Care Innovations on Workflow Management and Telehealth

Telehealth and telemedicine have many implications and great potential for healthcare workflow management. In preparation for today’s #HITsm tweetchat, Remote Patient Monitoring: Opportunities & Challenges, hosted by Marcus Grindstaff (@magrinds), COO of Care Innovations, I looked back over that past four years and picked the juiciest tweets from @CareInnovations to highlight here. Enjoy!

Links tweeted:

The tweets themselves!

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My Foreword and Chapter in Business Process Management in Healthcare, Second Edition

(Excuse my mug! It’s my current @wareFLO Twitter avatar.)


I am delighted to write the foreword to BPM in Healthcare. Forewords traditionally deal with genesis and scope. I’ll tell you why I, an emissary from the medical informatics and health IT community, traveled to another land, that of Business Process Management (BPM). I hope to convince you that the sky is the limit when it comes to the potential scope of BPM in healthcare. And, finally, I assure you this is the right book to start you on your own exciting path to healthcare workflow technology self-discovery.

I first wrote about “Business Process Management” (BPM) in a 2004 health IT conference proceedings paper entitled EHR Workflow Management Systems: Essentials, History, Healthcare. But I’d been writing about workflow systems in healthcare since 1995. From the Journal of Subacute Care:


In 2004 I applied the Workflow Management Coalition’s ( Workflow Reference Model terminology to an Electronic Health Record (EHR) ambulatory patient encounter. (The Workflow Reference Model itself dates from 1994.)


I attended my first BPM conference in 2010 (BPM in Government, which had a healthcare track). At that and many subsequent BPM (and Case Management) conferences I met many of the BPM experts and workflow professionals who co-authored many of the Future Strategies’ publications currently sitting on my own bookshelf. In particular, I’d like to thank Keith Swenson, (My Sandbox, Your Sandbox, in this volume) for answering my incessant questions and welcoming health IT colleagues to BPM venues over the years. Eventually I even became a judge in the annual BPM and Case Management excellence awards.

That’s where BPM in Healthcare comes from in my personal journey. But where is BPM in Healthcare going? The biggest big picture within which to appraise the potential for BPM to transform healthcare is The Fourth Industrial Revolution2. The Fourth Industrial Revolution (also known as Industry 4.0) is not about any individual technology, such as steam power, electrification, or computing (the first three industrial revolutions). The Fourth Industrial Revolution is not even about the Internet of Things (IoT), 3D printing, self-driving cars, artificial intelligence, or big data. It is about the interaction among all these technologies. In other words, The Fourth Industrial Revolution is not about innovative technologies, but innovative systems of technologies. It is about multiple, different, complementary, interlocking, and rapidly evolving technology sub-systems becoming part of an even larger, and way more complex, super-system, a system of systems. Wearing my systems engineering hat, I will argue that the Fourth Industrial Revolution is therefore about processes and workflows.

How do systems engineers manage system complexity? With models. Systems engineers gather data and optimize these models. These optimized models then drive system behavior. Then more data is used to optimize, and so on. In the old days, systems engineers sometimes gathered data with stopwatches and clipboards. I did exactly this, when I built simulation models of patient flow. Today, the Internet of Things and Machine Learning are reducing time scales to collect and process data down to mere seconds. And today, process-aware systems, such as BPM suites, orchestrate and choreograph system processes and workflows, potentially in seconds.

What are “process-aware” systems? These are information systems that explicitly represent, in database format, models of processes and workflows. The models are continually informed by data. The models are continually consulted when deciding what to do, say, or steer next. While process-aware systems “introspect,” they are not “aware” in a conscious sense, but rather in the sense that they can reason with these models; in real-time, in response to their environment and to exhibit intelligent behaviors that would not otherwise be possible.

