Healthcare Business Process Management, Adaptive Case Management & Process-Aware EHR & Health IT Systems

Health IT

Workflow Complexity: Complicated data and simple workflow is complicated. Simple data and complicated workflow is complicated. Healthcare's complicated data and complicated workflow is hypercomplicated.

No Cost Competition: In other industries, companies are forced to adopt technology to optimize workflow to minimize cost while maximizing flexibility.

Regulatory Environment: EHR and HIT vendors are stretched thin addressing Meaningful Use requirements.

Screens vs. Workflow: It’s easier to appreciate EHR screens (layout of data and controls over space) than workflow functionality (sequences of events over time).

Threat to Revenue Streams: Switching to new platforms is risky and threatens current revenue streams.

Billing Over Clinical Emphasis: As long as the right codes are generated to maximize revenue, nothing else matters.

Skeuomorphism: Misguided attempts to model EHR user interfaces on paper medical record forms.

Workflow Stereotypes: Workflow management systems and business process management once emphasized automating human users out of processes. Not true now!

Not Invented Here-ism: Most academic and commercial BPM activity occurs outside the US.

Paradigm Shifts: You stick with a paradigm unless you’re forced to change. Health IT picked a document-based, instead of workflow-based, paradigm.

*Top Ten Reasons EHR-BPM Tech Is Not (Yet) Widely Deployed in Healthcare

Blog Posts

Healthcare BPM

AppianWorld 2012 Trip Report, Just In Time For AppianWorld 2013 (Plus Ten Questions)

Almost a year ago I attended AppianWorld 2012. I love this conference (been more than once) and frequently tweet about Appian related news and blog posts (and retweet @Appian) especially about business process management in healthcare. I wrote the following trip report (starting below, after my ten questions for Appian) but didn’t publish it at the time. I think the conference was so good and gave me so much to think about that the draft trip report was quite a sprawl of interesting ideas. I kept thinking I needed to get back to it and reorganize, polish and publish. I finally did. On the morning of the beginning of the next AppianWorld conference, AppianWorld 2013!

Why do I go to AppianWorld? It’s a hometown favorite (I can walk to this year’s conference in the Reagan International Trade Center). Appian BPM is an excellent concrete example of how mobile, cloud, and workflow automation are coming together. There are some excellent Appian healthcare BPM case studies. Lot’s happened since last year's conference, including announcement of Appian’s partnership with Quest Diagnostics at the HIMSS conference (here’s my HIMSS conference trip report).

I’ve interviewed a lot of interesting people on my personal blog at I even “interviewed” a website. This year I think I’ll interview AppianWorld 2013. I’ll post my ten questions below. (After them I post my original, but finally published AppianWorld 2012 report.) It’d be great if someone from Appian were to take a stab at answering some or all of my questions. Most of my ten questions could apply to any BPM vendor venturing into the healthcare space.

Thank you for (tentatively) agreeing to this interview!

1. Let’s start of with your recently announced partnership with Quest Diagnostics. It made a splash at HIMSS, enough so I created a POW!HIT! Profile for Quest. (POW!HIT! stands for People and Organizations improving Workflow with Health Information Technology.)

Tell us about what each of you bring to the partnership and what you intend to accomplish together.

2. What is Business Process Management? What is an Intelligent Business Process Management Suite? How are they relevant to issues facing healthcare today?

The Appian combines a number of technologies from which healthcare can benefit, including Social, Mobile, Analytics, and Cloud (SMAC). Let’s explore these in the next several questions…

3. Let’s start with the Cloud. Essential to any BPM system is an “engine” that executes, or enacts, user-to-user, user-to-application, and application-application workflows and processes. And what are advantages of putting this workflow engine in the cloud?

4. How does Appian add Mobile technology to this mix? How can this help healthcare?

5. What is “WorkSocial”? How does Appian deliver it? How can healthcare benefit?

6. Healthcare conferences, such as the recent HIMSS conference, have lots of presentations and exhibiting vendors focusing on Clinical & Business Intelligence. Tell us about Appian’s iBPMS’s Analytics. Are there analytics, available in BPM software but might not be available in non-BPM software, of particular interest to healthcare audiences?

7. Considered separately, Social, Mobile, Analytics, and Cloud technology all seem poised to diffuse throughout healthcare. However, Appian integrates SMAC technologies into a single iBPMS platform. Tell us how this combination works together and how its combination benefits to healthcare.

8. Some of healthcare’s workflows are frequent and routine. Some are infrequent and highly variable, perhaps even one-of-a-kind. How does Appian support this spectrum from predictable to unpredictable workflows?

9. Do you have any other partners and case studies in the healthcare space you could tell us about or to which you could direct our attention?

10. Might we see your booth at the HIMSS conference next year?

Fantastic! Thank you. I’m a fan of business process management and adaptive case management in healthcare. Located, as you and I are, in the DMV region (District-Maryland-Virginia), I’m proud of such a local success story as Appian. And I’m particularly pleased to see your forays into healthcare.

I’ve been to several of your AppianWorld conferences. And I look forward to attending Appian World 2013, in downtown Washington DC!



Finally, disproving "Old news is no news!", here's my AppianWorld 2012 trip report…

Last month I attended Appian World 2012, the BPM vendor’s annual conference. It was a fantastic conference, especially for someone, like myself, interested in application of business process management technology in healthcare. As Ben Farrell, Director of Corporate Communications at Appian said on stage, “Interest in BPM in healthcare is exploding.” So it was an especially exciting time to attend.

[CW: Ben's right!]

