Language always fascinated me. My mom was a reading teacher who home schooled me. Oh I still went to regular school too. But that didn’t stop her. (Thank you Mom!) Eventually I was one of the first students in one of the first graduate programs in computational linguistics (I see lots, now). It eventually disbanded, though if you search for “Laboratory for Computational Linguistics” and “Carnegie Mellon” there’s lots of references to it. I also found the following blurb in a local Pittsburgh paper.

I took all the courses necessary for a computational linguistics degree. Then I transferred to artificial intelligence to get a degree in intelligent systems. Along the way, I took (from memory and after a deep breath) linguistics (intro), phonetics, phonology, morphology, syntax (Chomsky), syntax (GPSG), semantics, logic, pragmatics, formal languages and automata, natural language processing I, II and III, knowledge representation, and natural language generation (plus electives like neurolinguistics and communication pathology).

And then I switched majors! Why? Because “All grammars leak” as linguist Edward Sapir wrote in 1921.

I found this out the hard way. I wrote a grammar to parse sentences for DARPA’s Pilot’s Associate program. Well, my grammar leaked big time! At first writing it was easy. After a while, though, every time I tweaked a grammar rule to do something right, something else would go wrong. I’d fix the verbs; a noun would break. I’d fix the nouns, and a verb would be broken again. It reminded me of the joke about how many programmers does it take to change a light bulb (one, but in the morning the fridge and toilet are broken).

I’d hit the “All grammars leak” brick wall. I looked for a way around it, under it, or over it, but it was really wide, deep and tall. I’d invested all this time and effort, but my undergraduate degree in Accountancy saved me. The time and effort were sunk costs, irrelevant to prospective decision making. So I went off to artificial intelligence and cognitive science.

I did keep an eye on CL/NLP though. Gradually, over time, CL/NLP became less-and-less about symbols and rules and introspection and more-and-more about numbers and formula and machine learning. (Interestingly, the pendulum may be swinging back, but that’s another blog post!)

Techniques I’d learned during my Industrial Engineering courses popped up all over the place in CL/NLP. Markov models, dynamic programming, and other operations research and mathematical programming techniques were adapted, with great success, to stop grammatical leaks. Today, combined with good software engineering and cheap hardware, computational linguistics and natural language processing appear on the verge something big, though exactly what, only more time will tell. Google uses CL/NLP (I believe) to help understand what folks are searching for. IBM’s Watson uses CL/NLP to ask the right question (AKA an “answer” on Jeopardy). My guess is that CL/NLP (under the hood and perhaps not widely appreciated yet) already adds millions, if not billions, of dollars of value to our digital economy.

So, last month I attended an NIH workshop on “Natural Language Processing: State of the Art, Future Directions and Applications for Enhancing Clinical Decision-Making.” I’ll blog about that experience and my impressions later. However, the short version: The NLP/CDS workshop was great. I was impressed.

What motivated me to finally write about CL/NLP in this blog about EHR workflow? There are all sorts of interesting connections! I’ll list some below. I promise to write and tweet about them in the future.

• Business process management and computational linguistics/natural language processing share an important problem representation. BPM often represents activities, and CL/NLP sometimes represents sentence structure, with state transition networks (transition networks decorate this blog post). This should not be surprising though. State transition networks are used to represent a wide variety of complicated sequential behavior, from genetic sequences to, well, workflow patterns and sentence structure.
• Speech recognition promises ways to increase EHR usability, but workflow technology will be needed to optimally incorporate speech technology into EHR workflow. Executing process models also provide information about which words are most likely to be uttered where and when in the workflow.
• Interpreting clinical text ultimately requires more than just sound, structure, and meaning. It involves goal, plan, and task recognition. Process definitions that workflow engines execute are, themselves, a prime source for an EHR to “understand” what its users are up to, so as to then stay out of their way or to proactively and appropriately help.
• Clinical NLP, itself, is a complex set of “pipelined” tasks, getting from word to interpretation. Due to complexity of these sequences, processing steps need to be modular so they can be easily swapped in or out to improve global performance. Systems such as UIMA, used by Watson, have workflow engine and process definition mechanisms to manage this processing complexity.
• Finally, EHRs need to communicate with other EHRs and HIT systems. These interactions need to become more “conversational,” if they are to become more resistant to errorful interpretation. ”Which patient are you referring to?” (reference resolution) “I promise to get back to you” (speech act) “Why did you ask about the status of that report?” (abductive reasoning) These interactions include issues of pragmatic interoperabilty (workflow interaction protocols over and above semantic and syntactic interoperability).

I’m sure to think of other connections between computational linguistics and natural language processing on one hand, and EHR workflow management systems on the other. Stay tuned!

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In fact, when I go to IT conferences aimed at other industries, as I occasionally do, and I tell techies I’m from healthcare, they often shake their heads sadly in pity. Despite high-tech advances in such areas as medical imaging and medical chemistry, we have a reputation as an IT backwater. Sigh.

This is not to say that health IT does not have allure that other IT verticals lack. I’d rather design software to prolong life than shorten it, which may be the case with otherwise cool technology with military uses. Medical data has characteristics that make it more interesting than financial data (and I have an undergraduate degree in Accountancy, so I have some passing familiarity). I’m also fascinated by the philosophical, cultural, and ethical problems confronted, implicitly and explicitly, by healthcare information systems designers.

However.

There is one area in which healthcare lags most egregiously: use of workflow automation (AKA workflow management systems, business process management, adaptive case management, process-aware information systems).

For years I’ve toted around a yellowing article titled, “Workflow’s Unique Contribution to Healthcare.” It appeared in a supplement to Healthcare Informatics (Document Information Management and Workflow Solutions in the Healthcare Enterprise, Healthcare Informatics, 1996 Aug;13(8):S2-35.), written by Jamie Mendez (who I’ve looked for on the Web, Twitter, etc., with no success). She wrote:

Workflow systems depend on two fundamental capabilities: automating manual process steps and distributing information to members of the workgroup.

Members of the workgroup add value by adding more information or by making judgements based on the information information available to them through the application. Workflow systems also provide a context in which work is performed and bring resources together across organizational boundaries. These can be separate departments, different sites, or even different companies to create an environment that functions like a “virtual organization.”

Locally customizable: A workflow system must adapt readily to fit business processes for multiple users and organizations.

Process adaptability: Modular construction of the workflow applications should permit straightforward changes to the system such as adding fax or paging services to improve the workflow.

Flexible logic: The flexibility to support ad hoc process logic is important for directing actions, routing sequences, and distribution lists…This allows exception-driven activities based on knowledge-based decisions embedded in the process flow.

Workflow systems have the potential to do for healthcare processes what just-in-time manufacturing has done for production processes. An effectively planned workflow system leverages an organization’s information resources to improve interactions between people and create a virtual organization. In almost not other business does information play such a great part as it does in healthcare. When information flows efficiently, healthcare organizations not only improve delivery of patient care, but reduce costs and improve customer satisfaction at the same time.

I’ll often deconstruct a series of quotes to make a point. Sometimes I replace general phrases such as “information systems” with “EHRs” (for example, see Well Understood, Consistently Executed, Adaptively Resilient, and Systematically Improvable EHR Workflow). Sometimes I agree with parts of a quote but quibble with other bits (for another example, see Efficient and Moral Market-driven EMR and EHR Usability Innovation).

This time I’ll let the above quotations stand on their own. Except to say: In four more years, in 2016, these words will be twenty years–two decades–old. Let’s make them come true before it can be said that healthcare IT is literally decades behind in adoption of workflow automation.

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Credited father of user- or human-centered system design (variously HCD, UCD, HCSD, or HCD), Donald Norman (DN) wrote a contrarian essay in 2005 (“Human-centered Design Considered Harmful”) offering an alternative vision of usability and design he called “activity-centered design.” Business process management (BPM) and workflow management systems presuppose activity-centered perspectives. I’ve argued that EHRs and HIT usability will benefit from these ideas and technologies. So I’ve titled this essay, User-Centered EHR Design Considered Harmful (Try Process-Centered Instead).

