Blab: A New Way To Demo Health IT Software!

Believe it or not. That Hollywood Squares-esque social video platform, Blab, mostly populated by people talking about how great Blab is, is a really great way to demo health IT software! @dflee30 used the Blab Chrome extension…

…and gave about an hour demo of the ZenPRM collaboration and provider resource management system. Well, it would have been an hour, except I kept interrupting and asking questions. Which Don answered impeccably.

Couple of things to note. The live blab looked way better than either the replay or the youtube version. In both of the latter, the screencast is squeezed into a corner quarter of the video. But in the original blab, it stretches gloriously and crisply across about the top three fifths of the screen. I’m sure best practices will emerge, but in this case what seemed to work was lowering the screen resolution and bumping up the font size on the sending end, and playing around with the browser size and aspect ratio on the receiving end.

I am already looking forward to many demos of healthcare workflow software!

@wareFLO On Periscope!


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Trip Report: Day 1 BPM & Case Management Global Summit

Now in it’s third year, the BPM & Case Management Global Summit is my favorite annual conference (BPM stands for Business Process Management). I love the annual HIMSS conference, for its size, energy, and grandeur, but 41K plus attendees can be overwhelming. #BPMCM16 (its Twitter hashtag) is just right, just a couple hundred of the smartest workflow tech folks around. Oh the conversations!

This is not a blow-by-blow coverage of every keynote and breakout session and demo I saw. It is, as it usually is, a selective search for the healthcare workflow relevant ideas. (Here is my trip report from a couple years ago.) Also, as usual, I’ll use my tweets during the first day of the conference as a sort of graphical, social backbone to this post.

I arrive early, because @NathanielPalmer (BPMCM16 organizer) serves one excellent Ritz-Carlton breakfast.

We kick off with super keynote from Ron Ross (@ronrossecure), NIST, on cybersecurity. Several of the questions after Ron’s talk touched on the role of BPM in creating more secure IT systems. (By the way, see my list of five ways BPM can make health IT systems more secure.)

The second keynote was delivered by the always passionate Clay Richardson (@Passion4Process).

I’ve written before about Clay’s exciting ideas on how to use BPM to connect data and workflow silos into “empathic workflow” reflecting and supporting customer journey. While he did not directly visit healthcare, in previous presentations one of his examples was about a daughter worried about her mother falling, her mother feeling anxious and ambivalent, and using backend BPM connecting legacy systems to better support their customer journey.

My favorite breakout session was “Supporting Complex environments with BPM” presented by Steve Kruba (@Krubast), Northrop Grumman. Here are a couple of his healthcare-relevant slides. BPM is the “glue” connecting disparate applications. I’d say this is healthcare-relevant, because this is exactly what healthcare needs, see my series on Pragmatic Interoperability.

Here is a screencapture of the healthcare workflows, connecting people and systems, that Steve created with Northrop Grumman’s e-Power BPM suite. Note, these are not just pretty workflow pictures. These workflows are executable. Changing the workflow “picture” changes the workflow application behavior.

And here is Steve’s summary slides. Read it. Healthcare needs this.

My talk, on the relevance of BPM to healthcare, came off without a hitch. If you follow the link from the tweet you’ll find a complete video, all the slides, transcribed!

Every year I see some cool new technology (new to me, often they’ve been around for years, but just not in healthcare yet). This year the product was Kintone. Here Jana Berman (Account Exec at Kintone) is demoing enabling “process management” in Kintone, that is, popping open the workflow editors, adding, moving workflow steps, tweaking their business logic, etc. Previously Jana showed how easy it is for users to create and edit screens. If you put together non-programmer users creating both screens and workflow, well that is what is increasingly called a “citizen developer.” Healthcare needs citizen developers. This demo was about sales leads. But just think about clinical and health management users creating their own workflows. (Reminds me of the Maker Movement, which I’ve written about here… Makers in Healthcare | Health Standards)

Kintone is no new wet-behind-the-ears startup. 4,000 companies and 130,00 users have created 250,000 workflow apps. This kind of low-code/even no-code workflow application creating could transform healthcare (and I should note Kintone is not the only company in this space). Imagine if healthcare users could create and customize their own software screens and workflows…

I spoke with Dave Landa (@DaveLanda), who heads up US operations. Kintone is working with a number of US healthcare organizations. I’m excited to see the results of these partnerships.

