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

Healthcare Workflow-as-a-Service?

(Remarkably, two days after this interview, about healthcare workflow-as-a-service, a healthcare workflow-as-a-service won KiSSFLOW's War-of-Workflows context. Here's the press release. Thanks for mentioning me KiSSFLOW!) A single tweet can lead to all kinds of interesting conversations! For example, I tweeted about a new workflow-as-a-service for Google Apps. Why? I'm always looking for new, easy-to-use and deploy workflow technology that can be useful in healthcare. (Hmmm. Momentary flight of fancy: Meaningful Use 2.0 certified EHR based on Google Apps and KISSFLOW? Let's see, that'd require a variety of interfaces, lots of domain knowledge, etc. But just think of the scalable, customizable, clinical teamware... ... [Snap out of it, man!] Sorry.)

By the way, just in case you think Google Apps are non-starters in healthcare due to HIPAA, here's a systematic argument that Google Apps can be used in a HIPAA-compliant manner. Be sure to check out this Google Apps and HIPAA Security Standards Matrix!

Anyway, soon I'm tweeting back and forth with KISSFLOW's CTO Mani Doraisamy, half a world away in Chennai, India. One thing leads to another and I nabbed a One-Minute Interview via Skype (below). Afterward, by email, Mani followed up with answers to some very basic questions about how workflow, cloud, mobile, and social are coming together, plus potential implications for healthcare.

First, here's the One-Minute Interview. Mani is so enthusiastic and charming! Be sure to stick around until the second half so you see the big room he'll be speaking to the next day.

One-Minute Interview with Mani Doraisamy, CTO, KISSFLOW
At the very end of this post, I added Mani's unveiling of KISSFLOW at Google I/O. Be sure to watch it too! He demos creating of a workflow in just five steps starting at 3:30.

Mani does not work specifically in healthcare, but in "off camera" conversation, before the official One-Minute Interview, Mani was remarkably well informed. He also asked astute questions about the state of business process management (BPM) and adaptive case management (ACM) in healthcare. So, my questions sought to extrapolate Mani's expertise into healthcare IT and the EHR space, particularly regarding workflow-as-a-service.

My last question for Mani, number six below, simply scratched a personal intellectual itch: how do cloud, mobile, and social fit together? I recently tweeted about this potentially explosive (in a good way) combo.

Mani's answer to this question is amongst the more concise and perceptive I've yet read. Other industries, particularly BPM and ACM, seem further along in leveraging not just cloud, mobile and social, but, intriguingly, leveraging the combination of cloud, mobile and social technology. So read Mani's answer and ponder it's implications for healthcare.

Email from Mani Doraisamy, CTO of KISSFLOW:

Hi Charles, Please find my answers to your questions below:

1. First of all, to make sure everyone is starting off on the same page, what are Google Apps?

Google Apps is an office productivity software on the web. It has mail, spreadsheets and document editing capability similar to Microsoft office. But, you dont have to install it in your machine. It can be accessed on your web browser. It shines when multiple people in your team are collaborating together on a document or spreadsheet.

2. What is KISSFLOW and what value does it provide to Google Apps users?

Google Apps provides free form collaboration. KiSSFLOW is a workflow solution to streamline such collaboration. For example, treatment guidelines for patients requires the team to streamline collaboration for diagnoses. With KiSSFLOW, you can specify the sequence of diagnoses based on the treatment guidelines. Automating such process reduces errors, improves patient safety and reduces cost.

3. Can you expand a bit more on this whole idea of "Workflow-as-a-service"? What are it's implications for IT in general? Health IT in particular?

It has 2 implications:
  • Traditionally, you buy and install workflow software in your computer and upgrade them when new version is available. With workflow-as-a-service, it is available on your web browser over the internet. New versions are automatically upgraded and fully managed by the workflow service provider.
  • You have to pay upfront for traditional workflow software. With workflow-as-a-service, you dont have to pay upfront. You can pay based on your usage month-on-month.
It benefits industries like healthcare that are not tech savy, as it moves infrastructure and software headaches back to the vendors. It lets healthcare companies to focus on their core competency instead of worrying about IT.

4. Is it really possible for a non-programmer to create and customize their own workflows with KISSFLOW?

Yes. There is a difference in the way business users (non-programmers) and programmers think:
  • Business users think only about main flow e.g: what happens when you approve.
  • Programmers think of all the alternate flow irrespective of usage (e.g: what happens when you reject or when there is a clarification).
KiSSFLOW is created with business users in mind. With KISSFLOW, business user has to define only the main flow. KiSSFLOW takes care of the alternate flows.

5. Do you know of any current/potential/planned/imagined uses or use cases for KISSFLOW in healthcare?

KiSSFLOW can be used for automating clinical processes like patient care, safety initiatives and admission processes. Administrative processes like documentation, assessment completion and consent forms are also good use cases for KiSSFLOW.

6. In healthcare, as in other industries, there's much discussion about cloud and mobile and social, but other industries are further along using and even combining them. From your perspective, how are cloud and mobile and social coming together? Lessons for healthcare?

  • Cloud is about operational efficiency - How do you outsource your IT in a cost effective manner. It lets you focus on your core business problem.
  • Mobile is about accessibility and agility - How fast and easily can you access data from anywhere to server better.
  • Social is about customer retention and reputation management - How do we get customer feedback & improve on them and how do we spread the word from happy customers.
Together they create a powerful combination that help us to be better organized internally and customer focused externally. Please let me know if you any more information! Thanks, Mani
And here's Mani introducing KISSFLOW at Google I/O: Mani creates a Google App workflow in just five steps starting at 3:30
If you're intrigued, and do something interesting in healthcare with KISSFLOW, please come back here and tell me about it!