Welcome! (EHR + WfMS = EHR WfMS)
(from first post on this blog on 2/9/09)

DN starts out:

“Human-centered design has become such a dominant theme in design that it is now accepted by interface and application designers automatically, without thought, let alone criticism. That’s a dangerous state—when things are treated as accepted wisdom. The purpose of this essay is to provoke thought, discussion, and reconsideration of some of the fundamental principles of human-centered design. These principles, I suggest, can be helpful, misleading, or wrong. At times, they might even be harmful. Activity-centered design might be superior.”

Health IT tends to be behind the curve of what’s hot and what’s not in other industries. Seven years later human/user-centered EHR design is a hot topic in health IT. It promises, supporters say, to solve slow EHR adoption by making EHRs more usable. However, I argue, activity-, or process-centered, EHR design might be superior.

What are “activities”?

“To me, an activity is a coordinated, integrated set of tasks….One activity, many tasks.”

To me too.

“Consider the dynamic nature of applications, where any task requires a sequence of operations, and activities can comprise multiple, overlapping tasks. Here is where the difference in focus becomes evident, and where the weakness of the focus on the users shows up … The methods of HCD seem centered around static understanding of each set of controls, each screen on an electronic display. But as a result, the sequential operations of activities are often ill-supported.”

DN makes the same observation I’ve made about most EHRs. Optimization around a user, or user screen, risks the ultimate systems engineering sin: suboptimization. Individual EHR user screens are routinely optimized at the expense of total EHR system workflow usability.

“Note that the importance of support for sequences is still deeply understood within industrial engineering and human factors and ergonomics communities. Somehow, it seems less prevalent within the human-computer interaction community.”

I’ve seen EHR screens, which, considered individually, are jewel-like in appearance and cognitive science-savvy in design philosophy, but do not work together well. In contrast, industrial engineers start with understanding and modeling and optimizing interleaved and interacting sequences of task accomplishment. Information systems that can represent collections of task accomplishment include workflow management systems, business process management, case management and process-aware information systems.

“software gets more complex and less understandable with each revision. Activity-centered philosophy tends to guard against this error because the focus is upon the activity, not the human. As a result, there is a cohesive, well-articulated design model. If a user suggestion fails to fit within this design model, it should be discarded.”

Many EHRs suffer from “featuritis,” Simple elegant EHRs with simple elegant workflows are rare due to lack of cohesive, well-articulated design models; customers naively valuing quantity of features over quality of design; and regulatory requirements and penalties. (As my wife says: “There’s plenty of blame cake for everyone!”)

“Human-centered design does guarantee good products. It can lead to clear improvements of bad ones. Moreover, good human-centered design will avoid failures. It will ensure that products do work, that people can use them. But is good design the goal? Many of us wish for great design. Great design, I contend, comes from breaking the rules, by ignoring the generally accepted practices, by pushing forward with a clear concept of the end result, no matter what.”

User-centered EHR design does help get to good EHRs. Good isn’t good enough. If EHRs and HIT are going to help transform healthcare they need to be better than world-class (compared to what?). They need to be stellar. Traditional user-centered design isn’t going to get us there. We need to open the doors to cantankerous genius, like Steve Jobs, not afraid to break a few rules (or heads). And we need to move from user-centered to process-centered EHR design.

What about patient safety? Hard to argue with government certification and regulation, right? Public health and welfare is a traditional focus of government intervention. Instead of focusing on happy physicians happily adopting EHRs, user-centered EHR design has pivoted toward politically hard-to-argue-with prevention of medical error. User-centered myopic design takes its lumps there as well.

“[In] safety-critical applications, a deep knowledge of the activity is fundamental. Safety is usually a complex system issue, and without deep understanding of all that is involved, the design is apt to be faulty.”

Where might this insight lead? Forgive me for free associating: Safety. Error. Safe systems. Safety engineering. Reliability engineering. Systems engineering. How do all the EHR parts work together? How do all the screens work together? How do all the users work together? Workflow. Workflow technology. EHR workflow systems. True EHR workflow management systems, built with BPM technology. Fun! Thanks!

DN sums up “our” position nicely.

“The focus upon the human may be misguided. A focus on the activities rather than the people might bring benefits. Moreover, substituting activity-centered for human-centered design does not mean discarding all that we have learned. Activities involve people, and so any system that supports the activities must of necessity support the people who perform them. We can build upon our prior knowledge and experience, both from within the field of HCD, but also from industrial engineering and ergonomics.”

Substituting activity-, or process-, centered for human-, or user, -centered EHR design does not mean discarding user-centered design’s insights. Some user-centered EHR design verges on activity-centered design. 1986’s User-Centered System Design contains seminal insights relevant to activity-based design. Much of traditional user-centered design fits usefully into a larger activity-centered framework. Don’t throw it out like the proverbial baby, just let it grow up and be all it can be (to mix a simile with a slogan).

For example, I often distinguish between structured EHR documents and structured EHR workflows.

“[User-centered EHR design] deserve[s] a more instrumented and malleable EHR substrate than current EHRs typically provide….Structured-document-based EHRs and EMRs have relatively frozen workflows. They have no means to use workflow execution context (’enactment’ in BPM parlance) to decide intelligently 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. Structured-workflow-based EMRs and EHRs have exactly this means. Combining this means with traditional usability engineering methods promises more systematically improvable EMR and EHR workflow and therefore EMR and EHR usability.” Comment: Usability Expert Jakob Nielsen Would Like EMRs / EHRs with Big Targets, Less Functionality and Better Workflow Management

I couldn’t have said it better myself!

You may be excused if you wonder if activity-centered design and BPM are really related. And, do other people agree with Donald Norman? Yes, on both accounts.

For example:

“Most of today’s approaches to business process engineering (also called business process management) start from an activity-centered perspective. They describe activities to be carried out within a business process and their relationships, but they usually pay little attention to the objects manipulated within processes.” Business Process Modeling and Workflow Management

Not paying attention to objects manipulated within a process is useful. Process-centered designers can (temporarily) ignore non-workflow related details to focus on process.

And:

“[on Activity-Centered Design] understanding your users as people is far less important than understanding them as participants in activities “ Activity-Centered Design

That’s it, in a nutshell. Focus on processes surrounding users, then workflow roles, then users who fill the roles. At its core, that’s process-centered EHR design. Workflow management systems, business process management technology, and case management software make process-centered design easier. If healthcare needs process-centered EHR design and process-centered EHR design needs process-oriented EHR information systems then healthcare needs process-oriented EHR information systems.

That has been the message of this blog from its very beginning, three years ago: Welcome! (EHR + WfMS = EHR WfMS).

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Here’s an example from 2009:

Picture a graph that depicts progress toward higher and higher levels of market understanding of, and appreciation for, workflow management systems, EMR workflow systems, and business process management. By “workflow” and “workflow management” I don’t mean the meaningless ad copy that is thrown around and sprinkled on most brochures and websites. By “workflow management” I mean the same thing as what professionals and academics and workflow and business process management system vendors mean in the workflow and business process management system industry.

The X axis for that graph is now 10 years long. Data points are based on an unscientific series of impressions and vignettes: questions I received from an audience member at HIMSS, a presentation I attended, a conversation in an exhibit booth. I began to see material on the web besides my own around 2004, plus have an occasional encouraging conversation. But it wasn’t until recently that I began to get the impression of a large uptick surrounding recent discussions of certification, usability, and meaningful use.

This blog has a page called Healthcare BPM, but I stopped updating it when I created a companion Website: The EHR.BZ Report on EMR and EHR Workflow, Usability, (Patient) Safety, and Productivity. If you search that web page for the string “BPM” or “business process management” there’s a couple hundred hits. Even links that do not explicitly mention BPM have something to do with process-aware ideas and technologies on one hand and health IT problems with workflow, usability, patient safety and productivity on the other. EHR.BZ recently passed a thousand links and I add more each week. If a single Drudge Report-style page with over a thousand links seems large, they’re all short links (http://ehr.bz/ plus two characters), so the page is under 200K: download it yourself. Seems OK to me!

