The Power Of Process: Workflow, BPM, and Healthcare


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As healthcare organizations seek to maximize quality and protect revenue, they have discovered that simply investing in new technologies is not enough to get the results they require. It’s imperative that hospital leaders go the extra mile to analyze and improve the processes that drive the hospital.

Meaningful process improvement can be achieved through workflow automation and business process management (BPM), and their benefits aren’t just limited to clinical areas of the hospital. By automating tasks across the enterprise including supporting and operational processes, the hospital could realize significant cost savings and reduction in liability.

Join us for a free web event featuring healthcare thought leader Charles Webster, MD as he shares his insights into ways hospital leaders can take the next steps toward complete automation.

In this webinar, we’ll explore:
The need for workflow/BPM in healthcare
How other verticals are using these technologies to their benefit
Use cases in the clinical space
Use cases concerning supporting/operational processes
First steps to implementing workflow/BPM
About our Featured Speaker

Charles Webster, MD, MSIE, MSIS is a prolific thought leader in the health and health IT space. Noted by Healthcare IT News as one of the most important bloggers in the healthcare IT community and one of the most active health IT leaders on Twitter, Chuck is known to have his finger on the pulse of the healthcare industry. At the recent HIMSS conference in New Orleans his @EHRworkflow Twitter account was the top influencer on Twitter. You can read his blog, EHR Workflow Management Systems, at and follow him on Twitter at

With degrees in Accountancy, Industrial Engineering, Computational Linguistics, Artificial Intelligence, and Medicine, Dr. Webster’s wide range of expertise gives him a unique and comprehensive view into the healthcare sector. He designed the first undergraduate program in Medical Informatics, was CMIO for an EHR vendor, and wrote the first three award-winning case studies submitted for the HIMSS Davies Award for EHR Ambulatory Excellence. Chuck writes about healthcare workflow and related and unrelated topics from @EHRworkflow on Twitter,, and DMV: the District, Maryland, and Virginia.