Several disclaimers: I am not an employee, customer, or partner of Appian. But I do cheerlead for hometown accomplishments. Appian is part of a remarkable technological and entrepreneurial ascendancy of a DC/VA/MD (“DMV”) metroplex that continually impresses. While I am a proponent of workflow management systems and BPM software in healthcare in general, Appian is an excellent “reference implementation” to which to refer when making these general points.

Second: this post, as most posts on this blog, is heavily influence by the idea that there is a remarkably complementary relationship between BPM technology strengths and EHR/health IT problems. Combining these technologies just makes so much sense. Anyone who reads my blog, or follows my tweets, understands this “broken record” is my brand. If you’re new here, well, you are forewarned.

Third: There’s more than a little editorializing about the sad state of workflow automation in healthcare. The editorializing comes from me, not the Appian presentations. In fact, this "trip report" is more of an admiring reaction to Appian's BPM platform and its potential uses in healthcare, than it is a true trip report.

I loved that kickoff slide:

  • The world’s best way to organize work.
    • Ease of use.
    • Universal participation.

“The world’s best way to organize work,” “Ease of Use,” and “Universal Participation.” Anyone in the EHR and health IT industry must be struck, as I was, that this tag line and these themes resonate with EHR and health IT concerns that many current EHRs and health IT applications get in the way of work, are not easy to use, and divide healthcare into silos of users unable to communicate, let alone coordinate their patients’ care with each other.

If you think that slide about ease of use and universal participation was relevant to electronic health records and health information systems, wait you see this next slide.

For readability and emphasis sake I’ll outline some of the bullets…

  • Easy to create
    • Rapid Application Development – Drag & Drop, No Code
    • Single integrated suite – no integration [required] between BPM components
  • Easy to deploy
    • Write Once, Deploy Everywhere – All Mobile Platforms
    • Instant availability and easy upgrades
    • Identical platform on-premise & cloud
  • Easy to Adopt
    • Elegant interfaces – optimized for every device
    • Simple, no-training social interface
    • Same user experience on every platform
  • Easy to Reuse
    • Reusable
    • Modular components

I dare any health IT professional to claim any of these sterling qualities aren’t relevant to EHRs and HIT. 

Let’s start with “Easy to create.” Most EHRs highly customizable, they have to be. But one thing that is very difficult to customize, without being a programmer with access to their original source code, is their workflow. This is so unfortunate, since complaints by physician users about unusable EHR workflow are rife. That’s the great thing about BPM systems, you don’t have to be a programmer to create and edit workflows. Dragging and dropping, clicking and setting, entire screens, their contents, both for data review and data and order entry, can be customized and then assembled into whatever workflows the users require or prefer.

Regarding “integrated suite” and “components”, both screens and screenless activities can be programmed by non-programmers to work together in ways that EHRs, since they are not based on BPM technology cannot do.

How about “Easy to Deploy?” While some EHRs are making the move to the cloud, so anyone with a browser and a connection to the Internet can be up and running “Live in Five” (minutes, not months), this “Easy to Deploy” means way more than that. It means that the same application created by the domain expert, a non-programmer because they don’t need to be one, can be used on the desktop, over the Web, on a tablet or smartphone, iPhone, Android, and Blackberry (and likely more to come), without having to write separate applications for each platform. How many EHRs can claim this? (Yet.)

Now, what about, “Easy to Adopt”: EHR “adoption” is the subject of much hand wringing, in white papers, on blogs, and the Twittersphere. Given all their obvious benefits, EHR adoption has been frustratingly slow, so much so that the Federal government earmarks billions of dollars of subsidies to encourage physicians and offset productivity loss due to less than completely usable EHR workflow. A familiar refrain in the blog is that solving EHR workflow usability problems requires use of workflow technology, at the very least workflow engines and process definitions, ideally also the other modern aspects of BPM, including process mining, simulation, activity monitoring, and case management.

The “no-training social interface” referred to is the now almost classic activity stream. Folks are used to Facebook, LinkedIn, and Twitter, why not use a similar user interface? It takes less training and is naturally social to boot. Since each platform doesn’t require a programmer to create a different program, and therefore different user interface, consistency across platforms is achieved. So, not only does previous user experience with social media transfer to the EHR, training on one EHR platform (say, desktop Web) transfers to another (say, mobile, or, increasingly, from mobile to Web and desktop)

Finally we get to “Easy to Reuse”. Calls for modular EHR components far outnumbers the number of modular EHR components in evidence. This is in spite of meaningful use certification for both “complete” EHRs and EHR “components”. Oh there are lots of certified components advertised and listed, but true software components can be quickly and easily assembled into complete applications, in this case complete EHRs. The problem is that even if such chimeric applications can be assembled, their workflow is still is less than optimally usable. That is why we need BPM style workflow engine and process definition to more elegantly glue together these components into usable workflow wholes.

From presentation by @SKemsley

The “External Socialization Spectrum” refers to the degree to which an information system can ignore resources (human or not) outside the info system’s organizational confines versus degrees of interacting with, or including, outside parties in process execution. For example, a patient may need to know about an important lab result, but not need to be a full-fledged power user. Or, an outside specialist needs to become a full-fledged user of an EHR in order fully participate as a member of a patient’s care team.

I’ve written elsewhere that patients should be users of EHRs, with defined roles and tasks within EHR process definitions, but that was a comment on someone else's blog, so I think I’ll quote myself here by way of repatriation of content to one of my blogs:

Business process management ideas and software can accommodate both patient-centric and physician-centric emphases. The patient role is a “role”, just as the physician’s role is too. According to the Workflow Management Coalition’s “The Workflow Reference Model” a role is “a collection of participants based on a set of attributes, qualifications and/or skills."