Currently the industry most adept at representing work, workflow, and process explicitly, in a database, and using this data to drive, monitor, and improve process and workflow is called the Business Process Management industry. Why is BPM so relevant to creating and managing effective, efficient, flexible, and satisfying systems or systems? Because, as Wil van der Aalst, a leading BPM researcher writes, “WFM/BPM systems are often the ’spider in the web’ connecting different technologies” (and therefore different technology systems).

BPM, while not a direct descendent of early artificial intelligence research, inherits important similar characteristics. First, both distinguish between domain knowledge that is acted upon and various kinds of engines that act on, and are driven by, changing domain knowledge. Workflow engines are like expert systems specializing in workflow (warning, a very loose analogy!). Just as expert systems have reasoning engines, workflow systems have workflow engines.

Second, artificial intelligence (AI) and machine learning (ML) are critically about knowledge representation. Early AI used logic; current ML uses neural network connection strengths.

Finally, many AI systems, especially in the areas of natural language processing and computational linguistics, communicate with human users. When I say “communicate” I don’t just mean data goes in and comes out. I mean they communicate in a psychological and cognitive sense. Just as humans use language to achieve goals, so do some AI systems. Communication between humans and workflow systems is rudimentary, but real. Workflow systems represent the same kinds of things human leverage during communication: goals, intentions, plans, workflows, tasks and actions. These representations are, essentially, the user interface in many workflow systems.

To sum up, The Fourth Industrial Revolution is not about any one product, technology, or even system. It is about innovation in how multiple systems of technology come together. Process-aware technology, such as business process management, will play a key role in gluing together these systems, so they can be fast, accurate, and flexible, at scale.

You could go off and read a bunch of books about BPM. There are many excellent tomes. Then figure out how BPM and healthcare fit together. Or just keep reading this Second Edition of BPM in Healthcare.

If you are a healthcare or health IT professional interesting in healthcare workflow and BPM/workflow technology, you could start here:


Aalst, W. Business Process Management: A Comprehensive Survey, ISRN Software Engineering, Volume 2013 (2013), Article ID 507984, 37 pages.

Webster, C. Prepare for a Computer-Based Patient Record That Makes a Difference, Journal of Subacute Care, Vol. 1(3), 12-15, 1995. (

Webster, C. EHR Workflow Management Systems: Essentials, History, Healthcare, TEPR Conference, May 19, 2004, Fort Lauderdale. (

Terminology and Glossary. Winchester (UK): Workflow Management Coalition; 1994 Feb. Document No. WFMC-TC- 1011. BPM in Healthcare (2012) Future Strategies Inc., Lighthouse Point, FL.

Case Management in Industry 4.0: ACM and IoT – see chapter by Nathaniel Palmer” “

Free! My Book Chapter:

Marketing Intelligent BPM to Healthcare Intelligently!

@wareFLO On Periscope!


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What Is The Purpose of A Bee? Preserving Purpose In Medicine

When I heard @StorkBrian and @Paddy_Barrett were co-hosting the #HITsm tweetchat on the topic of Preserving Purpose in Medicine, the following question came to me, unbidden:

What is the purpose of a bee?

You see, Dr. Stork is an inveterate beekeeper. I’ve watched his bees on Periscope and Vine. We’ve discussed beekeeping on Blab (now replaced by Firetalk, get a “ticket” and come to our #NHITweek Firetalk immediately after the upcoming 9/30 #HITsm chat!).

Bees, hives, and honey, constitute one of the most potent collections of metaphors in all of metaphor-dom: busy as a bee, queen bee, hive mind, swarm societies, and honey has been likened to spiritual insight harvested from the ordinary!

I could go all kinds of places with this metaphor. But I will refer you to a wonderful book about work lessons we can learn from bees, called Waggle (named after the dance bees perform to communicate):


Check out the chapter titles. Compare to the #HITsm topics. I’m sure you’ll come up with lots of cool metaphorical ideas! See you at the tweetchat!

Here are the HITsm topics!