In a if-you-predict-the-inevitable-every-day-eventually-you’ll-be-right sort of way, I’m finally right. There’s the recent uptick I mentioned at #HIMSS12. Then there are six sessions (below) at the upcoming Forbes Business Leadership Forum, April 30-May 1 in Las Vegas. I prefer to link to such content, but for the life of me I could not figure out how to deep link to these sessions, so copy-and-paste it is. I do hope you visit the website and go to the conference (and come back and write a guest blog post here). I added the bolded phrases and comments after each abstract.

To see the “in situ” sessions go here

https://www-950.ibm.com/events/impact/sessions2012/

and search for “BPM” within “Healthcare and Life Sciences.”

BBA-2108 : Customer Case Study: Cigna Healthcare and BPM process-centric tools

Abstract See how Cigna Healthcare is investing in the innovation needed to maintain its position as a global health services leader by putting the Customer first. Cigna has embarked on what might become their most strategic and transformational initiative ever. Cigna is approaching this complex project utilizing a coherent set of BPM process-centric tools to extract the business rules out of their core systems and business processes. With the ability to link end to end business rules with business process, while supporting business policy, this business led transformation will allow Cigna to strengthen its customer-centric competitive edge while providing the agility needed to grow and evolve over time.

What caught my eye about this abstract was the juxtaposition of “process-centric” and “customer-centric.” How can both be true? Well, this “-centric” is not like the -centric in the patient-centric vs physician-centric debate. Think of it this way. User-centered design is about understanding and adapting to the user. If you adapt a process to a user (customer) it’s being user (customer)-centric. How do you adapt a process to, well, anything? Through process-centric tools, such as workflow management systems, business process management, adaptive case management, clinical groupware, etc. By the way, I think a process-centric approach is a good way to take into account all relevant stakeholders, including physicians and patients.

I didn’t find any relevant white papers about “Cigna” and BPM. But technology-oriented job titles and advertised job requirements are leading indicators for new technology adoption and “BPM” and “Business Process Management” are well represented. Also scan these tweets for BPM job openings at #HIMSS12 if you haven’t already.

BBA-1599 : Improving Healthcare Processes and Quality of Care by Leveraging BPM

Abstract Processes within healthcare systems are generally well standardized and managed. Unfortunately, much of the care delivery processes exist outside of these systems. While carried out with the highest degree of good intention and hard work, execution errors often occur in carrying out these processes and there is a high degree of process variability. With this in mind, The Ottawa Hospital is developing a Care Process Management platform leveraging BPM, rules, collaboration and analytics technologies, resulting in improved patient safety, patient flow and providing clinical areas a better view into how their processes are operating and where bottlenecks are occurring in order to solve problems in real-time.

Hmm. Not sure about the “Processes within healthcare systems are generally well standardized and managed.” But I agree with the rest of the abstract. The difference between “good intentions” and “execution errors” reminds me of cognitive psychology’s distinction between mistakes and slips. Workflow engines executing process definitions, tracking task states and alerting users if there is a problem, help prevent uncompleted tasks from slipping between the cracks.

You can see how BPM occasionally gets re-branded in healthcare, such as Care Process Management (here) or Healthcare Process Management. I think it’s to make BPM more palatable to those (like myself) who feel healthcare should be about more than profit. That said, the same technology that helps companies in other industries make lots of money can be used in healthcare to save lots of money (uppermost on healthcare executives minds).

“Views into…processes” and “bottlenecks” reminds me of BPM’s exciting new (to healthcare) process mining technology, about which I recently presented (video, paper) at the recent Healthcare Process Improvement Conference in Las Vegas (Again? What is it about that place?). Process mining has three purposes, all relevant to this abstract: process discovery (”view into…processes”), process conformance (”execution errors…patient safety”), and process enhancement (such as finding “bottlenecks”).

There’s also this podcast about Care Process Management at Ottawa Hospital (hundreds of views and 4.6 out of 5.0 stars, that is impressive).

TPA-1930 : Case Study (Independent Health): Increase Agility With a BPM Center of Excellence

Abstract Independent Health (IH) is striving to become a more process centered organization in response to the changing nature of the Healthcare Industry. Agility and Process Excellence are key elements in our ability to respond to the demands of Healthcare Reform. IH has recently built a Business Process Center of Excellence and implemented IBM Business Process Manager as our Business Process Management System tool. Learn about IH’s experience of building the Business Professional Code of Ethics, the selection process for our BPMS and the actual implementation of our Pilot Project for BPMS

There’s that phrase again: “process-centered.” In a nutshell, “user-centered” requires “process-centered” because health information systems need to adapt, or be easily and systematically adapted, to organizational and user workflow. I suspect we’ll see more Process Centers of Excellence in healthcare (whether prefaced by “Business,” “Care,” or “Healthcare”). Finally, the “selection process for [a] BPMS” will be increasingly relevant to healthcare organizations as awareness for BPMS advantages grows. “Selection” is smack dab between “awareness” and “implementation.”

TPA-1901 : Case Study (Lund University): Immunization Scheduling Optimization for Business Process Excellence

Abstract Around 1.4 million Children die because of preventable diseases today. Each 193 sovereign states of the world have their own immunization schedule regulating vaccines, doses and intervals. The schedules differ significantly. That is a major problem for General Practitioners (GPs) when fighting to prevent deadly child diseases. The situation is in need of remedy why the VacSam project designed a business rules centric digital service using IBM Websphere Ilog JRules. The immunization practice craves exact conformance to regulations, why the incorporation of SOA, BRA and BPM became a fruitful design method advocating to separate concerns in the SOA, permitting business logic to become boundless available i.e., a Service Oriented Business Process.

Here’s some links relevant to the VacSam project

VacSam - Digital eService for Coordinated Vaccination Control

Business Process and Business Rules Modelling In Concert for e-Service Design and Business Alignment

in which they say

Ideally, business rules (BRs) and business processes (BPs) should be kept as separate services. However, BRs and BPs are interrelated and should be designed in parallel. In this paper, we argue for why and how this is important with an example from a major development and research project called VacSam.

and

Service orienting the Swedish vaccination recommendation activity with the business rules centric digital service VacSam

The “Hold on to Your Hats: BPM in Healthcare is Taking Off” point I’ll make here is that as SOAs (Service-Oriented Architectures) become more popular and prevalent in healthcare (and they are becoming so), BPM will also become more popular and prevalent. BPM is a great way to coordinate all of these services in the cloud; they don’t coordinate themselves. By the way, BPM is also moving to the cloud, even Amazon is adding workflow functionality for free and then pay-as-you-go.

TPA-2593 : Case Study (MedImpact): BPM & Decision Automation for Benefits Management

Abstract Pharmacy Benefits Management is a process-centric and business rules intensive, multi-party information management business. As a benefits management service provider, MedImpact’s value to customers lies in the efficiency of its processes and the implementation agility and accuracy of customer-driven policies for the various benefit management decisions. MedImpact is leveraging the IBM BPM and WebSphere Operational Decision Management products to increase agility, accuracy and auditability of business functions. This presentation will review MedImpact’s success story in implementing BPM & JRules, to automate the Prior Authorization process and Coverage Determination decisions. The presentation will review our goals, challenges, and lessons learned.