So, what are a patient’s (or customer’s or client’s or whatever is consistent with political, marketing, or ideological orientation) attributes, qualifications or skills? When a process-aware health information system is designed, encompassing patient activities, the patient’s role needs to be defined as part of that design. More abstractly, the patient is a resource (a Human Resource, of course!), just as other users are resources, necessary to accomplish a business process (or clinical process, health process, or just “process”, again terminology varies according to agenda).

Just as physicians, nurses, technicians, transcriptionists, billers, and other staff have worklists in which workitems appear (placed there by a workflow engine executing a process definition, or placed there in an ad-hoc fashion by a human user), patients could and should have worklists of workitems too (perhaps appearing in smartphones). Of course, patients (and physicians and nurses and others too) may ignore these items, in which case these items can be programmed to automatically escalate. Some of these items also may be accomplished automatically or semi-automatically via home or mobile devices on, connected to, near, or ambiently present near, the patient.

Current structured-document, as opposed to structured-workflow, EHRs don’t have the necessary process-centered data models necessary to represent patient and provider roles and to automatically, semi-automatically, or manually (but with real-time activity monitoring and visibility plus subsequent opportunity for design-time improvement) execute, or “enact”, healthcare processes. This is a large part of the reason that I believe that health IT needs to move from debate about patient-centered versus physician-centered design (“Who is the real user?”) to a more encompassing view (including explicit and executable representations) of the processes within which users (including patients) are embedded.” (Link)

The idea of “patients’ work” appears occasionally in research literature, such as here, where they write

“[It takes work to be a cancer patient. During cancer care, all patients navigate the health-care system, communicate with clinicians, and manage information related to their health situation. However, patients’ work remains largely invisible [15–17]; we understand little of how patients accomplish their tasks or how existing systems and services relieve or exacerbate the burden of these tasks….Our study provided several examples of how patients’ work helps detect, prevent, and recover from medical errors. However, current clinical information systems do little to support that work. Generally, these systems do not extend functionality to patients, facilitate information sharing between patients and clinicians, or support clinical interactions beyond the treatment center. Consequently, patients have difficulty accessing and using information to participate in their own care.”

Certainly, there is much discussion of participatory medicine and patient access to their medical record (“Gimme my damn data”). It therefore seems reasonable and sensible to not just design systems to include, not exclude patients, but to choose EHR platforms that make such systems “designable” in the first place. By designable, I mean choosing a platform capable of delivering easy to create, deploy, adopt and reuse: from the patient’s perspective.

Traditional structured-document EHRs, even those based on user-centered design, do not explicitly represent the workflows necessary to include all members of the care team as users. Hence my recent call for process-centered design of process-aware EHR and health information systems.

Back to AppianWorld [CW: the 2012 conference, remember!]...


Mobile user interfaces and experience influences everything these days, from big “targets” to disappearing UI “chrome” to list-like activity streams (promoting “peripheral awareness”). Display on a smart phone, 30 percent of the UI disappears (but is available with a click or a gesture). Display in bigger screen, and see more items per list and more columns. We'll be seeing this come to most EHRs and health IT UIs eventually.

This presentation about adaptive case management (which I’ve written about previously) was one of the most interesting of the conference. There's a bit of debate going on within the BPM industry about structured versus unstructured processes (again, have written about this here).

(The print is small so...) This slide says that ACM...

“provides a support environment for the optimal performance of knowledge work cases in line with stated goals, together with management tools that enable analysis-based improvement of work effectiveness. In an ACM environment work is not carried out according to prescribed process definitions; instead it’s guided by teams of case workers working toward a clear goal, leveraging codified patterns of practice, and complying with rules that specify key business constraints.”

Described this way, but substituting “patients’ health” for “stated goals”, “evidence-based medicine” and “clinical outcomes research” for “analysis-based improvement of work effectiveness”, “care team” for “case workers” and “clinical” for “business” I’d venture to say that quite a few EHR and HIT designers, developers and (especially) marketers would argue “that’s what EHRs do!” “that’s what HIT does!” Well, it certainly what they should do, we can agree on that.

Unfortunately, more EHRs evolved from digital charting and reporting systems. They have lots more bells and whistles these days, especially due a long list is requirements to qualify for twenty-odd billion dollars earmarked for EHRs certified for meaningful use. The problem is, in many cases, these systems are often too difficult for individual users to learn and use, let alone facilitate workflows for the high performance care teams most thoughtful observers think healthcare needs.

What if EHRs were implemented with, that is, on top of, BPM and ACM system foundations? If users don’t like the workflow, if they don’t find them usable, well, change the workflow without having to go back to the Java or C# drawing board.

If user workflow is routine (as it is in many pediatric and family medicine clinics) automate the workflow using BPM process definitions executed by workflow engines. If the workflow is not routine (as say in complicated multiple-disease/system cases) fall back on more general ACM goals and constraints.

In either case, you have a shot at addressing one of the most pernicious and almost universally condemned disadvantages of most traditional structured-document EHRs: lousy workflow. Which should not be surprising. If workflow is the problem, then workflow technology is the solution.

Let's get back to the debate about “traditional BPM” versus adaptive/dynamic case management. Other industries, other than healthcare, have automated many or most of their routine workflows. Workflow that can be represented in advance and automated, has been. Given that these industries are literally decades ahead of healthcare in this regard, this should not be surprising. These industries have already moved on to providing automated support for what Peter Drucker call “knowledge workers”. Aren’t physicians and clinical staff knowledge workers. Shouldn’t healthcare skip traditional BPM and go directly to ACM? (A bit like so-called undeveloped countries skipping the telephone poles in favor of cellphone towers or satellites.)