Two more highlights. During my talk about BPM in healthcare I mentioned process mining. Scott Opitz (@ScottOpitz), President & CEO of TimelinePI (@TimelinePI) came up to introduce himself and his company. What he said was fascinating, from a healthcare workflow informatics point-of-view. I’ve not yet seen any demos, but I do wish to include this quote from

“TimelinePI is specifically designed with one purpose - to provide a new view into operational data focused on business processes. The TimelinePI engine consumes data from a variety of sources, often the same exact data being used today for other simpler analyses, to detect and present detailed views of your business processes. This new insight is delivered via a variety of new process and timeline visualization tools developed to not only make these new insights easier to understand but also to allow users to manipulate the information to gain deeper understanding of those processes. Users armed with this insight have concrete facts on which to take actions to improve operational efficiency by promoting clearly superior best practices and eliminating costly inefficiencies that previously went undetected.”

Very cool!

One last highlight!

Every time I happen to bump into Keith Swenson (@SwensonKeith) at a workflow tech conference, I systematically pick his brain about his ideas about work, workflow, BPM, case management and related topics, as they relate to healthcare. Keith finds healthcare an interesting area of problem solving and collaboration, and we both agree there’s a great fit between healthcare’s workflow management problems and the BPM industry’s workflow management solutions. During BPMCM16 I enjoyed listing to Keith participate in fascinating debates (especially with @denisgagne) about how to represent decision making in BPM and case management systems. The results of this debate will be important to better clinical decision support systems in healthcare.

Here are the #BPMCM16 Twitter statistics, as of the morning of the second day of the conference. The reason there appears to be a dip right at the end, is that it is still early, so lots haven’t tweeted yet today. 180 tweets (139 yesterday, during the first day of the conference), 58 tweeters with a potential reach of over a half a million (basically, aggregate users times their followers). Given the intimate size of the conference, these are pretty good statistics!

Thank you Nathaniel Palmer for putting on a great conference. And to Layna Fischer (@BPMbooks) for capturing Nathaniel in is element! :)

Have a great second day of the BPM and Case Management Global Summit!

@wareFLO On Periscope!


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Digitizing Healthcare: Business Process Management’s Unique Contribution (Two BPM Conferences, Video, Slides & Transcript!)

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…

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.


I’m basically going to talk about BPM in health care, and I’m going to go back a bit a few years and then also go forward and predict what I think is going to happen.


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 that’s sort of my short URL utility. Pragmatic in one case and [interop 00:16:24] in the other case. Thank you very much.

I’m going to pause here for a second just in case anybody is writing that down.


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!


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AHIP Institute Trip Report: Business Process Management & Workflow Engines

This year’s 2016 America’s Health Insurance Plans conference in Las Vegas was my second AHIP Institute and Expo. Last year and this year I focussed on workflow tech in healthcare, specifically Business Process Management (BPM) and workflow engines.

I tweet lot and I try to be substantive in my tweets (as in summaries of conversations, quotes from keynotes, etc). I’ve found that collecting some of these tweets into a blog post is a fast and efficient way to remember and reflect back on ideas, themes, people, and products I encountered. Let’s start with the vibe! One of my most popular tweets was this panorama of the AHIP audience from the back of the room. Thank you AHIP for including it (first!) in your Social Media Buzz from Day 1 of AHIP Institute & Expo 2016.

AHIP Panorama

Heading into AHIP I interviewed Scott Polansky about what we could expect at AHIP (BPM & Healthcare Q&A with Scott Polansky, Appian Practice Lead for Healthcare Payers).

If there was a zeitgeist that could be boiled down to one word, there certainly was competition! Engagement? Interoperability? “Action-ability”? (I know, not a word). But if I was forced to settle on s single, solitary work, it’d be: Simplification. Take a look at my most popular tweet!

In fact, I tweeted the same diagram during AHIP 2015, and it was also quite popular.

