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

Could BPM and Process Mining Save US Healthcare 600 Billion Dollars?

Prof. Wil van der Aalst is not a health economist studying cost, a surgeon promoting safety, or a pediatrician investigating quality. In fact, Prof. van der Aalst is not a healthcare researcher. He is a Dutch mathematician and computer scientist. His ideas and invented techniques are generally valuable to any industry that needs to better understand, manage and improve its processes. That said, about a fifth of his many academic papers deal with healthcare processes and workflow. His ideas about workflow models, patterns, and analytics have been tested generally, across many industries, and specifically in healthcare.

Could Prof. van der Aalst save U.S. Healthcare 600 Billion Dollars? Watch his One-Minute Interview. Read his answers to my questions. Decide for yourself. (Several of my questions have lengthy preambles. I do that sometimes. Feel free to skim directly to his indented responses.) aalst

Prof. Wil van der Aalst's "One-Minute Interview"
(without the "arrowhead")
The above image? It's so you can see Prof. van der Aalst without YouTube's irritating "arrowhead." Below is the actual embedded and runnable One-Minute Interview on YouTube .

Prof. Wil van der Aalst's "One-Minute Interview"
(with "arrowhead")
Here's a mini-table of contents for Prof. van der Aalst's interview: 1. What is your name? Where do you work? What is your role?

"I’m Wil van der Aalst and work as a full professor of Information Systems at Eindhoven University of Technology. I also have professorship appointments at Queensland University of Technology in Brisbane (where I’m now) and the National Research University Higher School of Economics (HSE) in Moscow. Besides running a research group in Eindhoven, I’m also chairing various committees, e.g., the steering committee of the Business Process Management Conferences and the IEEE Task Force on Process Mining."

2. What are process-aware information systems (PAISs)? How do workflow management systems, business process management suites, and recent debate about case management fit into your description?

"Any information system that is supporting processes beyond the limits of individual tasks is a Process-Aware Information Systems (PAIS). Process support in its purest form can be found in Business Process Management (BPM) and Workflow Management (WFM) systems. These systems are driven by explicit process models. Changing the model directly results in changes of the process that is supported: no coding is needed. However, there are also many process-aware information systems where process models are less visible. Consider for example systems where processes are hard-coded or the ERP (Enterprise Resource Planning) systems that can be found in most of the larger organizations. Many people do not realize that larger ERP (Enterprise Resource Planning) systems (e.g., SAP and Oracle), CRM (Customer Relationship Management) systems, case-handling systems, rule-based systems, call center software, and high-end middleware (e.g. WebSphere) are process-aware, although they do not necessarily control processes through some generic workflow engine.

The debate on case management is a bit silly. Note that we were already working on the foundations of case handling long before the term got popular. Also note systems such as FLOWer and ECHO that have been around for a long time. The key problem is to truly support flexibility and to move beyond simplistic flowchart modeling notations such as BPMN and the like."

3. On my blog I've a list of ten reasons BPM has not gained more advocates and use in the US healthcare industry. Top Ten Reasons EHR-BPM Tech Is Not (Yet) Widely Deployed in Healthcare Do they seem reasonable to you? Any other reasons? Any one or two that really seem to be key to you? How?

"The list seems to be very reasonable. The 10 items explain well why there is resistance against adopting BPM technologies. Items 4 (Lack of competition) and 7 (Self-interest) seem very important. I also think that there are additional reasons for the slow adoption:

Governments have been too passive in forcing care organizations to work in a more structured and standardized manner. A nice example is the so-called Diagnosis Treatment Combination (DBC in Dutch) introduced in 2005 in the Netherlands. Every hospital is required to use DTC's in order to determine the total cost of a medical treatment. Hospitals are required to report information in standard form to get reimbursed. The data is collected at the national level and has helped us a lot in our process mining research. It shows that a government decision can result in rapid changes of the underlying processes and IT systems as long as they have the guts to enforce it.

Another factor is the ignorance of end-user organizations of BPM technology (in this case hospitals). They do not know what is possible and therefore do not ask the right questions. As a result, technology providers get lazy and focus on superficial things like user interfaces (see also point 6 on your list). Health care managers and IT specialists need to be educated when it comes to business process management and process mining.

In Europe we are facing another complication. Many of the healthcare related regulations are country specific. As a result, there is no real competition and innovative software products developed in one country cannot simply be used in another country. Here the European Union should be more active rather than spending their energy on talking about Greece’s financial problems."

4. You keynoted the 2004 MedInfo conference in San Francisco. You said you'd looked at every instance of the use of the word "workflow" in the proceedings but, it did not seem to be used in the same way that you and your colleagues use the term. What did you mean? Has there been any convergence in meaning? I don't suppose you've looked at any MedInfo proceedings in the same manner recently, but you may have had other indications.

"There has been a long workflow management tradition in the business area. Already in the 70-ties there were workflow systems in place. Unfortunately, the same ideas tend to be reinvented in different domains. A nice example are the so-called medical guidelines languages (Asbru, GLIF, GUIDE, and PROforma) reinventing basic workflow patterns.

The terms Business Process Management (BPM) and Workflow Management (WFM) also have the problem that people do cherry picking: they focus a particular aspect and abstract from all other aspects. For example, people focus on execution engines and ignore management aspects or people only draw PowerPoint diagrams while closing their eyes for the actual Spaghetti-like processes and complex information systems.