I wasn’t able to find much but here is copy from a Webinar:

MedImpact has gained a competitive edge in the pharmacy benefits management arena by:

• Taking the first step to build a process based organization as part of a company wide BPM initiative
• Capturing important process knowledge that resulted in the deployment of consistent processes and improved business results
• Building an entry point for a governance structure that enables MedImpact to develop detailed steps for compliance measures and policy procedures

This initiative is pharmacy benefits management. I think it applies well to health information technology in general and even electronic health records in particular. EHRs are increasingly becoming healthcare organization-wide initiatives (that is, not just about patient documentation anymore). Current EHRs aren’t good at “capturing” (documenting, representing, tracking, mining, etc.) process knowledge needed to reduce clinical and business process variability and improve clinical and business results. BPM systems are.

TIH-2422 : Transforming Canadian Healthcare - Why The Ottawa Hospital Chose IBM for BPM

Abstract Canadian hospitals and health ministries are focused on improving delivery of health services while managing budgets and satisfying government regulations such as wait times. Health professionals are a highly mobile workforce and recognize everything they do is a process, heavily interactive, but currently in a siloed environment of technologies. No Canadian academic health sciences centre sees more patients than The Ottawa Hospital (TOH). TOH is a leader in healthcare and serves people across eastern Ontario, striving to provide each patient with the world-class care, exceptional service and compassion. This session will discuss why the hospital started the journey with Business Process Management, why TOH chose IBM as its partner, the results and the steps taken on its journey to date. BPM has already provided significant value in areas such as chart management, and is demonstrating how BPM and the partnership with IBM will realize the hospital of the future.

The Ottawa Hospital is represented twice in these six sessions. I’ve already commented and provided a link to a podcast. So I’ll move on…but not before noting the word “journey” and the phrase “hospital of the future.” HIT and EHR BPM systems are not static applications. They are designed to flexibly change, and to be changed, over time. Once BPM infrastructure is in place, this is when real opportunities for systematic improvement of healthcare processes present themselves. Sort of like opening a Pandora’s Box full of opportunities (instead of troubles).

So that’s my latest evidence that BPM in healthcare is taking off. Whether it does so like a rocket or a heavily-loaded crop duster remains to be seen. It will probably be somewhere in between. In either case, hold onto your hat!

P.S. In case you may think I’m making a big deal about a single data point (though, technically, it’s five or six), here’s another. Check out this recent series-of-three articles about BPM in healthcare.

1. BPM: Healthcare’s prescription for serving patients better
2. BPM offers healthy prognosis for improving electronic health records
3. BPM plays a critical role in healthcare compliance

Not long ago I would have been hard-pressed to find even a series-of-one about BPM in healthcare. “Series-of-one”: that’s a joke. (Not a good one. But I couldn’t resist.) I suspect we’ll be seeing lots of other series’s, sponsored magazine inserts and eventually even conferences (besides ProHealth, an academic more than a trade conference) before long.

And, if you still think I’m making way too big a deal about BPM in healthcare, generalizing from not enough data points, well, how about a thousand points of data?

After tweeting a HatCam interview I’d sometimes check my Twitter stream to check that it posted. Didn’t work. Watching my Twitter stream felt like standing at the edge of Niagara Falls. I’d tweet. Check my tweet stream. Not there. Oh it was there. Just already hundreds of tweets ago. However, except for the increased volume #HIMSS10 Best Ever: Due in Large Part to Social Media is still a pretty accurate qualitative description. And regarding this year’s Meet the Bloggers at the Health Social Media Center, a lot of what was said two years ago (sometimes by the same people) still applies (at least to blogging): Meet the Bloggers Revisited: Can You Identify Who Said What?

I was going to wear the HatCam at the Society for Health Systems 2012 Healthcare Systems Improvement Conference (#SHS2012, where I talked about EHRs, BPM, and process mining) but I chickened out (first time attendee and all). When #HIMSS12 arrived and I saw all the bright and shiny mobile gadgets, I found my resolve and donned my own bright and shiny mobile gadget.

(By the way, regarding #SHS2012 and #HIMSS12, I tweeted both hashtags for couple days, figuring early bird #HIMSS12 folks were in town during the #SHS2012 conference. #HIMSS12 attendees are great at building #HealthIT systems but could use #SHS2012 process improvement techniques to systematically improve #HealthIT -mediated processes.)

I came to #HIMSS12 with two separate goals that unexpectedly (to me) melded together. (1) Have fun (especially with my HatCam). (2) Network with attendees about healthcare workflow and analytics.

I’d interview someone and tweet it. Then, they’d ask why I’m doing this (or I’d bring it up) and I’d whip out my business card (specifically the back of my business card, see below) and ask if I could deliver a 60 second pitch. No one refused and most seemed entertained in bemused sort of way. Since I’d many more conversations about what I was doing than actual doing, I got to (briefly) talk about process mining EHR and HIT data with lots of tolerant, then intrigued, #HIMSS12 attendees.

What a gimmick! I’m even mentioned on @TechGuy’s much trafficked EMR and HIPAA blog. Here’s the bit mentioning me:

In between this keynote and the afternoon keynote, I planned to do a 1 minute video interview with Charles Webster, MD who had a hat cam. Well, the 1 minute video didn’t turn out quite like I thought it would go. I guess HIMSS finally caught up with me. Here’s the video :

Charles Webster has a really simple but powerful service called EHR Workflow. He allows someone to take some really simple to create data elements from an EHR and to create a nice looking map of where the bottlenecks in your EHR workflow exist. I encourage people to take a look at it and let me know what you think.

I hope you visit EMR and HIPAA because it’s one of my favorite blogs and, eventually, if you post or interact with John on Twitter, he is a most generous social media maven.

This dynamic, of giving something fun and potentially valuable (from a marketing perspective) in exchange for an opportunity to explain what I am passionate about, made my antenna quiver. I’ve been writing and presenting about EMR and EHR workflow management systems, business process management, process-aware information systems since the 2000 HIMSS in Dallas. More recently I’ve advocated process mining EHR event data (here, here, and especially here).

Back to the HatCam…

The HatCam is controlled by bluetooth from my Android (or iPhone) smartphone, which serves as a viewfinder (you’ll see it once in a while in the videos). I’ve a bunch of different lenses attaching to the HatCam, from zoom to fisheye to macro (for close ups, small print perhaps?). Anyhoo, here’s a fisheye tour of #HIMSS12, from education session and onto the exhibit floor.

Expand to full screen (lower right) for full fisheye effect!

My favorite “serious” interview was @pekharrison a statistician from Mercy who co-authored a wonderful poster about Process Mining of Clinical Workflows for Quality and Process Improvement. I’ve been interesting in process mining ever since I met its godfather, Prof. Wil van der Aalst, at MedInfo2004 in San Francisco. I follow, on Twitter, a bunch of BPM and process mining researchers in Europe and some of them follow me back (Hi!).

And here’s my favorite “fun" interview (serious content, ebulliently delivered), @MelSmithJones of @Perficient_HC.

@MelSmithJones had just interviewed me! ... in full HatCam regalia no less. Yep. HatCam was running. I’ll post the HatCam version of this interview later. (It has a "Being Chuck Webster" a la "Being John Malkovich" sort of feel.)

The Whole HatCam Etiquette Thing

If you listen to me talking to myself during the fisheye tour of #HIMSS12, I do address some issues I confronted. If the HeadCam is running and I bump into someone I know or turn into a vendor booth, I turn off the HatCam and point it upwards. (Reminds me of my father's gun safety lessons. "Never point it at anyone unless you intend to use it!”.) I was afraid that folks might think walking around with a HatCam was obnoxious, but the opposite was true. Folks chased me to find out what I was doing and then dragged me back to their booth to interview someone. Sometimes I had to take it off because I couldn't get to where I was going otherwise.

The HatCam was, and is, fun. I'd (and will) do it again.

By the way, might you be interested in a one-minute tweetable interview on a topic of your choice? If you were to do so, what would be a good question for me to ask you? That's a fantastic question! Let's do it!

I think you get the idea. I'm always looking for an angle. My HatCam was a fun way to introduce myself at #HIMSS12 to complete strangers and start conversations about BPM-style workflow automation, case management, and process mining.