Here is the interesting thing. The complexity of the diagram struck a chord in 2015 and 2016. In both tweets I mention “Business Process Management.” Now, do I think folks RTed because I mentioned BPM? No. I think folks simply like the idea that something needs to be done to simplify health insurance (and if BPM might be helpful, sure, why not? The more the merrier!).

But I do wish to focus on the BPM at AHIP. I participated in a blab about innovation during AHIP. Almost the entire blab, I’m sure due to my stubborn persistence, was about how Business Process Management is rapidly seeping into healthcare, health IT, and health payer IT. If you are a video-visual person, you could do a lot worse than watching this Youtube of that blab (start about 6:30 to skip introductions and get to the substance).

Last year, since it was my first AHIP (focusing on healthcare insurance payer IT) while I poked around looking for evidence of what academics call “process-aware” IT, I spent most of my time simply trying to understand the health plan space and workflows. This year I searched every exhibitor website for “Business Process Management” or BPM or “workflow engine” and came up with a list of 14 companies, out of almost 200 exhibitors. I then created a set of questions about BPM/workflow tech that I could use to systematically visit and dialogue with these progressive members of the health insurance plan payer community. The questions were just a framework. In some cases, some questions didn’t apply. In every case, new topics organically inserted themselves into the conversation. And, finally bowing to convention, I got a selfie with denizens of each booth. And tweeted out a short précis of what we discussed.

I only made it through seven of the fourteen vendors with interesting workflow angles (plus one), but I had previously prioritized the order so I feel I got a very good sense of the current state of Business Process Management -style tech at AHIP.



I started my tour of workflow duty at the Intersystems booth. By the way, I actually used their object-oriented Caché database back in the ’90s. When I Google “Business Process Management” during HIMSS, and now AHIP, Intersystems always occurs near the top (their Ensemble tech, on which HealthShare is based). I had a great convo with Clint, Clayton, and Brian about the nitty-gritty of what it takes to empower users and organizations with intelligent, flexible workflow. They get it! I’d love to go into more detail here, but if I did, for every vendor, this post would be 10,000 words long. So let me just leave this as this. C, C, and B, I’m greatly looking forward to more world-class conversations about BPM in healthcare.


I’ve been following Box relative to workflow since 2014 (see my Box Brings Cloud-Based, Intelligent, Open Workflow Engine to Healthcare) Recently I’ve seen demos of their Orion workflow technology, which allows Box users to create their own automatically triggered, executed, monitored, and managed workflows, driven by their content stored in Box (the “user-driven process management” in the following tweet). Great to see Box adding workflow tech to their already sophisticated cloud/content tech. I look forward to seeing Orion’s growth and evolution. I could write another couple thousand words here, but I already gotta move on the next AHIP exhibitor vendor with a cool workflow tech story. :)


Virtusa Polaris was an interesting conversation because, unlike Intersystems and Box, they don’t sell software. They sell the ability to understand a healthcare customer and to design, implement, deploy, and management business process management solutions in healthcare. I’m reminded of early days, when clinical folks needed IT folks to implement EHRs. Workflow is a whole other layer and wrinkle. Traditional health IT folks know about data and databases really really well. About workflow and workflow tech? Not so much. Healthcare BPM consulting organizations such as V-P fill that void. Again, I could write a lot more about Virtusa, but I gotta move on in this particular post.


This was a very interesting conversation with Nick Bennett of Cognizant about their TranZform product. But instead of me telling you what Nick said, just skip to the next tweet below and play the embedded 30 video of nick explaining how TranZform uses digital workflow, from enrollment to outcomes, to transform healthcare.

Play it! :)


The following conversation was interesting because Availity wasn’t actually on my initial list. However, they saw me tweeting about AHIP vendors and workflow and basically demanded I come to their booth. I’m glad I did. As Mark Martin explained, they provide the APIs (and a portal) which can be consumed by workflow tech. In fact, if you think about it, even if you have the best workflow engine in the world, you still need the data you need to achieve whatever strategic goal you set. Availity goes beyond currently, typically available standard APIs to empower necessary administrative workflow between healthcare organizations. I love it. Thank you for your enthusiasm, seeing my #AHIPinstitute tweets, and reach out about this important topic.