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  • Aaron: At this time, I’d like to introduce today’s featured presenter, Dr. Charles Webster. Charles, or Chuck as he’s often called, is a prolific thought leader in the health IT community. He was listed as one of the top ten HIT bloggers to follow on Twitter by Healthcare IT News and was a top influencer in social media at this year’s HIM’s Conference. You can follow him on Twitter at @ehrworkflow (, or you can read his blog at degrees in accountancy, industrial engineering, confrontational linguistics, artificial intelligence and medicine, Dr. Webster has unique insights into how healthcare can be improved.He’s noted for designing the first undergraduate program in Medical Informatics and for writing the first three award-winning case studies submitted for the HIM’s Davies Award for EHR Ambulatory Excellence. Chuck is a strong proponent for BPM and Workflow Solutions and today, he’ll be sharing his insights about those technologies and how they could be used in a healthcare environment. Chuck, at this time, I would like to turn the presentation over to you.Chuck: Thank you. I see my slide. Excellent. Well, thank you for that introduction. Are you hearing at that end and I presume out there as well?Aaron: That sounds great.Chuck: Great. Good introduction and thank you to everybody who’s attending this session called, “The Power of Process: Workflow Automation, Business Process Management and Healthcare.”
  • I’ll give a little background. I will argue that healthcare needs business needs process management. I will compare healthcare to other industries. I will look at a couple of use cases, both at the point of care and not at the point of care and then I’ll talk about next steps after the webinar.
  • I could read my bio but it’d be really boring so I’m going to just say it is…
  • …boring…
  • …but a Venn diagram, especially a colorful one, is more interesting. I’ve got these four degrees. I was pre-med accountancy major, eventually went to medical school. I also have a masters in industrial engineering and artificial intelligence with some focus in computational linguistics and cognitive science.
  • Okay. I have a bunch of websites, a bunch of content out there, mostly educational and news. I’m trying to build a community of people who are interested in what the academics call, process-aware information systems. Information systems that actually represent and understand and reason and can improve processes automatically or semi-automatically. http://chuckwebster.comhttp://hcBPM.comhttp://EHRworkflow.comhttp://EHR.bzå
  • You’ve probably seen this big wave and you’ve heard the phrase, “big data.” This is actually an animation. It’s a series of slides so it’s not quite as smooth but you can imagine that wave is moving. I will argue that close on the heels of big data is something I call, “big workflow.”Well, if you ever think of data about data, that’s metadata. Thinking about thinking, that’s meta cognition. Well, workflow about workflow is meta workflow but l like workflow of workflow better as a phrase.
  • Now what do I mean by “big workflow?” Well, about 10 years ago, I wrote a white paper on healthcare workflow that’s been number one in Google, at the top of the first page almost for ten years and I used a phrase there, which is “the workflow of workflow.”
  • Let’s start with the definition workflow. I’ve looked at hundreds and this is my distilled definition. It is simply a series of steps consuming resources that achieve a goal. I’ve seen simpler definitions like series of steps and I’ve seen many much more complicated definitions but we’re going to work with this one.
  • Here’s the visual representation of workflow. We have a series of states. Transitions between those states, that’s a workflow. Theyachieve the goal of of the workflow.
  • Now, let’s think about improving that workflow. Well, that’s a workflow, too. The workflow of workflow is improving workflow. To get from workflow to better workflow into even better workflow is a series of steps and obviously, one wants to creates a virtuous cycle in which you’re improving all aspects of workflow, both reducing errors, reducing variability, increasing speed, reducing cycle time, the amount of time it takes to get from the beginning to an end of a workflow and if you do that, you usually can increase volume of transactions. You’re trying to hit that goal, hit that target and do it with the least amount of resources.
  • My wife, right about now, says, “Chuck, cat, dog, tree.” It’s all very Zen. I realized after a while what she meant was, “What is the simplest set of simple ideas that can only fit together in one way that achieves my goal or communicates my point. I kind of like the way the question marks are over this dog because he’s wondering how things are going to turn out. Well, I think most of us stereotypically would know that this is the way it’s going to turn out. The cat’s up the tree, the dog’s at the base of the tree. I kind of like the way the question marks are over this dog because he’s wondering how things are going to turn out.
  • Well, I think most of us stereotypically would know that this is the way it’s going to turn out. The cat’s up the tree, the dog’s at the base of the tree. Well, I’m going to turn cat-dog-tree into a verb and I’m going to cat-dog-tree workflow.
  • “Engine!” That’s what’s the thing that does the work. In the real world, this is a corvette engine. It does a lot of physical work. In the software world, workflow engines do work for users. They do digital work. Well, how do they know what to do? How do they know which task to hand to which person or which data to download from which database automatically without requiring anybody to click on anything?
  • Well, a workflow engine follows a definition, a workflow definition. Down at the bottom here, we have the definition of definition, speaking of meta. This is from the 1755 dictionary of the English language. It was the first one of a comprehensive nature by Samuel Johnson. He described definition as “a short description of a thing by its properties.” Well, you can describe workflow as a list of steps and a list of resources that are consumed and a goal that is achieved.
  • Well, where does that workflow definition come from? It traditionally comes from a human, someone who understands the work’s domain. Here we have the harried editor, the person understands the domain. They create this process model, a model of the workflow and then that is fed to the machine, to the engine to execute. While it is being executed, things are being tweaked. You’re observing. You’re adjusting the carburetor. If it runs out of gas, you put gas in so there’s kind of a real-time management of the workflow system as well.