No. Why? Because we haven’t yet modeled and automated all the routine processes of healthcare that can be modeled and automated. Yes, much of medicine is knowledge work, but a lot of that knowledge is compiled down to repetitive pattern recognition. Ask the pediatrician who loses money if he or she can't diagnose and order treatment for an ear infection in less than thirty seconds.

That same pediatrician, though, does need to deal with complicated cases, in which there is no set chronic asthma process definition to make the EHR behave super efficiently. That is where the ACM comes it. Healthcare needs both: traditional BPM, with it tried and true modeling and execution of healthcare processes; and nouveau approaches managing more complicate cases such as adaptive case management.

Luckily, BPM and case management vendors aren’t standing still. Both are working hard, as Appian is with version 7, to combine user-initiated less structured processing with process definition directed automation, in which tasks and screens are pushed to users to reduce their work and increase their workflow usability.

As a cheerleader for local companies I’d like to think Appian is representative of the best that BPM and case management can offer to healthcare. And I think I am right in this assessment. As noted at the outset, interest in application of BPM in healthcare is indeed exploding. I tweet about it at @EHRworkflow and archive the best of these tweets at http://EHR.BZ (over a thousand links to material at the interface between healthcare and BPM, with more added every week, sometimes every day).

I'll end with a slide from the Beneden Healthcare Society presentation at AppianWorld 2012 (their case study).

  • Questions?
  • Thank you!


Smart Health IT Requires BPM Tech

Over on the EMR & EHR blog @TechGuy titled a post "Is Your EHR Stupid?" I waited a day or two, because I assumed there'd big pile-on of comments, and I was looking forward to reading them. But not a peep. Crickets!

So I wrote my first comment. And then my second comment. And then my third, for a total of almost 2,000 words. Hey, I was asked a question! That's like four times the size of an average blog post. Anyway, after investing all that work, I thought I'd repost my comments here as a blog post.

Here's a roadmap:

  • In my first comment, I equate "smart" with "intelligent" and argue that BPM's workflow engines (AKA process or orchestration engines) are the closest thing we have today to a "brain" we can embed in EHR and health IT systems.
  • In my second comment, I elaborate about physicians's natural and understandable resistance to workflow-oblivious EHRs and health IT systems
  • In my third comment, I talk about screenflow, frozen workflow, Meaningful Use, speech recognition and natural language processing workflow, and mobile and cloud workflow.


Adapted from comment #1:

Question: Do We Need Smarter Users or Smarter User Interfaces?

Answer: Smarter User Interfaces.

Consider the distinction between intuitable EMRs (EMRs that are “figure-outable” by their users) versus intuitive EMRs (EMRs that figure out their users and do something useful with that insight). Intuitable usability corresponds to what I call shallow usability. It’s the “surface” or skin of an EMR.

In contrast, intuitive usability (used “correctly”) corresponds to what I call deep usability. It is about how all the components and processes deep down behind the user interface actively work together, to perceive user context and intentions, reason and problem solve, and then proactively anticipate user needs and wants. Deep usability is like having the hyper-competent operating room nurse handing you the right data review or order entry screen, with the right data and options, at the right moment in your workflow.

To perceive, reason, and act (let alone learn) EMRs need at least a rudimentary “brain.” When many folks think of medical artificial intelligence, they think of medical expert systems or natural language processing systems (rule-based, connectionist, or statistical). However, the most practical candidate “brain” today, with which to improve usability by improving workflow, is the modern process-aware (and context-aware) business process management (BPM) engine (AKA workflow or process engine).

Intuitive EMRs need to represent user goals and tasks and execute a loop of event perception, reasoning, and helpful action. BPM process definitions represent goals and tasks. During definition execution, goal and task states are tracked (available to start, started, completed, postponed, cancelled, referred, executed, etc) and used to coordinate system-to-system, user-to-system, system-to-user, and user-to-user activity.

BPM engines “perceive” by reacting to not just user-initiated events, but potentially other environmental events as well, an example of complex event processing. For example, a patient entering or leaving a patient class or category, going on or off a clinical protocol or regime, moving into or out of compliance, measuring or needing to measure a clinical value, or a clinical value becoming controlled or not controlled, are all complex events that can and often should trigger automated workflow.

Smart EHRs are adaptive, responsive, proactive, and capable of autonomous action.

  • “Adaptive systems: these learn their user’s preferences and adjust accordingly….
  • Responsive systems: these anticipate the user’s needs in a changing environment.
  • Proactive systems: these are goal-oriented, capable of taking the initiative, rather than just reacting to the environment.
  • Autonomous systems: these can act independently, without human intervention.”

Learn, anticipate, goal-oriented, initiative, independent…none of these describe the behavior of today’s typical EMR towards its users. As a consequence physicians must compensate with a torrent of clicks (so-called “clickorrhea”) to push and pull these EMRs through what should be simple patient encounters.

What “drives” this smart behavior? An executable process model. In older terminology, a workflow, or process, engine, executes a collection of workflow, or process, definitions, relying on user input and context (the who, what, why, when, where, and how) to select and control definition execution. If the engine encounters inputs for which there is no model, then fall back on general purpose adaptive case management techniques for tracking goals and tasks, making them visible and actionable by physician users. Traditional BPM technology automates the predictably routine. More recent adaptive case management supports dealing with unpredictable exceptions—the high value-added knowledge work that diagnoses and treats the complicated cases.