Kofax (Lexmark)

Kofax was interesting to me because of the way they combine a traditional (but still seldom seen in healthcare) workflow technology, a workflow engine executing workflows created with a workflow editor, with sophisticated document capture, from scanning paper to parsing emails to etc. They showed me an example of automatically understanding a form, and then moving that structured data through a structured workflow, in which lots of workflow stuff happened automatically: archiving, notifying, escalating, etc. And, since these workflow are created in a workflow editor, non-programmers can change the workflow behavior to best suit their needs and preferences.

Viva la workflow (editor)!


Here is my selfie with the Softheon folks…

Here the the web page on the Softheon that got me to their booth…

And here is a tweet linking to an excellent article by Softheon’s CEO about how BPM is new to healthcare, what is BPM, and why healthcare needs BPM.


My last stop during the last day of the AHIP exhibit hall was the Appian BPM booth. Appian’s product is fascinating, because it allows non-programmers (non-Java/C#/MUMPS) to create from scratch, in a matter of weeks, sophisticated workflow apps running on a wide variety of devices. After you design your forms and draw your workflow, native iPhone, iPad, and Android apps are literally one radio-button click away. If the idea of “citizen developer” intrigues you, I hope you’ll ready my lengthy interview with Scott Polansky (@sppolan1 on Twitter), who is on Appian’s health plan payer side.

But I’ll end with a quote from Fritz Hamburger, who is on Appian’s provider side.

“Great to see workflow [in healthcare] takeoff, since Appian does it so well!”

LOL That’s the spirit!

By the way, at this year’s AHIP I successfully recruited Fritz to Twitter! You can follow him at @AppianHealth.

Anyway. AHIP Institute, my second, was awesome. Both in generally, because I got to seem so many HITsm tweeps (see below), because I am seeing a surge workflow tech and business process management too.

By the way, follow me on Twitter, Periscope, and Blab!

@wareFLO On Periscope!


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BPM & Healthcare Q&A with Scott Polansky, Appian Practice Lead for Healthcare Payers

Welcome to one heck of a freewheeling discussion with Scott Polansky, of Appian (Booth 238 at AHIP Institute), about the wide variety of ways to use BPM software to obtain 360-degree comprehensive and integrated views of member patient data, and then do really cool things in real-time contributing to member experience. What stood out to me, after rereading the transcript, is the intriguing fit between Scott’s experience designing management health plan products and his job, since Appian BPM can be used to so quickly create and deploy mobile software necessary to support new health plan products.

BPM stands for Business Process Management. It is rapidly diffusing into health insurance IT infrastructure. I’ve long been a fan and proponent for more use of workflow technology, AKA BPM, in healthcare, so I am delighted to have this conversation with Scott Polansky, Appian Practice Lead for Healthcare Payers.

CW: Scott, tell us about yourself!

Ha! Where do you want to start? I started in this business back when HSA stood for Health Systems Agency, not Health Savings Account.

CW: That was late 70s under Nixon, right? My graduate advisor headed the Health Systems Agency in central Illinois.

Right. I started as a premed major and then got a Masters of Public Health from UCLA. I did product development for health plans, leveraging my quantitative background and what is now called predictive analytics. I sold cost accounting software. Consulted for some boutique consulting firms helping providers get into the health insurance business. I came to Appian because I realized health plans must become more efficient and effective and Appian provides that kind of smart work platform.

CW: I want to drill down on Appian’s special work and workflow secret sauce in a moment. But first, I’d like to follow up on our conversation at Appian World.

CW: You emphasize something you call “relentless incrementalism.” What’s that?

Relentless incrementalism is all about taking a series of small steps toward a goal and being persistent. Even daunting tasks, from eating an elephant (a bite at a time, not that I recommend doing so, I love elephants) to cooking a frog (while doing so, up the temperature a degree at a time, and I like frogs too!) can be accomplished through small but persistent steps. Think of Agile Development, which in my mind is a form of relentless incrementalism.

CW: “Relentless incrementalism.” I like that. How does it relate to health plans and the software they use to achieve their goals?