  • Well, this is an actual, simplified workflow definition of a patient encounter. Here we have a set of screens. The screens are popping up automatically. A nurse, in the red role, is going to collect some vitals information, enter that into a screen, either by touching things or using speech recognition. Then there is a sequence of screens to well, “Are you on any new meds recently? Should I take any off the list? How about allergies, what are you allergic to?” Then down here in the blue role, we have a physician may conduct several steps, such as doing an exam and then making an assessment and ordering some treatment, such as a prescription that’ll be sent someplace. Then there’s cycle of steps here in the green role (naturally) in which you try to get the money from the insurance company. Someone who understands the patient encounter can model that patient encounter, can create a description of it, a workflow definition. This can be executed by the workflow engine putting the right screens in front of the right person so that they don’t have to click a lot. A lot of folks complain about “click-arrhea,” my analogy to diarrhea, too much clicking. Plus, it can accomplish things automatically in the background, saving a lot of time and, of course, it’s consistent because it’s a computer.
  • The really cool thing from the point of view of meta workflow, the workflow of workflow, big workflow, is while that engine is working, it is generating immense amounts of timestamped data. Up here at the top, we see that 85% of the time, the nurse, and I’m going to bring up my little cursor here, 85% of the time, the nurse chooses to go collect meds and allergies through the template but 15% of the time, she goes over and uses speech recognition to generate a note. Then down here, it converges. You can use this information along with the time of eight minutes between vitals in the note to spot bottlenecks and go and ask the nurse, “Well, why did you take so long and why did you do it this way?” She can explain and you can then change and improve the workflow. Okay.
  • Well, if that was workflow, what is business process management? Well, the BPM industry evolved out of the workflow management systems industry and for a long time, people said, “Oh, that’s just old wine in new bottles.” It’s workflow with a whole bunch of adjectives like transparent, agile, that sort of thing.
  • In fact, the way I think of it is that harried human editor, how about you give that human all kinds of great tools to improve the workflow, either after the fact or to monitor the workflow? That’s called business activity monitoring. By the way, that computer right there, that’s the Altair 8800. It is the first PC. It ignited the PC revolution and it was invented and developed and sold by a pediatrician. I just love to find those connections between the IT and the medical side.
  • Okay. Back to workflow of workflow. If you look up business process management in Wikipedia, there’s a phrase there which is, “process optimization process,” again, it sounds meta, the process of optimizing a process. It kind of should remind you of that diagram I showed you of the workflow of workflow, the steps between bad workflow to good workflow.
  • Well, business process management has a life cycle. Here we have design, model, execute, monitor, optimize. It should be similar to what I just described. Design and model, that’s creating the process definition, the process model. Execute it, that’s what the workflow engine or the orchestration engine or the process engine does. Those are approximate synonyms. Then you’ve got monitoring so while it’s executing, if there’s an exception, if it falls off the happy path, you want a human to intercede and fix the problem. Then optimization, all this data that gets generated can be fed back into reducing cycle time, increasing throughput, decreasing errors, increasing the accuracy with which the goal is achieved and achieving the same amount of work with fewer resources.
  • If that cycle reminds you of something called PDCA, Plan, Do, Check, Act or Adjust, it should. It’s software-based PVDCA. So much of work today in healthcare is being mediated. It is being in … it’s actually in the software and so if you want to improve that work in that workflow, why not use the software to do it?
  • This is the last non-healthcare slide. Just to give you a sense of perspective, the global BPM market is about $3 billion and is heading to about $7 billion over the next four years. It’s growing at about 18% a year.
  • Just to give you a sense of perspective, the health IT market is about a magnitude greater, about eight to 12 or 13 times as big, depending on which year you are looking at in this projection. It’s growing at a rate of about 7%.
  • I strongly believe, and I have been arguing for over a decade, with increasing success, that healthcare needs business process management. Why?
  • The IOM, Institute of Medicine, estimates that the U.S. wastes more than $765 billion a year, one-third of the total $2.5-plus trillion healthcare economy.
  • What’s causing this waste? Unnecessary services, medical errors, uncoordinated care, excessive variation, fraud, there’s a great variety here, such a variety. What do all of these have in common? They all have in common, workflow. They are complicated workflows, complicated processes, complicated series of steps consuming resources and achieving goals or maybe in some cases, not achieving goals. If we modeled more of those and we executed those models and we generated the big data necessary to improve those workflows, we could go a long way to reduce the amount of waste in healthcare.
  • I interviewed the world’s expert on workflow technology. He’s Wil van der Aalst. He’s in the Netherlands. He’s written over 200 papers, chapters, three or four books and about 20 or 30 of his articles are about healthcare. He’s very interested in healthcare and he estimates back-of-the-envelope calculation, mind you, that the U.S. could save as much as $600 billion if we fully adopted process-aware information technology, which is what the academics call, business process management. I think it’s worth reading this quote, “We, the BPM researchers, have a particular interest in healthcare because processes are much more chaotic than in other industries and potential savings are enormous. Healthcare is very challenging, very challenging and therefore there a very interesting application domain.”
  • All right. Slight change of gear, if you’re in health IT, you know that doctors are complaining about EHR usability. Here are some example headlines: satisfaction is falling. Usability is a bigger issue. We need more user-friendly EHR’s. We’ve got a long way to go and editorials that vendors must solve the usability issues. Guess what? These usability issues of EHR is just the tip of the iceberg.
  • …These usability issues of EHR is just the tip of the iceberg…
  • Both EHR’s and non-EHR health IT systems have massive problems with effectiveness, efficiency and user satisfaction.