Usability can’t be “added” to EMR. It has to inform and influence the very first design decisions. And there are no more fundamental early design decisions than what paradigm to adopt and platform to use.

No matter how “intuitable,” EMRs without executable process models (necessary to perceive, reason, and act, and later systematically improve), cannot become fully active and helpful members of the patient care team. Wrong paradigm. Wrong platform.

A truly smart EHR, on the other hand, has a brain, variously called a BPM, workflow, or process engine. This is the necessary platform for delivering context-aware intelligent user interfaces and user experience to the point of care. Right paradigm. Right platform.

In the spirit of advice from my Speech teacher about effectively and efficiently beating dead horses (”Tell them what you’re going to tell them. Tell them. Tell them what you told them.”)


Do We Need Smarter Users or Smarter User Interfaces?

Answer: Smarter User Interfaces.

Adapted from comment #2:

The workflow-usability connection, or in this case, disconnection, is at the technological heart of what’s wrong with many EHRs today. Most EHRs are, essentially, structured-document management systems. All the bits and pieces of the medical document are stored in rows and columns of databases. And this is fine, as far as it goes.

However, without *also* structured workflows, amenable to execution by workflow engines (also called process engines or orchestration engines in today’s business process management suites), physicians are forced to become workflow engines themselves. That’s what all the clicking is, the clicking that they hate. It’s the navigation from screen-to-screen and the manual triggering of events that should really happen automatically, without requiring physician attention.

Ironically, and I think somewhat cruelly, physicians are sometimes characterized as Luddites for resisting modern, more efficient, technology. This is wrong in two ways. First, the Luddites attacked automated looms (precursors to our modern digital computers since they executed programs stored on punched cards) because they were *too* efficient. They eliminated the need for human labor.

In contrast to those automated looms, and most modern technology today, many EHRs actually create *more* work for physicians (and, unlike the Luddites, they don’t want it). So that particular aspect of the physician/Luddite analogy is completely wrong. Second, Luddites had nothing against modern technology. They were angry and frustrated with their working conditions, such as they were.

That part of the analogy holds up. Much health technology, even while it improves healthcare for patients, isn’t improving the lives of physicians. Until this mismatch between the goals and consequences of EHR technology is addressed and resolved, we will continue to see finger-pointing about who and what is to blame for slow adoption of EHR technology. Speech recognition and natural language processing will be part of that resolution, but it won’t be all of it. That is going to require the embedding of more sophisticated workflow automation into more EHRs.

Adapted from comment #3:

The single most essential characteristic of “workflow” is task sequence. What tasks? What sequence? Task sequence varies greatly across who’s performing the tasks, where the tasks are performed, how the tasks are performed, what the tasks are, and why they are being performed (that’s context, and context drives workflow). By and large, tasks correspond to screens, or subsections of screens, in EHRs. That said, screenless tasks exist. In fact, one way to make an EHR smarter is to turn screen tasks that require user interaction into screenless tasks happening automatically.

But screenflow is a good place to start. Here, the user is the expert. He or she knows what they need to do to do their job and in what order. But, while the user knows best, they don’t know everything. That’s why flexible, user-customizable workflow is so important. Later, after they’ve used an EHR for a while, they need to be able to modify workflows without requiring a trip back to the Java or C# programmer. If that happens, it takes forever, it introduces bugs, the software needs to be redeployed, users need be retrained, etc.

That is the saving grace of modern workflow technology, also called workflow management systems or business process management systems or suites. There’s a workflow engine executing process definitions (turning manual screen-oriented steps into screenless automatic steps). The process definitions can be examined graphically, much like a decision chart, and then edited by someone who isn’t a programmer. This human editor of workflow may be a clinical analyst, or maybe even an ambitious and precocious user, who, after all, knows their own workflow better than anyone else.

Use the Litmus Test for Frozen Workflow. Ask to see a demo. Ask them to pull up some sort of editor and to edit a representation of that workflow. Ask to see the demo again. The workflow behavior should change in the way that one would predict, assuming there is a workflow engine to execute the just edited process definition.

It’s tempting to imagine an alternate history of Meaningful Use, one in which MU features and functionality were implemented on structured-workflow management systems instead of human labor-intensive structured-document management systems. Many screens could be created and edited by non-programmers. Then the workflows could be edited and reedited until users were happy with them, instead of the situation now, in which is workflow is the biggest Meaningful Use complaint (my subjective impression, others may disagree).

Speech recognition and natural language processing technology is a special workflow case. The advantage of this tech is not just that speaking is faster than clicking (not always true, by the way), but that SR/NLP tech typically relies on more sophisticated workflow technology to weave it into point-of-care workflow. Early on this had to be true because layers of workflow were required to catch and correct speech recognition errors.

Now that SR is so good, this workflow technology uses context (the who-what-why-when-where-and-how of what users says or even, heaven forbid, types) to automatically drive workflows. It turns tasks that otherwise require human intervention into tasks executed automatically by a workflow engine.

Right now, speech recognition and natural language processing is viewed an adjunct and value add-on to EHRs, to make them more usable and useful. However, in the not too distant future, as SR/NLP platforms add more-and-more EHR-like functionality, we’re going to seen some very interesting competition: “Don’t buy a clunky EHR when you can have a Meaningful Use certified SR/NLP smartphone that sings!”

But speech/language/workflow tech isn’t the only game in town. Much of the attraction of smartphones and tablets to physicians is that they appear to have much simpler workflows than EHRs. Part of this comparison is an illusion, but part of it is becoming real too. There’s often a direct correspondence between context, app, and workflow. If you want to do one thing, quickly, and that app is on your home screen, and that app has a two or three-step non-branching workflow: fast and easy!