Cheers

Chuck

PS You can follow KISSFLOW on Twitter at @KISSFLOWBUZZ and Mani Doraisamy at @ManiDoraisamy.

BPM in Healthcare is Taking Off!

I’ve been writing, presenting, blogging, and tweeting about HIT / EHR workflow management systems and business process management (BPM) for more than a decade. My 2003 white paper has been number one in Google for "EMR" and "workflow" for years (now watch it drop like a rock!). Also see Well Understood, Consistently Executed, Adaptively Resilient, and Systematically Improvable EHR Workflow.

Here’s an example from 2009:

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

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

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

In a if-you-predict-the-inevitable-every-day-eventually-you’ll-be-right sort of way, I’m finally right. There’s the recent uptick I mentioned at #HIMSS12. Then there are six sessions (below) at the upcoming IBM Impact 2012 Global Conference in Las Vegas. I prefer to link to such content, but for the life of me I could not figure out how to deep link to these sessions, so copy-and-paste it is. I do hope you visit the website and go to the conference (and come back and write a guest blog post here). I added the bolded phrases and comments after each abstract.

To see the "in situ" sessions go here

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

and search for "BPM" within "Healthcare and Life Sciences."

BBA-2108 : Customer Case Study: Cigna Healthcare and BPM process-centric tools
Abstract See how Cigna Healthcare is investing in the innovation needed to maintain its position as a global health services leader by putting the Customer first. Cigna has embarked on what might become their most strategic and transformational initiative ever. Cigna is approaching this complex project utilizing a coherent set of BPM process-centric tools to extract the business rules out of their core systems and business processes. With the ability to link end to end business rules with business process, while supporting business policy, this business led transformation will allow Cigna to strengthen its customer-centric competitive edge while providing the agility needed to grow and evolve over time.

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

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

BBA-1599 : Improving Healthcare Processes and Quality of Care by Leveraging BPM
Abstract Processes within healthcare systems are generally well standardized and managed. Unfortunately, much of the care delivery processes exist outside of these systems. While carried out with the highest degree of good intention and hard work, execution errors often occur in carrying out these processes and there is a high degree of process variability. With this in mind, The Ottawa Hospital is developing a Care Process Management platform leveraging BPM, rules, collaboration and analytics technologies, resulting in improved patient safety, patient flow and providing clinical areas a better view into how their processes are operating and where bottlenecks are occurring in order to solve problems in real-time.

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

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

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

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

TPA-1930 : Case Study (Independent Health): Increase Agility With a BPM Center of Excellence
Abstract Independent Health (IH) is striving to become a more process centered organization in response to the changing nature of the Healthcare Industry. Agility and Process Excellence are key elements in our ability to respond to the demands of Healthcare Reform. IH has recently built a Business Process Center of Excellence and implemented IBM Business Process Manager as our Business Process Management System tool. Learn about IH's experience of building the Business Professional Code of Ethics, the selection process for our BPMS and the actual implementation of our Pilot Project for BPMS

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

TPA-1901 : Case Study (Lund University): Immunization Scheduling Optimization for Business Process Excellence
Abstract Around 1.4 million Children die because of preventable diseases today. Each 193 sovereign states of the world have their own immunization schedule regulating vaccines, doses and intervals. The schedules differ significantly. That is a major problem for General Practitioners (GPs) when fighting to prevent deadly child diseases. The situation is in need of remedy why the VacSam project designed a business rules centric digital service using IBM Websphere Ilog JRules. The immunization practice craves exact conformance to regulations, why the incorporation of SOA, BRA and BPM became a fruitful design method advocating to separate concerns in the SOA, permitting business logic to become boundless available i.e., a Service Oriented Business Process.

Here's some links relevant to the VacSam project

VacSam - Digital eService for Coordinated Vaccination Control

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

in which they say

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

and

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

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

TPA-2593 : Case Study (MedImpact): BPM & Decision Automation for Benefits Management
Abstract Pharmacy Benefits Management is a process-centric and business rules intensive, multi-party information management business. As a benefits management service provider, MedImpact’s value to customers lies in the efficiency of its processes and the implementation agility and accuracy of customer-driven policies for the various benefit management decisions. MedImpact is leveraging the IBM BPM and WebSphere Operational Decision Management products to increase agility, accuracy and auditability of business functions. This presentation will review MedImpact’s success story in implementing BPM & JRules, to automate the Prior Authorization process and Coverage Determination decisions. The presentation will review our goals, challenges, and lessons learned.

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

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

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

TIH-2422 : Transforming Canadian Healthcare - Why The Ottawa Hospital Chose IBM for BPM
Abstract Canadian hospitals and health ministries are focused on improving delivery of health services while managing budgets and satisfying government regulations such as wait times. Health professionals are a highly mobile workforce and recognize everything they do is a process, heavily interactive, but currently in a siloed environment of technologies. No Canadian academic health sciences centre sees more patients than The Ottawa Hospital (TOH). TOH is a leader in healthcare and serves people across eastern Ontario, striving to provide each patient with the world-class care, exceptional service and compassion. This session will discuss why the hospital started the journey with Business Process Management, why TOH chose IBM as its partner, the results and the steps taken on its journey to date. BPM has already provided significant value in areas such as chart management, and is demonstrating how BPM and the partnership with IBM will realize the hospital of the future.

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

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

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

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

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

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

My Next Speaking Engagement!

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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

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