Topic 1: When we aim to maintain purpose (in healthcare), what is that purpose exactly? What is it you? #HITsm

Topic 2: How can we as physicians work together to build more purpose for ourselves, and work with organizations to promote it? #HITsm

Topic 3: In what ways can healthcare technology work with physicians to improve the EHR experience? What would you change? #HITsm

Topic 4: What are some strategies for preserving purpose in medicine? How can we bring more compassion and caring to healthcare? #HITsm

Topic 5: Will healthcare become less effective in treating the whole person with less in-person visits & the growth of telemedicine & virtual visits? #HITsm

P.S. More about bees and beekeeping in this wonderful video from Brian!

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Process-Aware Healthcare Marketing Automation Workflow Technology

This blog post is really about marketing automation workflow technology, not healthcare marketing automation workflow technology. But hey, I wrote it in preparation for the #HCLDR tweetchat on healthcare marketing. Workflow technology has so much potential for all areas of healthcare, including healthcare marketing! I’ll be on the alert for tweets that I can cross index back to my favorite obsession, workflow tech! See you there… or saw you there, depending on when you read this… Based on the tweetchat, I may circle back and flesh out the relevance of workflow tech-based marketing automation to healthcare marketing in general.

(By the way, “Process-Aware” is the academic phrase applied to IT systems using executable, introspectable, models of work and workflow.)

What is Marketing Automation?



Workflow Builder. Create customized campaigns from templates or scratch



GOAL-BASED NURTURING Every workflow you build in HubSpot can easily be tied to a clear goal, so you’ll always know what is working


How to Build a Successful Marketing Automation Workflow

  • Determine trigger
  • Determine individual steps
  • Make the workflow live

7 Game-Changing Marketing Automation Workflows

  • Hot Lead Workflow
  • Closed-Lost Reason Nurture
  • Re-Engage Notification Workflow
  • New Subscriber Nurture
  • Mini-ABM Hack (Account-Based Marketing)
  • Nurture By Buyer Role
  • Go-to Customer Marketing


5 Workflow Automation Campaigns to Wow Consumers and Marketers Alike


“X2Flow, is an intuitive workflow designer and engine where you can leverage all the data in X2CRM to model simple yet sophisticated flows incorporating a variety of actions and conditions. Drop down menus and drag & drop capabilities are used to establish ‘triggers,’ along with associated conditions which must be met before any flow is executed. Then the flow actions will be automatically performed, allowing your team to focus on the more creative aspects of marketing”



How Small to Mid-Sized Businesses Can Use Marketing Automation to Sell Smarter, Not Harder



What Exactly is a Marketing Automation System?



Design an email marketing automation campaign workflow with campaign builder


Why marketers should learn how to program [that is, draw executable workflows!]



Bislr Brings a Bunch of New Tools for Easier Marketing Automation



Drag and Drop Designer: Define your marketing workflows with an easy drag-and-drop designer. Build multi-step marketing campaigns visually in just a few minutes


The Future Of Marketing Automation


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Social Determinants of Health: Eat Your Beans? Or Speak Truth to Power?


Before I got the degrees I have (Accountancy, Industrial Engineering, Artificial Intelligence, and Medicine) I wanted to become an Anthropologist! I still read a lot of anthropology. I consider myself a (rank) amateur anthropologist. And I’ve a bit of anthropology in my workflow work, especially ethnography, the systematic study of people and cultures. In that light, take a look at these three quotes about medical anthropology and the social determinants of health.

medical anthropologists have contributed significantly to understanding social determinants of health… through exposing the processes by and through which people are constrained, victimized, or resist external forces in the context of local social service arenas”

“Evaluation of social determinants of health interventions require rich qualitative data in order to understand the ways in which context affects the intervention and the reasons for success or failure.”

Trying to convince poor people to eat vegetables is one thing, acceptable and safe; attacking the inequity in power, money and resources is altogether less safe

That last quote is from Sir Michael Marmot, Chair of the Commission on Social Determinants of Health at the World Health Organization, author of the most authoritative textbook on the Social Determinants of Health, cited over 5300 times in Google Scholar.