P.S. By the way, there was substantial uptick in the marketing of BPM at #HIMSS12. Just take a look at the results below from searching Twitter for #HIMSS12 and #BPM. Against a backdrop of many thousands of #HIMSS12 tweets, these may not seem like a lot (and, of course I admit, lots are mine) but it's still impressive when you think that the last time I attended HIMSS (#HIMSS10 in Atlanta) I didn't see any at all besides mine.

I will go out on a limb and make a quantifiably testable prediction. The same search for #HIMSS13 and #BPM next year will return even more tweets. I can hardly wait!

Tweets at #HIMSS12 mentioning #BPM:

Charles Webster, MD @EHRworkflow
Dear #HIMSS12 : I tweet year long on #EMR #EHR #workflow #usability #productivity #ptSafety #ROI #BPM checkout » ehr.bz Best, Chuck

Charles Webster, MD @EHRworkflow
Negotiating Deadline Constraints in Inter-org. Logistic Systems: Healthcare Case Study ehr.bz/qb #BPM #HealthIT #HIMSS12 not

Chris Taylor @BPMForReal
Back in Pasadena following #HIMSS12 . A great conference for passion and controversy. successfulworkplace.com/2012/02/23/hea… << Some takeaways #Healthcare #BPM

Gilles Tousignant @docseggi
Healthcare: Set my data free! #HIMSS12 #BPM zite.to/Arv7U2 via @zite

Melody Smith Jones @MelSmithJones
#Healthcare set me data free! #HIMSS12 #BPM #healthcare lnkd.in/Epq_hU #FreeAtLast

Charles Webster, MD @EHRworkflow
Need #EHR #WfMS #BPM #ACM ehr.bz/8u RT @SuccessfulWork Our health depends on EMRs #HIMSS12 #BPM #healthcare ehr.bz/ud

Chris Taylor @SuccessfulWork
Our health depends on having electronic medical records #HIMSS12 #BPM #healthcare lnkd.in/Epq_hU

Chris Taylor @BPMForReal
Healthcare: Set my data free! #HIMSS12 #BPM wp.me/p1pL4e-Nk

Perceptive Software @PerceptiveSW
Executive Meet and Greet starts NOW in #HIMSS12 booth 5130. #ECM #BPM #healthIT #HCSM

Charles Webster, MD @EHRworkflow
RT @SuccessfulWork #MeaningfulUse requires coordination of humans, not just technology. #EMR systems failing 4 #BPM reasons. #HIMSS12 @TIBCO

Charles Webster, MD @EHRworkflow
Alert! #BPM #Healthcare sighting "EHR…Simplify business processes 2 remove workflow bottlenecks" @PerceptiveSW #HIMSS12 pic.twitter.com/EwjrG206

Perceptive Software @PerceptiveSW
Don't miss the Perceptive Exec Meet & Greet Thur @ 10:30 @ #HIMSS12 booth 5130. Hear #ECM #BPM #healthcare f/ the execs.

Perceptive Software @PerceptiveSW
Booth 5130--demos happening now! See how #ECM amd #BPM can make all the difference in your #healthcare organization. #HIMSS12

Jonena Relth @relth
RT @perceptivesw : Join us in booth 5130 at #HIMSS12 for @Gartner_inc research VP Barry Runyon for IT Consolidation Strategy. #ECM #BPM ...

Chris Taylor @SuccessfulWork
#MeaningfulUse requires coordination of humans, not just technology. #EMR systems failing for #BPM reasons. #HIMSS12 @TIBCO

Perceptive Software @PerceptiveSW
#ECM , #BPM #healthcare demos happening now...and what happens in Vegas... Booth 5130 #HIMSS12

Perceptive Software @PerceptiveSW
Join us in booth 5130 at #HIMSS12 for @Gartner_inc research VP Barry Runyon for IT Consolidation Strategy. #ECM #BPM #HCSM #healthIT

Charles Webster, MD @EHRworkflow
TX! Lots #EHR #HeathIT #workflow chatter but not much #BPM RT @fluxiconlabs @EHRworkflow How is #HIMSS12  Love Ur 1min interviews! #EHRvideo

[relatively speaking!]

Charles Webster, MD @EHRworkflow
Here’s a great thinking game 2 play @ #HIMSS12 Every time any1 says “workflow” every1 has 2 think #BPM #workflowEngine mobile.twitter.com/#!/EHRworkflow…

Charles Webster, MD @EHRworkflow
Like to welcome @6Vidya to Twitter! She co-authored #HIMSS12 clinical process mining poster mobile.twitter.com/EHRworkflow/st… pls follow! #BPM #healthIT

Michael Hopkins @MHopkinsPS
Don’t miss @gartner_inc analyst Barry Runyon speaking - @PerceptiveSW at booth 5130 tomorrow at 10:30am. #ECM #BPM #himss12 #HIMSS #HIT

Perceptive Software @PerceptiveSW
15 min #healthcare overview on #ECM & #BPM solutions at booth 5130. Just 20 min away! #HIMSS12

Perceptive Software @PerceptiveSW
Don’t miss the Perceptive 15 min #healthcare overview at booth 5130. Just 1 hour away! 3pm at #HIMSS12 #HIT #healthIT #HCSM #ECM #BPM

Perceptive Software @PerceptiveSW
Find out about #ECM and #BPM #careers . We’re #hiring at #HIMSS12 . Booth 5130.

Perceptive Software @PerceptiveSW
We’re hiring at #HIMSS12 . Drop by booth 5130 and ask about out open positions in #healthcare . #hiring #jobs #ECM #BPM #careers

Perceptive Software @PerceptiveSW
Don’t miss the Perceptive 15 min #healthcare overview. 3pm, booth 5130 #ECM #BPM #HIMSS12 #HIT #HIE #HCSM

Perceptive Software @PerceptiveSW
Don’t miss our 15 min #healthcare solutions overview TODAY 3p, booth 5130 #ECM #BPM #HIT #HIMSS12 #HCSM

Chris Taylor @SuccessfulWork
Would #healthcare #interop be more effective if frameworks used? #BPM @apqc @rwebb_apqc successfulworkplace.com/2012/02/20/hea… #HIMSS12 << Provocative!

Charles Webster, MD @EHRworkflow
LEAN Strategies/Rapid Response #Workflow Improve #ptSafety “HIT & #BPM 2 automate care process” ehr.bz/rr #HIMSS12 #SHS2012

Charles Webster, MD @EHRworkflow
Following #HIMSS12 ? Check out #SHS2012 too iienet2.org/shs/conference increasing overlap btwn #HealthIT #Lean #process #BPM #EHR#EMR #simulation

Charles Webster, MD @EHRworkflow
RE last tweet: if U don’t want LOTS of tweets abt #HealthIT #workflow #usability #BPM this wk U prolly ought 2 unfollow me #HIMSS12 #SHS2012

Chris Taylor @SuccessfulWork
Power of the CHECKLIST! Prepping to leave for #HIMSS12 on a Saturday morning. #DeathValley on the way to #LasVegas , Baby! #BPM #healthcare

Update (2/20/12): as promised here are the proceedings paper and narrated slide video.

I’m presenting “EHR Business Process Management: From Process Mining to Process Improvement to Process Usability” this upcoming Monday, February 20, at the Healthcare Systems Process Improvement Conference in Las Vegas. Here’s the abstract. (I’ll add a link to the associated proceedings paper on the 20th.) Hope you’ll stop by. I’m also attending HIMSS after HSPI, so tweet me at @EHRworkflow or use this blog’s contact form if you’d like to network about these topics.

I look forward to seeing you, in person or online!