Good question! Consider different, ultimately flawed approaches, to transforming health plans with information technology. On one hand there are those who are accused of automating “cow paths.” What’s the point if you going to accomplish the same bad workflow faster and more consistently? On the other hand some recommend “big bang” re-engineering: fix all the workflows at once, because you won’t get another opportunity after you’ve automated them. Appian BPM is third way to use IT to transform health data and process management.

CW: Huh! Now you’ve got my attention (though I must admit I do suspect where you are going with this…).

The key to transforming health plan data and process management is through relentlessly changing and improving data and process management strategies, all the way from, perhaps, cow paths, to eight lane super highways, one bite, one degree, one lane at a time. Entire sophisticated health plan software applications can be built in just week, sometimes days. And then, even after they have been deployed, you can gather data (the software gathers it for you) and then use that data to change the software (both data views and process activities) gradually and systematically until you get your desired intended level of efficiency and effectiveness. Figuratively, Appian BPM allows you to automate and then still change, subject to human users’ tolerance for change, until you eat the entire elephant.

CW: I love it! BPM software, and Appian is consistently top ranked in that category by Forrester and Gartner, is so cool.

CW: OK, let’s talk about another couple areas near and dear to my heart. First, let me note, some parallels between your background and my background. I was a premed accounting major. I took a wide variety of operations research and management science courses. I ended up incredibly excited by Business Process Management in healthcare. You were premed. You’re foray into actuarial science and predictive analytics reminds me of some of the topics in those courses. And here we both are, just before the 2016 AHIP Institute and Expo, enthusiastic about what Business Process Management can do for health plans.

CW: So, here’s a question for you. I think it may have been Einstein who said if you can’t explain something simply, you don’t understand it. What is actuarial science and why do we need it?

I am not an actuary. I don’t have that degree or initials after my name. But I am a recovering underwriter.

Actuarial science is using historical data and trends to predict future costs or incidents. Why do we need it? When you are building new products or managing existing products, actuary science allows you to look at historical costs and utilization, and when you put those together you can calculate an overall premium. Note well, actuarial science tells you what the rates should be based on historical data but actuarial science does not necessarily look at market or competitive forces. (BTW, actuaries don’t always appreciate this comment…). Basically, premium pricing is an art form and actuarial is a key input. Folks sometimes joke that actuaries drive down the highway looking in rearview mirror. To drive we need to look both backward and forward. What we seen in the mirror can predict a lot. But sometimes we need to incorporate other information.

CW: You mentioned cost. Do healthcare organizations and health plans know their true costs?

I can definitely say, as someone who used to sell cost accounting software to hospitals and health plans, that the answer is typically no. Hospitals have a much greater sense of their cost and do use sophisticated cost accounting systems, whereas most health plans do not. They typically measure medical loss ratio as an approximation. Ultimately, both health plans and their healthcare organization partners need a better and more comprehensive view into the costs associated with a patient member episode. In fact, I suspect that part of the reason we see such remarkable disparities in pricing, say $4K for vaginal delivery at a good community hospital versus $13K at the downtown medical center, is lack of accurate internal cost information (along with the fact that the patient isn’t paying that difference, rather the insurer is).

In general, providers have better overall cost information that health plans. But even there when you are a member facing a specific diagnosis or procedure, that cost/price doesn’t always add up to the overall cost/price.

To health plans, they may know cost of product lines at the level of commercial vs Medicare. But when you start drilling down toward specific products and benefit packages within product lines, they start losing accuracy, since they don’t have a good way to allocate administrative costs. Also, many companies offer both PPO and HMO products and it is important to price the PPOs higher even though the experience at a specific employer might show the HMO to have a worse claims experience.

Admin costs are maybe 10% so they have pretty good idea of overall costs, but when margins are 1-2% this is still a problem.

CW: How can BPM software, such as Appian’s, help better manage costs?

Whether about costs or care management or market intelligence, most of the software at health plans tends to be fairly siloed. Even when users can get at all the information they need, they’re using swivel chair interoperability, they’re sitting there with three screens on their task and they are looking back and forth trying to connect them.