However, mobile apps are “sandboxed” for security reasons, preventing them from easily sharing clinical context. So, while workflow within an app is simple, workflow across apps, in any attempt to comprehensively replicate EHR functionality, gets you right back to where you were, if not worse, with traditional EHRs, at least with respect to workflow usability.

While limitations on secure sharing of clinical data and context across solo apps are being addressed by various cloud-based technologies and platforms, many of these systems also rely on (wait for it…) workflow engines in the cloud. At the recent HIMSS conference I saw some let-us-mobilize-your-legacy-application-without-much-programming-required vendors in the exhibit hall. I suspect that workflow engines play important roles in their Model-Driven Composition Environments (that’s a Gartner term for codeless, or nocode programming).

So, regarding existing EHRs, apply the Litmus Test. Regarding the near future, language technology and workflow technology are traveling into healthcare along with the SMAC techs (Social, Mobile, Analytics, Cloud) in all kinds of interesting and promising ways.

In the short term, what to do? Do a Google search of “workflow” and “EHR” or “EMR”. Check out some of the EHR tag lines. If they emphasis great workflow, well, maybe there’s a correlation with actually having great workflow. (But apply the Litmus Test of Frozen Workflow: trust but verify!)


Welcome To The Healthcare Business Process Management Blog

Welcome to the Healthcare Business Process Management Blog!

I’ve been blogging and tweeting about BPM in healthcare for years, with 200+ blog posts on Electronic Health Records Workflow Management Systems at, over 32,000+ tweets from @wareFLO, and more than 1700 archived links at EHR.BZ. Not all of them are about healthcare BPM, but a majority are.

Physicians are often blamed for slow adoption of electronic health records. They're sometimes compared to Luddites, the workers who destroyed automated looms during the 1700s. This is indeed an ironic accusation, since these looms were precursors to the modern digital computer (they executed "stored programs", essentially punchcards). Luddites didn't like looms because they were too efficient and reduced the necessary amount of human labor to operate. Many physicians don't like workflow-oblivious EHRs and health IT systems because they are the opposite, not efficient enough, creating more workflow for their users. So I need to pivot from the “EHR” brand to the broader healthcare and health IT about workflow, efficiency and productivity I’m already writing about anyway.

Then there’s the “Workflow Management Systems.” Back when I first started writing about workflow automation in healthcare that’s what they were called. Now they’re called business process management systems or, increasingly, suites. Back then a workflow engine, process definitions, and means for a non-programmer to edit definitions to change workflow were all a system needed. At their heart, iBPM (for “intelligent” BPM) suites still have engines and definitions and editors. Now workflow engines are called orchestration engines. They are way down deep within suites of BPM modules adding lots of value.

On this blog, on your right, is one semi-canonical list of intelligent BPM components. On your left, on this blog, is a list of reasons it’s taken so long for workflow technology to diffuse into healthcare and health IT.  I’ve run this list past lots of folks familiar with both health IT and business process management. Most agree it’s a good list, though some will emphasize some obstacles over others (billing's a particular favorite). I’ve placed these two lists, one of problems and one of solutions, on every page and post of because the problem/solution design pattern is so prevalent in our can-do society. No matter what you read, it will be omnipresent in your peripheral visions. Call it overt subliminal advertising, if you will.

Recent increase in interest in workflow technology in healthcare is undeniable. I wrote about it in my recent #HIMSS13 conference trip report. Healthcare is poised to triple investment in BPM tech (above tweet).

In my view this higher rate of investment is the inevitable consequence of years of underinvestment. “Underinvestment”? Perhaps “non-investment” is a better description, as more than once on EHR Workflow Management Systems I’ve referred to a two decade lag in adoption of true workflow automation (such as today's iBPMSs) in healthcare.

We need to move to modern process-aware EHR and HIT platforms. I refer to this as a shift from structured document management systems to structured workflow management systems. The best examples are business process management suites today.

Luckily, many technologies flooding into healthcare IT -- social, mobile, analytics, cloud (so-called SMAC) -- also have workflow engines, executable process models, graphical editors, and other useful BPM-like capabilities. is part of the following strategy:

  • Influence the Influential: Use social media and complementary methods to get process-aware ideas and technology noticed, discussed, absorbed, and acted upon.
  • Highlight the Highlightable: Flush out hidden workflow engines, process definitions, and graphical editors among existing and new EHRs and HIT systems.
  • Reach out to the Reachable: Virtually every BPM professional I've met, in person or online, believes healthcare workflow is ripe for automation (where it can be automated) and support (where can't be automated) using modern BPM and case management platforms, systems, and expertise.

The time is ripe!

Welcome to my new Healthcare Business Process Management blog!

Head of BPM Research at Perceptive SW on Healthcare BPM

Short Link: Last week, during #HIMSS13, I tweeted out individual questions and answers from the following interview with Prof. Hajo Reijers, runner up for “BPM Personality of the Year” in the Netherlands. Here is the combined interview. I've included the original tweets so you can retweet answers to individual questions....