–Chuck
Follow @EHRworkflow

EHR Business Process Management:
From Process Mining to Process Improvement
to Process Usability

Abstract

Process mining of event log data from electronic health records (EHRs) promises new methods to systematically improve EHR-mediated patient care processes and workflow usability. Process mining is part of a larger front of process-aware business process management (BPM) technology diffusing into the healthcare information technology (HIT) industry. Process mining can discover evidence-based process models, or maps, from time-stamped user and patient behavior; detect deviations from intended process models relevant to minimizing medical error and maximizing patient safety; and suggest ways to enhance healthcare process effectiveness, efficiency, and user and patient satisfaction. Process mining provides an “X-ray” of processes that can explain clinical business intelligence report and dashboard key performance indicators (KPIs). Demand for better evidence-based process maps will drive demand for better EHR event logs, which in turn will drive demand for more process-aware BPM-based EHRs and HIT. Many complaints about EHR usability are about EHR workflow. Process mining techniques and process-aware EHR and HIT systems will increase EHR usability and increase EHR adoption. They are relevant to the central issues of healthcare reform: identification of best practices, coordination of care among clinical staff, consistency across patient care processes, and efficient use of healthcare resources.

Keywords: Electronic health records, process mining, business process management, usability

Webster, C. EHR Business Process Management: From Process Mining to Process Improvement to Process Usability, In Proceedings: Healthcare Systems Process Improvement Conference, Las Vegas, USA, Feb. 18-21, 2012.

(Shot this in Alexandria, Virginia.)

Christmas lights, passers-by, wet snowflakes, a donation and a smile, and one hot saxophone version of my favorite Christmas tune: Carol of the Bells.

• 0:24 A tinkly riff, but a some false notes…
• 030: You realize he’s wearing thick gloves…
• 0:52 His sax begins to wail…
• 0:57 He frowns, off come the gloves…
• 1:07 Hmmm, better…
• 1:27 Adjust that mouthpiece…
• 1:55 Zoom in on his face…
• 2:00 A little improv…
• 2:10 Wow!
• 2:50 “Carol of the Bells!”…(yeah!)
• 2:58 “Merry Christmas all!”…

Merry Christmas all!

A.S. I publish this on Thanksgiving Day and give thanks for our American tradition of innovation. It is a unique product of personality (forebearers and forerunners), platform (laws and traditions,) and opportunity (Thanksgiving’s Land of Plenty).

“There is a dream dreamed by engineers and designers everywhere that they will someday be put in charge, and that their rigorous vision for the world will finally overcome the mediocrity around them once and for all. Resist this idea - the world does not work that way, and the dream of centralized control is only pleasant for the dreamer.” (Clay Shirky, An Open Letter to Jacob Nielsen)

As a graduate student in Industrial Engineering, studying aviation human factors and health systems engineering at the University of Illinois, I would have felt personally insulted by the above quote. Now that I’ve grown up, not so much.

Twelve years ago Clay Shirky wrote a remarkable open letter to a senior spokesman and advocate for Web usability, Jacob Nielsen, in defense of market-driven improvements of Web usability over centralized enforcement of usability standards. His remarks apply remarkably well to one side of the EMR / EHR usability certification debate. In the fine spirit of Shirky’s philosophies of open source and evolvable systems I’ve adapted his letter to the EMR/EHR usability standards debate.

(By the way, I don’t know if Nielsen still agrees with himself (heck, in the words of Marshall McLuhan, even “I don’t necessarily agree with everything I say.”). I certainly agree with Nielsen about big targets, less-is-more functionality, and screen flow that matches task flow.)

In some instances the Shirky quote is close to word for word, except the substitution of “EMR / EHR” for “website” or “EMR / EHR industry” for “the Web”, and in others I more liberally adapt the quote to current EMR / EHR industry circumstances. Quotes and paraphrases are blue and indented; my comments are black and unindented.

For maximum impact you might just read the indented blue material straight through, skipping over my comments until later.

Flame on!

An Open Letter about Enforcing EMR / EHR Usability Standards

Let me preface all of this by noting what we agree on:

• the EMR / EHR industry is host to some hideous dreck;
• things would be better for users if EMR / EHR designers made usability more of a priority;
• and there are some basics of interface usability that one violates at one’s peril.

So far, so good!

Where we disagree, however, is on both attitude and method - for you, every EMR / EHR is a piece of software first and foremost, and therefore in need of a uniform set of UI conventions, while for me, a EMR / EHR function is something only determined by its designers and users - function is as function does. I think it presumptuous to force a third party into that equation, no matter how much more “efficient” that would make things.

Depending on which side you’re on in the EMR / EHR usability standards debate, you may agree or disagree with this sentiment. However, it’s a close approximation of how some EMR / EHR developers feel.

What about patients, payers, public health agencies and clinical outcomes researchers? Don’t they have a stake? Yes they do: as users (and, in some cases, designers).

You despair of any systemic fix for poor EMR / EHR usability and so want some sort of enforcement mechanism for external usability standards….I believe that a market for quality is in fact the correct solution for creating steady improvements in EMR / EHR usability.

Let me quickly address the least interesting objection to your idea: it is unworkable. Your plan requires both centralization and force of a sort it is impossible to achieve. You say

“…to ensure interaction consistency across all EMRs / EHRs it will be necessary to promote a single set of design conventions.”

and

“…the main problem lies in getting EMR / EHR vendors to actually obey any usability rules.”

…I am relieved that there is no authority who can make EMR / EHR designers “obey” anything other than data interoperability….With the EMR / EHR use poised to go from 10-30 percent (depending on your definition of an EMR / EHR) to close to 100 percent in the next few years…the idea of enforcing usability rules will never get past the “thought experiment” stage.

The analogy breaks down a bit here. Government-enforced EMR/EHR usability standards may indeed get past the thought experiment stage.

…I want to address why I think enforced EMR / EHR conformity to EMR / EHR usability standards is wrong, even in theory. My objections break out into three rough categories: creating a market for EMR / EHR usability is better than centrally enforced EMR / EHR usability standards for reasons of

• efficiency,
• innovation, and
• morality.

EFFICIENCY

..The “Enforce EMR / EHR Usability Standards” Solution - redesign EMRs / EHRs not presently complying with a single set of usability conventions - takes care of 100% of the problem, while the “Create a Market for Usable EMRs / EHRs” Solution, let’s call it evolutionary progress for a highly usable EMRs / EHRs, well what could that possibly get you?

…a surprising amount, actually, if it’s properly arranged.

By ignoring the mass of EMRs / EHRs with just a few customers each and instead concentrating on making the popular EMRs / EHRs more usable and the usable EMRs / EHRs more popular, a market for quality is a more efficient way of improving EMR / EHR usability than trying to raise quality across the board without regard to user interest.

In other words, instead of raising average usability of all EMRs / EHRs, raise the usability of the most usable EMRs / EHRs through market-based innovation.

INNOVATION

A market for EMR / EHR usability is better for fostering innovation. Good tools let EMR /EHR designers do stupid things. This saves overhead on the design of the tools, since they only need to concern themselves with structural validity, and can avoid building to complex usability guidelines….

Consider the use of HTML headers and tables as layout tools. When these practices appeared, in 1994 and 1995 respectively, they infuriated partisans of the SGML ‘descriptive language’ camp who insisted that HTML documents should contain only semantic descriptions and remain absolutely mute about layout. This in turn led to white-hot flame fests about how HTML ’should’ and ’shouldn’t’ be used.

I recall these flame fest’s well. During the early 90’s I was part of a team of developers who created one of the first clinical browsers based on SGML. (A Tcl/Tk Based Graphical Interface to Medical and Administrative Information, presented at the 1994 18th Annual Symposia on Computer Applications in Medical Care)

It seems obvious from the hindsight of 1999, but it is worth repeating: Everyone who argued that HTML shouldn’t be used as a layout language was wrong. The narrowly correct answer, that SGML was designed as a semantic language, lost out to the need of designers to work visually, and they were able to override partisan notions of correctness to get there. The wrong answer from a standards point of view was nevertheless the right thing to do.

Remember the competition between networking standards and which one won? TCP-IP did, even though it was not deemed the most elegantly or correctly designed networking standard at the time. The market will do what the market will do.