The reason I’ve been so interested in medical anthropology, ever since I met of bunch of Med Anthro grad students in medical school, is that “rich qualitative data.” It is the kind of data that systems engineers, such as myself, can use to design products, services, and workflows. This is Applied Anthropology, the “application of the method and theory of anthropology to the analysis and solution of practical problems.” In other words, I’ve aimed to use the methods of anthropology to build systems. This is simply health systems engineering using anthropology as a tool.

I often define workflow to be a series of tasks, consuming resources, and achieving goals. Workflows are represented as models in the computer, and then various kinds of workflow engines operate on them. These are workflow systems. Workflow systems, organizational psychology and culture, interact with each other in complicated ways.

Replace “tasks” with “activities” and you’ll arrive somewhere familiar to anthropological fieldwork. Anthropologists document sequences of activities (particularly rituals). They document resources consumed (animal and non-animal substances, human time and attention). And they speculate about goals served (honoring ancestors, community bonding, satisfying material needs such as sustenance, safety, protection from the elements). Just as workflow professionals do, anthropologists also construct models, of rituals, families, tribes, organizations, etc. Of course, these models not usually recorded in executable formats. Instead they are written about and published in anthropology theses and journals.

Culture greatly influences the social determinants of health. Anthropology is a major contributor to social determinants of health research. Culture and workflow interact synergistically. Field anthropologists understand culture in terms resembling systems engineers understanding workflow. So naturally I am interested in connections between social determinants of health and healthcare workflow.

If you cross index Social Determinants of Health with workflow on Google search, you’ll find lots about including SDoH data gathering in clinical workflow. I’ve included, at the end of this post, some recent tweets with links to material about exactly this. It’s an important topic, but I’m going to pivot in a different direction.

There is another relationship between anthropology and the social determinants of healthcare. Anthropologist study power and the powerless. If you don’t at least acknowledge the role of power, poverty, and powerlessness in poor population health (ppppp!) I submit you are missing much of what is important about the social determinants of health.

I’m not a political person. I don’t tweet about politics much (or sex or religion, for that matter, two other potentially controversial topics). But I also think of myself as amateur political philosopher (I guess I’m an amateur at a lot of things!). If you drill down into the social determinants of health, you land on both political ideology and workflow! Bugger! I love workflow. Political ideology not so much. So this post is a bit of a balancing act.

Medical anthropologists resemble medical professionals, because, well, they are. They take medical courses. They observe strict ethics regarding divulging the identity of their subjects. Many are motivated to diagnosis and improve the health of the communities they study.

One of the most interesting aspects about anthropology, particularly medical anthropology, is a tension between techniques (for gathering data, building theories, leveraging insights) and anthropological social activism. Since anthropologists study power structures and inequity, they are a bit like a journalists torn between documenting and intervening during a news event. They see something unfair, and they are torn between objectively documenting versus getting personally involved. This dynamic can potentially bias the research. I’ve followed debates within anthropology about this tension within anthropological research for decades.

Again, I’m basically just a technocrat in search of tools to better perform my technocratic activities. However I do think it is worth reflecting about not just the technical side of the social determinants of health (collecting, using, etc.), but also the political, economic, and ethical context of social determinants of health as well…

…something to think about, while we debate the finer points of integrating social determinants of health into healthcare, and health IT, workflows.

I’ll end with a couple more quotes.

“a substantial body of scholarly work in anthropology seeks to link wider social, economic, and political forces to local experiences in sickness and suffering

From that 2008 WHO report on SDoH..

“the ‘unequal distribution of power, income, goods and services … the subsequent unfairness in the … circumstances of people’s lives … and their chances of leading a flourishing life’ (p.1) are the primary causes of the poor health of the poor.”

P.S. Here are those tweets about social determinants of health and clinical workflow I promised you!

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