From Prof Hajo Reijers’ personal home page:

“I am a full professor in the AIS group of the Department of Mathematics and Computer Science of Eindhoven University of Technology (TU/e) as well as head of Business Process Management (BPM) Research at Perceptive Software…. My research and teaching focus on process-aware information systems, business process improvement, and process modeling. I am closely cooperating with companies from the services and healthcare domains”

If you read this blog, EHR Workflow Management Systems, or follow me on Twitter at @EHRworkflow, you know how delighted I feel to engage Professor Reijers (Hajo!) in this interview. The good professor is also on Twitter… twitter-profile2

Prof. Reijers, 1. Splitting your time between academia (TU/e) and industry (Perceptive Software) do you ever feel pulled in multiple directions? How are you integrating and synthesizing across roles and subjects? Unexpected advantages?

"Yes, the difference of pace in these domains is what it makes it a bit challenging sometimes. Industrial issues need to be solved yesterday, but an academic puzzle may easily span months. What I try to do is to find a balance between working on what is urgent and what is important. For example, we are looking into a new style of process modeling and need to know how usable it is. So, I am having a lightweight workshop next week with a handful of professional modelers within Perceptive Software, which gives me some tentative insights. Concurrently, I am setting up a much more rigorous experimental comparison that involves a hundred modelers, but will run in a couple of months .

Unexpected advantages? Well, I found out that in industry people seem to take you more seriously when you have an academic affiliation. But that advantage is almost completely negated by those academics who take me less seriously because I do practical stuff!"

2. You’ve authored, or co-authored, over 150 papers, reports, chapters, etc., plus two books. Roughly speaking, how many are directly about healthcare? How would you characterize the current state of the art, regarding relevance of process-aware, BPM-style technology to healthcare and its information management problems?

I would say that 10% of my work is related to healthcare and that this ratio is increasing. The healthcare domain is probably the most underdeveloped area with respect to the use of process-aware technologies. I simply cannot think of a domain that is more functionally oriented, which is an enormous obstacle for the uptake of BPM. I am mildly positive that this situation will improve, though. You can see the influence and positive experiences with clinical pathways, which bring a process focus to the work floor. For example, in China each hospital is required by law to implement IT systems that support healthcare professionals in adhering to clinical pathways. Also, given the enormous pressure on healthcare institutes to reduce costs, handle more patients, and improve safety, I think it is inevitable that process-aware technologies will become widely adopted. It's a pity that it takes so much time and that the current focus is purely on records.

3. When and how did you come to become Perceptive Software’s Head of BPM Research? From your unique perspective, one foot in research and one in industry, what are you most excited about in Perceptive Software’s product pipeline?

I started in this new role in September 2012. Perceptive Software offers a wide suite of products, which include tools to search through large amounts of data, tools to turn unstructured information into a manageable form, a wide set of process management tools, and content management tools (for which it is best known for). What thrills me are the opportunities that there are in combining the data that is collected and managed by what were once separate tools. Process management, for example, will become more effective through deeply understanding the data context of the activities that are being managed. Also, access to historic and contextual data will help to better predict the nature of new cases and how they can be managed best.

4. In an earlier role, I had the opportunity to work with process mining technology that is now part of Perceptive Software. I’ve blogged processing mining of healthcare event data. What is the key to productizing this amazing, and potentially very useful, technology in the healthcare space?

There are some things that have to be in place, of course. The technology must be powerful and accurate; it must also be easy to use and configurable by its target users. Once you have that, what is needed most are success stories. And I think they are coming in fast. One of the postdocs in our group, Ronny Mans, is carrying out a lot of these projects. We have recently used process mining to investigate dental implantology and are turning to eye surgery now. It's amazing what we find out and I think that these insights are hard to get by in any other way.

5. Going beyond process mining how about todays modern business process management suite. I’ve written about why BPM has been slow to defuse into healthcare. What is it going to take, to get the workflow out of hardcoded Java and C# code and into formats more easily created, understood, edited, and improved?

Well, perhaps a certain generation of healthcare professionals needs to die out first. My experience is that many of the younger doctors are more open-minded to the use of technology and are really interested in holistic approaches to improve the quality of care, including BPM. I have seen this during my long-lasting cooperation with a group of Dutch dermatologists, who are willing to try out any good idea. Come to think of it: They are all women as well, by the way--not sure whether this plays a role. And we need people like you, Chuck, who spread the word 24/7. Keep it up.

6. Europe has been, and is, ahead of the US in exploiting workflow management systems and business process management suites. Netherlands appears, to this observer on US side of the pond, to be the largest and most influential center of process-aware thinking and technology in Europe. What are the historical roots of how this came to be?

Here is my ten cents. In many European countries, there is a tradition of purely documenting how work is being done. Perhaps this is still a relic of all these bureaucratic empires we had here. I am not saying that mere adiministration is always that useful but capturing existing operations is at least the basis for thinking about processes and re-thinking them. In the US, there is much more emphasis on direct results. And I admit that it is hard to answer the question of what the ROI is of modeling a process or how it will contribute to quarterly results. Europeans seem more receptive to the idea that you may need to invest in something that pays off in the long run. At the same time, I am still flummoxed about a highly efficient people as the Americans not being interested more in BPM.

7. I understand that you recently came in second place in a contest to chose the “BPM Personality of the Year” in the Netherlands. You mention this during the open session of the recent BPM Round Table in Eindhoven, Netherlands. Have you gotten over this loss?

Ouch, thanks for reminding me. No, I will not get over that.

I grabbed the following shot of a slide shown during your introduction. conference That’s an interesting list of topics:

  • Healthcare
  • Process Improvement
  • Data and Process
  • Visual Analytics
  • Harmonization
  • Public Sector
  • Process Architecture
  • Process Modeling
  • Process Mining
  • Model Management

I arranged them in order from familiar to unfamiliar to a health IT professional. Even “Harmonization” should resonate, since there’s been efforts to harmonize among different healthcare data standards. But one gets toward the bottom of the list it’s less familiar. Those last four terms, process architecture, modeling, mining and management. What are they and why should they interest a health IT professional?