Enforcing any set of rules limits the universe of possibilities, no matter how well intentioned or universal those rules seem. Rules which raise the average quality by limiting the worst excesses risk ruling out the most innovative experiments as well by insisting on a set of givens. Letting the market separate good from bad leaves the door open to these innovations.

Correctomundo!

MORALITY

This is the most serious objection to your suggestion that standards of EMR / EHR usability should be enforced. An EMR / EHR is an implicit contract between two and only two parties - designer and user. No one - not you, not Don Norman, not anyone, has any right to enter into that contract without being invited in, no matter how valuable you think your contribution might be.

Here is where the analogy between 1999’s consumer-facing website and todays EMR / EHR industry is, perhaps, but only perhaps, the weakest. What about patients, payors, public health agencies and clinical outcome researchers? Don’t they have a right to interfere in the contract between EMR / EHR user and EMR / EHR user because they are directly or indirectly affected, or in the name of public good? Perhaps.

On the other hand, these stakeholders are users with their own contracts with the EMR / EHR developer. I think one especially important role for the EMR / EHR usability engineer is to help create, and then enforce, the winningest set of user-designer contracts possible. However, while I think we can agree on this, it doesn’t shed much light on the government-needs-to-enforce-EMR-EHR usability-guidelines debate. Usability engineers on one side of the debate will favor one set of contracts while those on the other side of the debate will favor a different set.

By the way, I’ve met Donald Norman, and read and reread his books. I especially recommend Things that Make You Smart.

IN PRAISE OF EVOLVABLE SYSTEMS, REDUX

I believe that the EMR/EHR industry can be a market for quality -

• if switching costs can be lowered,
• word of mouth effects made large and swift, and
• redesign relatively painless.

If I design a usable EMR / EHR, I will get more repeat business than if I don’t. If my competitor launches a more usable EMR / EHR, it’s only a data export/data import away. No one who has seen the development of Barnes and Noble and Amazon or Travelocity and Expedia can doubt that competition helps keep sites focussed on improving usability. Nevertheless, as I am a man of action and not just a theorist, I am going to suggest a practical way to improve the workings of this market for usability - lets call it usable-emr-ehr.lycos.com.

This paragraph is, I think, key. The reason that some feel we need to “resort” to enforced EMR / EHR usability standards is because of a perceived market failure (not a uniform perception by the way). One byproduct of increased data interoperability (admittedly facilitated by government promulgated data standards) will make it easier and easier to switch between EMRs/EHRs. And as more and more EMRs / EHRs become web-based, there is less infrastructural lock-in too.

Word of mouth among physicians and along physician social networks is a powerful potential propellant (and deterrent) of EHR / EHR adoption. If switching costs can be lowered, harness this.

I am particularly interested in the phrase “redesign relatively painless,” because the Achilles heel of EMR / EHR usability has been frozen workflows that are expensive to change and which frustrate users. Most of the over one hundred posts on this blog are about technologies such as workflow management systems and business process management suites that could be used to address the problem of frozen EMR / EHR workflow.

So,

• reduce the cost of switching between EMRs / EHRs,
• rely on physician word of mouth and social media, and
• increase EMR / EHR flexibility of redesign (especially regarding workflow),

and the need for enforced EMR /EHR usability standards (and the unintended consequences) will diminish.

By the way, at CMU I took an artificial intelligence course from Michael “Fuzzy” Mauldin, Ph.D., before he founded Lycos. (Hi Fuzzy!)

The way to allocate resources efficiently in a market with many sellers (EMR/EHR vendors) and many buyers (users) is competition, not standards. Other things being equal, users will prefer a more usable EMR / EHR over its less usable competition. Meanwhile, EMR / EHR vendors prefer more EMR/EHR business to less, and more repeat EMR / EHR customers to fewer.

Econ 101 anyone? Actually, Production Possibility Frontier, but: “Production Possibility Frontier anyone?”

Imagine a search engine that weighted EMR / EHR usability in its rankings, where users knew that a good way to find a usable EMR / EHR was by checking the “Weight Results by EMR / EHR Usability” box and owners knew that an EMR / EHR could rise in the list by offering a good user experience. In this environment, the premium for good EMR / EHR UI would align the interests of buyers and sellers around increasing quality. There is no Commissar of EMR / EHR Design here, no Bureau of EMR / EHR Usability Standards, just an implicit and ongoing compact between users and designers that improvement will be rewarded.

When I first read this suggestion about usability-weighted search engine results, I was skeptical. But the more I thought about it the less skeptical I became.

I’ve read that Google sorts web pages using over 200 criteria and that they constantly tweak these criteria. I pay close attention to this sort of thing because I pay attention to where this blog ranks for certain phrases (“EMR + workflow”). I believe Google does in fact take into account website usability in its ranking system, that certain usability heuristics, those that can be search engine spider mechanized, do in fact give more usable websites a boost in their search ranking. At the very least, Google’s PageRank website link voting algorithm must reflect some aspects of website usability. All other things remaining equal, websites are more likely to link to more usable websites then less usable websites, and this should affect SERP (search engine result pages/position) via Google’s PageRank algorithm.

Of course, EMRs/EHRs are not websites, indexed in search engines, cross-linked so a PageRank-style Usability-Rank voting algorithm can rank them. Nonetheless, there is an interesting germ of an idea here. More later.

The same effect could be created in other ways - a Nielsen/Norman “Seal of Approval”, a “Usability” category at the various EMR / EHR awards ceremonies, a “Usable EMR / EHR Web Ring”. As anyone who has seen “Hamster Dance” or an emailed list of office jokes can tell you, the net is the most efficient medium the world has ever known for turning user preference into widespread awareness. Improving the market for quality simply harnesses that effect.

Ha! Remember web rings! The “Hamster Dance”? (wiki) I also like the idea of industry awards for EMR / EHR usability. (A self-serving disclaimer, I helped three medical practices win the first three consecutive HIMSS Davies Awards for ambulatory excellence. The submitted applications–accessible from previous link–include commentary about EMR / EHR usability.)

Web environments like usable-emr-ehr.lycos.com, with all parties maximizing preferences, will be more efficient and less innovation-dampening than the centralized control which would be necessary to enforce a single set of EMR / EHR usability standards. Furthermore, the virtues of such a decentralized system mirrors the virtues of the Internet itself rather than fighting them. I once did a usability analysis on an EMR / EHR which had fairly ugly but a good UI nevertheless. When I queried the EMR /EHR vendor about his design process, he said “I didn’t know anything when I started out, so I just built and EMR / EHR with an email link on every screen, and my customers would mail me suggestions.”

Open source EMRs / EHRs have not yet played much of a role in the EMR / EHR usability debate, or in usability in general (I love Ubuntu, but Windows 7 and Apple OSX provide better user experiences for the less technical minded). On the other hand, open source software has the advantage of a tight loop of interaction between user and programmer (à la EMR / EHR users emailing suggestions via links on EMR / EHR screens). Perhaps there is an opportunity here for open source EMRs / EHRs to exploit this potential advantage.

There is a dream dreamed by EMR / EHR usability engineers and EMR / EHR user experience designers everywhere that they will someday be put in charge, and that their rigorous vision for the EMR / EHR world will finally overcome the mediocrity around them once and for all. Resist this idea - the world does not work that way, and the dream of centralized control is only pleasant for the dreamer. The Internet’s ability to be adapted slowly, imperfectly, and in many conflicting directions all at once is precisely what makes it so powerful (would that EMRs and EHRs emulate this!), and the Web has taken those advantages and opened them up to people who don’t know source code from bar code by creating a simple interface design language (something EMRs and EHRs could use too!).

“[O]pened them up to people who don’t know source code from bar code by creating a simple interface design language”, in the long run, this is what needs to happen to the relationship between EMR / EHR users and EMR / EHR designers–they need to become one and the same. The key to this is user-customizable workflow. (But don’t get me started here, if you are interested you can read about it here, here, and here.) The EMR / EHR ecosystem needs to become more similar to the Web ecosystem. In which case the analogy between Web usability and EMR / EHR usability becomes even stronger.