Plus, a lot of health plans have outsourced a lot care management components. One company is doing disease management and another company is doing DME (Durable Medical Equipment) and then you have the pharmacy benefit management…. the point is you have all these disparate systems. So health plans have a difficult time integrating all this data to obtain a single 360-degree view the member and/or patient. And! Even if they can get this information, the information is so old it is not actionable.

BPM can pull data from different systems and make that data actionable by allowing the user to drill down. Appian also incorporates powerful workflow management capabilities so that tasks can be assigned when data falls outside a prescribed expected value range . As a result providers interacting with health plan get a much better impression of care managers because the care management really do have a more comprehensive and integrated real-time actionable view of patient member data.

By eliminating manual spreadsheets, care management improves and cost overhead drops.

CW: How does Appian’s BPM software help accomplish this comprehensive, integrated, real-time, actionable view patient and member data?

We’re a platform. We don’t have pre-canned applications. We come in to our customers and help them with workflow management and business processes, by using our very flexible platform application to connect and automate data and workflow silos. This platform application is low-code/no-code to it is the actual users who create their applications. At the core of our platform is the concept of a “record” which can be defined by the user. Think of Products, Providers, Members, That is how flexible the Appian software is. Or course IT is still involved, because they provide access to data in existing systems.

We’re not trying to conquer world hunger. We aim for quick solutions and then build off of those. Back to our discussion about “relentless incrementalism”… We see a lot of competitors with large inflexible applications that can take years and millions of dollars to get to a solution. We’re able come in with quick fixes, sometimes in just weeks, that then flexibly scale. Their rebuilt applications can’t be customized anywhere near as much as Appian’s BPM software, in which entire workflows can be reworked without involving traditional programmers.

Another problem with traditional approaches is that companies buy and collect a bunch of company applications that don’t talk to each other easily. With Appian all of our workflow applications automatically already talks to each other because they are on the same workflow platform.

CW What are some other advantages of the Appian BPM platform?

Well, we are the leading provider of cloud-based platform as a service. We give our customers the options of hosting their own applications or host in the cloud. Second, when you deploy a workflow application in Appian, it is automatically available across a wide variety of platforms natively, desktop, iOS, Android, etc. Both of those advantage, cloud and native mobile, is totally where the world is moving. Everyone wants to manage everything from anywhere whenever they want.

CW: I’m reminded of a recent conversation with several consultants aiming to build a practice applying BPM in healthcare (and looking at Appian for the enabling tech). We noted that Appian’s draw-workflow-once, deploy native-everywhere and especially to mobile, would be fantastic for health plan member mobile self-service apps. Any thoughts on that?

Scott: For example, how about providing health plan members with real-time update about their physicians’ schedules? I thought about this the other day, when I was comparing real-time emergency room wait times on billboards as I drove past. Why can’t we do this for physician offices too? Think about the incredible loss of productivity in this world because people show up at the doctor’s office and have to wait for an hour and a half, when the physician knew they are running later. There are plenty of valid reasons for running late. Someone shows up for a routine physical and it turns out they have some significant symptoms that need to be dealt with. Imagine a native mobile BPM app receiving a notification the physician is running late. IT provides access to internal systems, such as scheduling, and mobile, cloud BPM provides the smart workflow and mobile experience necessary to improve health plan customer/user experience.

CW: I love your idea, especially since medical office scheduling systems both drive, and are driven by workflow design and real time workflow state. A schedule is a set of timed tasks kickoffs, with additional downstream tasks, because each schedule appointment is really a collection of tasks. For example, chronic asthma versus camp physical, and so on. If providers and health plans could make task and workflow state more transparent, in real-time, and then feed that out to the folks who need to know that real-time info, it could be a big win-win, for the health plan member and health plan provider.

CW: Let’s see, premed, cost accounting, actuarial science, product development, health insurance… I’m always fascinated by how folks reflect the evolution of an industry. I know we opened talking about how you got to Appian, but let’s drill down a bit more.

