and making things automatically happen. Reminding folks to take their medications or detecting if the low fat milk is low in the refrigerator and so forth.
Okay, now the most exotic technology that seems to be in the [inaudible 00:18:31], is Blockchain. Blockchain is a distributed database hardened against tampering. I’ve got a copy of it, you’ve got a copy of it, other people have a copy of it. Changes to this database are essentially voted upon. If everybody agrees that, or above a certain percentage agree that this update is valid then that gets replicated everywhere. Bit coin, virtual currency is based on blockchain, but blockchain is being suggested for a variety of other purposes including in healthcare. For sometimes addressing for example, healthcare interoperability, quote “ownership” patient ownership of data. Blockchain will obsolete somewhere close. If you think about having to go through a bank to get paid by a business partner verses having that automatically happening by virtue of the bit coin and Blockchain’s smart contracts. These workflows will enable other workflows which will need to be managed. When you need to manage workflows, workflow technology seems like a good way to do it. You’ll see Blockchain harnessing workflow technology in that way.
Then there are some other interesting connections between the two. That is, these databases do not contain just data. They also contain code, much of this code are what are called smart contracts. They’re contracts that execute so that if you fulfill the necessary requirements of the contract you automatically get paid. It’s a way in a sense, cutting out the lawyer or potentially the court. By the way, these smart contracts are state machines. If you’re familiar with the theory behind workflow technology and business process management, under the hood you have models of workflow and these are state machines essentially. The blockchain has implications for cross organizational workflow. I have a copy of the database, you have a copy of the database, they both replicate and stay consistent with each other. That’s relevant to cross organizational workflow, therefore cross organizational workflow in healthcare.
Then, blockchain is a fairly new technology and it’s really complicated. It’s hard to write these contracts, it’s hard to set up and do the kind of [devops 00:21:03] necessary to set up blockchain systems. You’ll increasingly see a variety of blockchain process orchestration engines to support that.
There’s an internet of things angle, ad that is when some little device out there interacts with some little device, you’re going to see micro payments. If you’ll give me a little bit of information about the weather, I’ll pay you one-tenth of a cent automatically. At that level it doesn’t scale unless you can do it automatically. Then of course these blockchain systems will have their own application programming interfaces that BPM will operate against. If the data’s healthcare data then you’re going to see an intersection with the API-zation of healthcare.
In order to predict the future, you have to look into the past. Here we are in 2016, eight years ago, cloud, social networks, app store, Google chrome, financial crisis, now you go all the way back to 2000. I wrote a paper in 2000 and presented it at [HMMS 00:22:16], that conference, I mentioned at the beginning about eleven paperless physician offices. It was, I believe the first example of a clinical electronic health record based on a workflow management system.
I’m not going to make you read this text, but I did abstract a bit of it. This is sixteen years old. Keep in mind that what I’m going to be talking about here is incredibly well known, and understood, and accepted, [inaudible 00:22:46] in the workflow technology industry, back then - because I track this - nobody was talking about health IT or workflows in this fashion. Today, sixteen years later, we’re just starting to see systems that do this routinely.
Let me start at the top here. Workflow automation refers to the automation of the business process in whole or in part during which documents information or task are passed from one person to another for action according to a set of procedural rules. That should sound familiar, that is the definition from the workflow management coalition. Then I talk about workflow systems, tasks, actors, roles, processes. I talk about workflow engines extensively elsewhere in the paper. Keep in mind, sixteen years ago, if you subtract this paper there was virtually zero of this kind of conceptualization or technology.
Now, what is the relevance of this to predicting the future? Well, a science fiction writer is quoted as saying, the future is here, it’s just unevenly distributed. If you want to predict the future, you can go and find that local example of the future and then extrapolate. What I wrote about here and presented here sixteen years ago is coming true today in health care. I would say that I’ve got some props here, some credibility. The other thing is that health IT moves remarkably slowly. That also makes it easier to predict the future.
I want to mention, I really like this answer to Peter [inaudible 00:24:29] daily BPM question from David [inaudible 00:24:33]. If David is here I hope I’m pronouncing your name right. Now, I’m going to read this and it is IT supplies the infrastructure, hardware security and the legacy to be used by the new outside in systems driven by BPM principles. Hold that phrase in mind, new outside in systems driven by BPM principles. IT is not required to build this next generation of applications, the build is direct with users and their input is in their language. The leader in the build would be the business focused well within the business analyst skillset. In healthcare, you’ll increasingly see clinically focused well inside the clinical analyst skillset.
Now, at a conference last year I saw a Passion for Process, on his twitter handle, had this wonderful slide in which he was showing the relationship between customer journey, sales process, delivery process, and servicing process and how they sales, and the delivery, and the servicing workflows need to be driven by what’s happening at the customer level. This is an example of outside in.
Now we get to the prediction. Okay, so here’s I’m going out on a limb. Of course this is so far out in the future that if I’m wrong, so what? I do hope to be around, I do archive this stuff an look back on it. I believe that in the next eight years you will see modern business process management enter the mainstream in healthcare and health IT. Healthcare BPM will leverage and be leveraged by fire and non-fire applications programming interfaces, the internet of things, and Blockchain. We’ll see major progress toward full-stack pragmatic interoperability and the system behind the smiles become reality. The system behind the smiles is this idea that half of the interaction between a consumer or a patient and a organization or the healthcare system is due to the attitude, the culture, the personality of who they’re dealing with. Half of it is due to the systems behind the smiles, whether they work or not. Those are the systems that we need to fix and that business process management can help fix. The system behind the smiles will become a reality.
Now we’re really off into the distant future. Although no farther into the future than into the past when I talk about my sixteen year old presentation about clinical workflow systems. There will be technologies and new terminology that there’s no way I can … I wouldn’t have the temerity to predict. I do want to offer a kind of a concept, a kind of a steady state of where I think we’re headed. It’s based on the analogy to an operating system. I spent a lot of time arguing that we need more workflow and more process management, not just date; well, what systems out there do both data and process as well?
Well the modern operating system. In fact I’ve argued that the modern operating system is the single most important technological development of the second half of the last century. Where we are is down here at the bottom, data persistence. That’s the syntactic and semantic interoperability there. We are virtualization that data through a layer of API’s and other technologies and then we are adding on top of that a concurrency management layer. Concurrency, virtualization, and data persistence are the three main topics. If you were to take a course for example in operating systems theory and we’re building a vast healthcare operating system. We’ve partially data persistence, we’re starting on the virtualization necessary and we’re just in the beginning of starting to build the workflow and the process management component of the healthcare operating system architecture. I don’t think, and since the operating system idea has been around for a few decades I don’t think that this is going to be necessarily outdated in the year 2032 when we look back.
Thank you very much. These are some of the ways to contact me. I’m chuckwebstermd Gmail. I’m on twitter, very active on twitter. I’m also on blab, which is kind of like a talk show. Periscope, in fact I’m periscoping this and my Skype ID is chuckwebstermd
@wareFLO On Periscope!