The drawback of people misusing terminology is that some technologies get a bad reputation because of unrealistic promises and organizations do not even try to use them anymore."

5. Your bio notes you've published "more than 150 journal papers, 17 books (as author or editor), 290 refereed conference/workshop publications, and 50 book chapters". You seem interested in any innovative use of BPM or process mining, no matter the industry. However, many of your papers happen to be about healthcare processes. Approximately how many papers related to healthcare processes have you published? Is healthcare a special case?

"The techniques and tools we develop tend to be very generic. We are not interested in tailoring them towards a particular application domain. For example, we have applied our process mining tool ProM in over 100 organizations covering very different industries. I guess that about 20 of my papers are focusing on healthcare applications of our technologies. We have a particular interest in healthcare because processes are much more chaotic than in many other industries, and potential savings are enormous. For example, we did quite some research into workflow flexibility. It is interesting to see that many researchers working on this topic are inspired by applications in healthcare. This illustrates that healthcare is a very challenging, and therefore interesting, application domain for BPM."

6. What is process mining? How is it relevant to healthcare?

"Process mining can be used to discover and analyze emerging processes that are supported by systems that are not even “aware” of the processes they are used in. It is definitely one of the “hot topics” in BPM research and I love to work on it because it is driven by real data rather than simplistic diagrams.

Imagine this: in 2060 your laptop can store the whole digital universe as we know it today. All books, movies, music, articles, the whole internet, etc. known today will fit onto your hard disk in 2060. This can be shown by simply extrapolating Moore’s law. This means that more and more data will be available and we should use it to analyze processes. The “Big Data” wave will also impact the healthcare industry. Unfortunately, most people working with data are not very interested in processes because they lack the proper tools and focus on specific activities rather than end-to-end processes.

See the websites processmining.org and healthcare-analytics-process-mining.org to learn more about applications of process mining in healthcare."

[CW: Also my EHR Business Process Management: From Process Mining to Process Improvement to Process Usability]

7. Many professionals in health IT have had some personal health experience, or observed that of a relative or friend, motivating them to use their knowledge to improve healthcare information management. Do, or can, you relate to this?

"This also holds for me. We have four children and our oldest son Willem has Down’s syndrome. In his first year he had heart surgery because of a serious Atrioventricular septal defect (AVSD). Over the last 11 years he has seen many hospitals from in the inside. Overall, I’m impressed by the work done in hospitals. However, I also see that with our aging population and advances in medicine, it is vital to do things more efficiently. Therefore, I’m eager to contribute. In banks and insurance companies our techniques can be used to make things even more efficient and effective. However, improvements in managing healthcare processes are much more urgent."

8. Are there process-aware aspects of the world we take for granted in our daily lives? (products we buy made possible by process-aware factory automation, smart consumer-facing web services, stuff that happens we don't think about until there is a glitch). Headlines are full of "mobile", "cloud", "social", and "bigdata". Does "process-awareness" not get the awareness it deserves?

"Processes are of course everywhere. When you rent a car, book a flight, buy a book, file a tax declaration, or transfer money there are process-aware information systems making this possible. Processes are as essential as data, but less tangible. Moreover, process support is much more difficult than managing data. Indeed it should get much more attention. The problem is of course that processes have always been there, while “big data”, “mobile computing” and “clouds” are perceived as something new."

[CW: The next question? One of those lengthy preambles I warned you about.]

9. To put the following numbers in perspective, World Gross Domestic Product is about $81 trillion and US and European economies are about $15 trillion each. Over the next ten years the US health industry sector is projected reach $4 trillion. It spends twice as much per capita as other similar industrialized countries. The growth rate of US spending on healthcare is also considerably higher than other similar countries. Health Care Spending in the United States and Selected OECD Countries Why does U.S. health care cost so much? The US is estimated to waste more than $765 billion/year on healthcare spending, one third of the total $2.5 trillion dollar healthcare industry, due to:

  • Unnecessary services
  • Frequency
  • Defensive medicine
  • Unnecessary use of high-cost services
  • Administrative waste
  • Duplicative costs of administering different plans
  • Unproductive documentation
  • Inefficiently delivered services
  • Medical errors
  • Uncoordinated care
  • Inefficient operations
  • Too-high prices
  • Prices higher than competitive levels
  • Excessive variation in service prices
  • Fraud
  • Medicare/Medicaid fraud
  • Insufficient investment to detect fraud
  • Missed prevention opportunities
  • Poor delivery of clinical prevention services
I hate to put you on the spot (actually, I relish the opportunity to do so, in this case), but, approximately how big is the opportunity for workflow management systems technology, business process management suites, and healthcare process mining in US healthcare?
  1. 0 - 7 Billion
  2. 7 - 70 Billion
  3. 70 - 700 Billion
  4. Greater than 700 Billion
Justify your answer!

"As far as I can recall 8000 dollars are spent per person per year in the US (17% of the GDP). Assume that we could save 2000 dollars through process improvement and better IT support. This would amount to 300 million x 2000 = 600 billion. Of course this is just a guess. However, both the absolute numbers and the relative increase in spending due to our aging society show that there is a need for action! Therefore, I appreciate your efforts to bring these issues to the attention of medical professionals and decision makers."

I take it your answer is #3!

Thank you Prof. van der Aalst. It will be fascinating to watch workflow management systems, business process management, and process mining technology diffuse into and throughout US health IT and healthcare.

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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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