Scott: Well, after my MPH from UCLA I did marketing for an HMO, then finance, accounting, underwriting, sales, business development, product management, I really like to move around, learning new things all the time. I think my favorite area is product management, because it bring a lot of disciplines together when your building and launching and managing health plan products you really have to be aware of almost everything going on in the organization, to be able to price these products accurately, you need to be able to market and sell them appropriately, so you have to provide a lot of training and education to sales and customer service folks, and ultimately you need to make these new products as understandable as possible to health plan members.

You have to understand your customer. That’s one of things thats always driven my career, you always have to take the “outside it” route to product development. One of my favorite saying about health payers is we’re too busy looking in the mirror instead of outside the window.

CW: “Outside In.” I like that. It reminds me of I’ve heard of BPM applications as “outside in” systems. IT manages IT infrastructure (networks, hardware) and supplies access to data. Then BPM applications are crafted by, or at least with direct input from users, using low-code approaches, to build from the “outside” (closest to the customer) toward the “inside,” the traditional enterprise transactions systems.

CW: Your background in product management… it seems like a lot of the folks you are interacting with now are probably trying to figure out how to create new products and services for their members.

Scott: What drew me to Appian when I first heard of it is I do not have a software background. I am more of a business and applications guy. What really intrigued me about Appian was this opportunity and ability to start with a blank slate and to connect all of these data sources together and incorporate workflow management plus the sophisticated reporting. Ultimately, it all comes down to providing timely actionable information.

CW: That word “actionable”… how does Appian BPM make health plan data actionable?

Scott: In a couple of different ways. First the data is presented in an appealing and easy-to-use reporting output with a user interface in which you can easily drill down into any and all of the data. You start out at the top of the funnel and then in just a couple clicks you can get down the level of an individual claim. You can start out looking at a specific product line and then in a matter of minutes you can look an entire class of claims, such as how much are we spending on pharmacy for HMO products that have $5000 or more deductibles. That’s just a quick example.

Second, the data is timely and coming from multiple sources. Here is one example from my product background. One of the things we struggled with was that we’d launch a new product, and, unlike manufacturing, we have a large lag between claim information being meaningful and when we could act on that info. When someone has a claim it can be two to three months before it comes into system because maybe the provider sat on it, maybe the claim wasn’t clean, so it has to go back to the provider, the point is there is a significant built-in lag in trying to observe the performance of product form a claims standpoint.

For example, Appian could link drug data (which can impact product performance), for which there is less lag, to product performance. The point I’m making is that with Appian we have the opportunity to link customer service data and product data. In the past I did not have this linked data so I had no idea whether a product was getting an inordinate number of claims kicked back or a large volume of customer inquiries. If we are able link the systems together, I could have had early warning data, in the “canary-in-a-coal mine” sense, whether a health saving account product we launched was a disaster or not. If I had that call volume data upfront we could have made adjustments to the product in a matter of weeks instead of instead of waiting nine months to start seeing some of the financial data. We could have seen the problem sooner in the customer service data.

CW: You’re getting better data sooner and then you are more easily changing your workflows and processes via BPM’s low-code to improve the data.

Scott: Right, it’s Relentless Incrementalism. It comes back to that. We’re able to keep tweaking the products workflows without have to go back to the software vendor for customization. You have much more flexibility with Appian software. Here is a quote from our CEO Matt Calkins who said, “Software in the first 30 years was about efficiency. We see the next thirty years as using modern BPM software to empower.”

CW: Fantastic. I so agree. Well, Scott, I know you have to go soon, so just one more short question. I just want five words from you. You’ve been to AHIP, the America’s Health Insurance Plan conference many times before. Now you are with the Appian business process management company. In five words, what on people’s minds at this years AHIP Institute? What will be in the air, almost symbolizing a moment in time in the history and evolution of health insurance?

Scott: …… [long pause] Can I have seven words?

Chuck: Sure!


  • Consumer Engagement
  • Interoperability
  • Actionable Reporting
  • Efficiency & Effectiveness

Chuck: OK! I suspect you have accurately captured this year’s Zeitgeist at the AHIP Institute and Expo. And I look forward to seeing you there! What’s Appian’s booth number?

Scott: Booth #238 in Las Vega, June 15 and 16 at AHIP. Thank you very much! I enjoyed this.

Chuck: Me too. See you there.

@wareFLO On Periscope!



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