The obvious short term effect of this has been the creation of an ocean of bad EMR / EHR design, but the long term effects will be different - over time bad EMR / EHRs die and good EMRs / EHRs get better, so while those short-term advantages seem tempting, we would do well to remember that there is rarely any profit in betting against the power of the marketplace in the long haul.

I couldn’t have said it better myself! (Wait a minute, I just did! In an open source, evolvable, attributed sort of way.)

EPILOGUE

The biggest difference between Shirky’s 1999 websites and today’s EMRs / EHRs is potential impact of EMR / EHR-induced medical error on patient safety. If someone can’t find their way around Amazon or Orbitz, so what. If a physician cannot find his or her way around an EMR / EHR, a critical piece of missing patient information might result in disaster for that patient. Narrowly focusing EMR / EHR usability on patient safety concerns–publishing suggested formats, an EMR / EHR incident database, educating EMR / EHR users about EMR / EHR usability–are good ideas.

However, keep in mind that standards always reduce innovation…somewhere…in hope of increasing innovation elsewhere. Draconian enforcement of EMR / EHR usability standards may increase EMR / EHR usability in the short run, but decrease the EMR / EHR usability (including patient safety) in the long run.

P.S. Follow me on Twitter at @c_wb.

In spite of yesterday’s prediction, here are some photos:

Several days before, looking east…

…then the autumn equinox, September 23 evening, the sun reflecting back from glass-surfaced building many blocks away…

…same reflection seen parallel with sidewalk…

…then looking west toward the Friendship Arch from several blocks away…

…Cheers!

P.S. Follow me on Twitter at @c_wb.

The Office of the National Coordinator for Health Information Technology (ONC) recently published the Federal Health Information Technology Strategic Plan for 2011 – 2015 (announcement, pdf).

The word “usability” is used twenty-five times.

Not going to read the full 80 pages (shame on you!) but want to stay up to date about government plans for improving EMR EHR usability? You came to the right blog post. I’ve abstracted each use of “usability” below. Emphases in bold are my own.

P.S. I like the HealthIT.gov’s tagline: Putting the “I” in Health IT℠. So much so, I’m going to use the parallel-themed tagline, Putting the “U” in EHR Usability℠, for a new website I working on. “U” refers to “you” the “user”. Stay tuned!

From the strategic plan:

pp 12-13

Strategy I.A.9: Encourage and facilitate improved usability of EHR technology.

The government is collaborating with industry and researchers to improve the usability of EHRs. The usability of EHRs is considered a key barrier to adopting health IT and achieving meaningful use. NIST is conducting ongoing research and advancing the development of standards and test methods that can be used to evaluate and improve the usability of EHRs. It has released a Common Industry Format (CIF), a standard for developers to report usability test findings and demonstrate evidence of usability in their products in a format that allows for independent evaluation of a single product and comparison across multiple products. NIST is also developing guidance and tools for RECs and professional societies on available tools and resources to incorporate concepts of usability in selecting and implementing EHR systems. The Food and Drug Administration (FDA), in collaboration with NIST and the Agency for Healthcare Research and Quality (AHRQ), will develop best practices to address systematic evaluation of usability with regard to patient safety to ultimately improve patient care. AHRQ is developing toolkits that medical practices can use to assess the usability of EHR systems and assess the redesign workflow. In addition, AHRQ is conducting research and convening industry workgroups that provide perspectives on what constitutes usability and how to systematically improve the usability of EHRs.

ONC will explore ways to improve the ability of providers to select or change EHR products by improving data portability. Reducing the cost associated with switching products while increasing data fluidity and choice can help drive market competition to improve the usability of EHR products.

ONC has directed one of its four Strategic Health IT Advanced Research Projects (SHARP) (see Strategy V.B.2) to further EHR usability through the identification and development of better cognitive and user-centered design. In addition, ONC is working with private sector groups to encourage the collection of usability information and its dissemination to vendors and consumers through mechanisms they can trust.

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OBJECTIVE C Improve safety and effectiveness of health IT

Strategy III.C.1: Provide implementation and best practice tools for the effective use of health IT.

AHRQ’s Health IT Portfolio supports health services research grants and contracts that create new knowledge, synthesize and disseminate best evidence and provide tools for implementation addressing health IT’s impact on the quality of health care. Current initiatives address clinical decision support, patient safety, patient centered care, quality measurement, and usability and workflow issues. In addition, ONC is actively working to make resources available to providers that allow them to maximize the value of using health IT by avoiding common challenges and legal issues associated with adoption, implementation, and use of EHRs and other health IT. Professional societies, licensing boards, and continuing education programs are developing best practice resources related to issues such as workflow redesign, the need for ongoing maintenance and upgrades, and legal concerns related to vendor contract clauses. There are important legal issues that providers should be aware of when entering into agreements with EHR and other health IT vendors. ONC will work to equip providers with information and help address potential barriers they may face in achieving meaningful use, including improved usability of EHR technology (see Strategy I.A.9). ONC and RECs will ensure that appropriate best practice resources about these issues are distributed to the providers that need them.

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Accommodate the range of user capabilities, languages and access considerations, including effective strategies for ensuring accessibility and usability of electronic health information for people with disabilities and meaningful access to such information for individuals with limited English proficiency

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Accommodate the range of user capabilities, languages and access considerations, including effective strategies for ensuring accessibility and usability of electronic health information for people with disabilities and meaningful access to such information for individuals with limited English proficiency

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Strategy V.B.2: Make targeted investments in health IT research. The federal government is committed to investing directly in health IT research and development in areas that hold great promise for improving the health of individuals and populations. NIH and ARHQ, in particular, are funding dozens of research projects related to the development of health IT. Through the HITECH Act, ONC established the Strategic Health IT Advanced Research Projects (SHARP) Program, a four-year program funding research in health IT security, patient-centered cognitive support, health care applications and network platform architectures, and secondary use of EHR data. The progress made by grantees will assist in developing best practices which can be applied nationwide, possibly through meaningful use requirements. AHRQ sponsors projects focused on best practices and integration of health IT into the practice of medicine. Focus topics include usability of EHRs, clinical decision support, consumer health IT, health information exchanges, and telehealth.

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Appendix B: Programs, Initiatives, and Federal Engagement

NIST collaborates with HHS/ONC in realizing the health IT goals of the Administration and Congress. This relationship allows ONC to draw upon NIST expertise in applying IT to health care through standards, conformance measurement, prototype implementation, security, and usability, and in consulting on the Nationwide Health Information Network, standards, and certification processes.

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NIST has funded a grant on the “Relationship Between Health IT Usability and Patient Safety: A Human Factors Engineering Framework for Action.” This grant will develop a framework explaining how the multiple facets of usability may be linked to different aspects of patient safety.

AHRQ’s Health IT Portfolio has supported health services research grants and contracts that create new knowledge, synthesize and disseminate best evidence and provide tools for implementation addressing health IT’s impact on the quality of health care since 2004. Current initiatives address clinical decision support, patient safety, patient centered care, quality measurement, and usability and workflow issues.

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Testing the usability and feasibility of smartphone-based applications and patient links to clinical services, including, but not limited to a recovery tool called Addiction Comprehensive Health Enhancement Support System (A-Chess) – an online peer support group and clinical counselors, a GPS feature that sends an alert when the user gets near an area of previous drug or alcohol activity, real-time video counseling, and a “panic button” that allows the user to place an immediate call for help with cravings or triggers.

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Appendix F: Goals, Objectives, and Strategies

Goal I: Achieve Adoption and Information Exchange through Meaningful Use of Health IT

Objectives

Strategies

I.A. Accelerate adoption of electronic health records

I.A.9. Encourage and facilitate improved usability of EHR technology.