Process architecture is about how processes relate to each other and becomes increasingly important once you start working in a process oriented manner. After all, processes interact in different ways, most notably because people may work in different processes. This topic is about how to capture and manage the relations between processes.

Modeling is mostly about graphical ways to describe processes. Pictures are really liked by people and simplify communication between them about processes. I think it's the most widely researched topic by BPM academics, too.

Process mining deals with techniques to infer from historic records how operational processes actually work. A guy you previously interviewed, Wil van der Aalst, is the godfather of this area.

Finally, model management is about how to deal with large collections of process models. In Europe and Australia, we see that large companies now have repositories of thousands of process models. These are real treasure toves for these companies. Just think how you can use such a collection to identify redundant work and find opportunities to standardize work.

8. What question do you wish that I’d asked? How would you have answered?

That's easy: "The next time you are in Washington DC, Hajo, will you come with me and visit the Smithsonian together? I will give you a personal tour." I would have said: "Gladly."

9. I believe we connected through Twitter. Did I find and follow you first? You’re lots of fun to follow, by the way. Links you share are interesting. And you are very interactive, retweeting and replying and so forth. I’m sure you’d agree that Twitter is fun. But is it useful?

I recall that I found you. You were Tweeting long before I started. Yes, it's highly useful, I would say. First, I thought that Twitter is mainly used by people who wanted to share things like: "Just taken a shower" , "Off to work", and "Busy with stuff". I found out that when you follow the right people that this is an efficient way of becoming aware of great content. In other words, I most value the filtering function Twitter provide me with.

10. This is a request, not a question. Perceptive Software will have a booth at the Health Information Management Systems Society Conference in New Orleans, March 3-7. They were a very active tweeter at last year’s conference in Las Vegas. I hope you’ll monitor the #HIMSS13 hashtag and retweet, reply, etc. Could you tweet an introduction to yourself so I can embed the tweet here, as well as retweet it during the conference?

Thank you Hajo. That was fun!

My pleasure, thanks for having me!

Best Chuck

Process-Aware Info Systems Come to Healthcare: BPM in Healthcare


Process-Aware Information Systems Come to Healthcare:
Business Process Management in Healthcare

Mobile, social, cloud, big data, etc. move over: PAIS.

Process-aware information systems (PAIS) ideas and technology -- workflow management, business process management (BPM), and adaptive case management systems -- are diffusing into healthcare from other industries. A Process-Aware Information System is "a software system that manages and executes operational processes involving people, applications, and/or information sources on the basis of process models." The best known PAIS is a business process management system or suite. BPM suites include many of the following technologies:

  • Executable process models
  • Codeless development
  • Groupware-based collaboration
  • Event-driven processes
  • Process intelligence and monitoring
  • Simulation and optimization
  • Business rule management
  • Process component archives

Some of these technologies have counterparts in healthcare IT. Others are just beginning to appear. Regardless of maturity of individual technology, perhaps the BPM suite's greatest value is as a model for how all of these technologies can fit together.

In some instances, process-aware ideas inform new solutions from health IT vendors. PAIS platforms developed outside healthcare are imported and adapted. Key PAIS components, such as workflow engines and process editors, are embedded in new health IT systems or retrofit to existing HIT systems. A cursory search for "workflow engine" AND "EMR" OR "EHR" in Google turns up increasing hits.

After a short history of process-aware systems, I’ll present a meta-analysis of twenty-five de-identified BPM in healthcare case studies. The de-identification prevents incidental, but unnecessary, commercialism. By “meta-analysis" I simply mean I’ll contrast and combine results from different case studies to identify patterns, disagreements, and aspects of interest to a health IT audience. Cases will be compared and contrasted relative to where in healthcare they occurred (hospital vs. ambulatory, back-office vs. point-of-care, and so on), who sponsored the case (academic vs. vendor), and claimed results (both qualitative and quantitative).

I’ll close with...

  • developing and deploying workflow via cloud (including Amazon and Google),
  • mobile workflow (including cross-platform),
  • structured versus unstructured data and workflow, and
  • how to incorporate social into the mix.

As healthcare avails itself of new platforms-as-services, it will find PAIS under the hood and along for the ride.

Takeaways include a powerful new idea (the executable process model), examples of successful applications of PAISs in healthcare, and a positive but skeptical attitude useful for further investigation. This presentation will be the first place many attendees will hear the next big idea in healthcare IT: process-aware information systems.

My Next Speaking Engagement!


BPM Solutions

Process Orchestration Engine (AKA workflow engine) to drive the progression of work in structured and unstructured processes or cases

Model-Driven Composition environment for designing processes and their supporting activities and process artifacts

Content Interaction Management supporting e progression of work, especially cases, based on changes in the content itself (documents, images and audio)

Human Interaction Management enables people to naturally interact with processes they're involved in

Connected Processes and Resources they control, such as people, systems, data, event streams, goals and key performance indicators (KPIs)

Continuous Analytics monitor activity progress, and analyze activities and changes in and around processes

On-Demand Analytics to provide decision support using predictive analytics and optimization

Business Rule Management systems guide and implement process agility and ensure compliance

Management and Administration monitor and adjust technical aspects of BPM platform

Process Component Registry/Repository for process component leverage and reuse

Cloud-Based Deployment of about features and functions across desktop platforms and mobile devices

Social Media Compatible external and/or similar internal activity streams integrated with workflows

*Adapted from Gartner

Login Form