  • Both EHR’s and non-EHR health IT systems have massive problems with effectiveness, efficiency and user satisfaction. What’s so interesting about those three qualities is they are the International Standards Organization’s definition of usability. “Usable products and services are effective, efficient and they make their users, whether they’re someone clicking on a screen or a patient someplace, happy.”
  • Compare the definition of usability to a definition of business process management. “It is a systematic approach to making an organization’s workflow more effective, more efficient and more capable of adapting to an ever-changing environment.”
  • Effectiveness, effective, efficiency, efficient, user satisfaction, I would argue that the single biggest problem with user dissatisfaction with current health IT systems is that they are not capable of adapting and customizing workflow to their local preferences and needs and to do so overtime, to change as the regulatory environment as the business needs change.
  • Now, I imagine we may have some healthcare process improvement folks out there and so what is the relationship between BPM and the healthcare process improvement? Back when I got my masters in industrial engineering, the management engineers that worked in hospitals and elsewhere, they were involved in both sides of an equation. They were creating and implementing many of the first information systems.
  • I worked in a hospital information systems department where the payroll system had been developed and implemented and managed by a management engineer, an industrial engineer. Then what happened is a bunch of folks went off and they started developing electronic health records and other health IT systems and you’ve got this research behind it, which is medical informatics. I don’t think they spent enough energy and time thinking about workflow problems and workflow theories and creating workflow tools.
  • Meanwhile, over on the other side, we’ve got the total quality management folks, Six Sigma and Lean. They’re finding the causes of errors. They’re finding the sources of variation and eliminating it. They’re figuring how to do the same amount of work but with less waste. Well, the problem is, is that more and more work is actually done in a kind of a mind-meld with the software. We really need to knit together these two traditions and I think that the healthcare business process management hybrid is a way to do that.
  • I go to many health IT and business process management conferences and I have seen many impressive case studies, insurance, banking, manufacturing, energy, hospitality, transportation, trade associations, where’s healthcare? Well, until recently, it’s not been present a lot but it is showing up and those case studies are very impressive. I’ve written about them and I have descriptions of a variety on my blog.
  • Healthcare is catching up! (in use of business process management technology)
  • There was survey recently of IT professionals asking which vertical they were in, which industry they were in and whether they were using business process management or not. Six percent in healthcare were using BPM. Most of these systems are in the back room. They’re used for human resources and for healthcare insurance but that’s moving out of the back room as people see the potential for this kind of technology closer and closer to the point of care. In fact, almost 20% plan future investments and I think that percentage is actually going to be much higher.
  • Okay, healthcare. Healthcare is like a very large insular country that’s been closed off from the rest of the world for a long time but now it’s opening up. The same forces that are affecting many other verticals, such as social, mobile, analytics and cloud, particularly, are also affecting healthcare. These technologies and these new industries, if you look under the hood, often the most successful platforms have workflow automation, workflow engines, the ability to draw out a workflow or to systematically improve the workflow with the data, possibly big data.
  • That is essentially kind of like an epidemiological vector. It is bringing into healthcare workflow automation, which is not to say that workflow automation hasn’t always existed in healthcare, however, it’s not been widely prevalent or appreciated or understood. I think the profile is dramatically rising because of this confluence of these internally developed workflow automation systems and the ones that are being brought in by the social, mobile and analytics cloud platforms.
  • Point of care workflow automation, let’s look at a use case.
  • What is a use case? In Wiki, it says, “A use case is a list of steps to finding interactions between a role, such as a physician or a nurse or someone in the health records department, and a system, such as an information system, to achieve a goal.”
  • That sounds kind of familiar to me, sounds a lot like my definition, a workflow is a series of steps consuming resources, which I think is implied by a use case, to achieve a goal. The difference is, the use case is a list of steps, whereas workflow is the steps themselves.
  • Well, what about a workflow definition? A definition is a short description of a thing by its properties. The most essential definition of workflow is the list of steps. A use case and a workflow definition are approximately similar to each other and that’s part of the secret to the sauce, the fact that a use case could be a drawing of stick figures interacting with a system over time or a pseudo-English description. It’s also a workflow definition, which can be executed and improved by a computer.
  • Here’s the classic-looking workflow editor. If you’ve ever used Visio from Microsoft, it looks kind of familiar. I’ve drawn this kind of thing. I’ve been in a boardroom where all four walls were covered by butcher paper and it was covered with Sharpie pen-written workflows. The problem with those kinds of workflows is after you have it, you have a pretty picture but you can’t turn around, turn a crank and turn it into a computer program. Now, in this case, just to ground it a little bit in the clinical side, we’ve got a patient coming in and they have had a possible cerebral vascular accident and these decision points, the little yellow diagonals, are decisions that have to be made. Should we check the neurological status? Is this a thrombolysis candidate? Have we confirmed that there was an accident? What about hemorrhage? Then a decision. These little icons here, the nurse, physician and so forth are dragged and dropped to create it.
  • Now, I want to compare that classic workflow editor with a simpler workflow editor. In this scene … slide, it doesn’t look that simple but it will look simpler in a moment. If you can think of a health information system or in this case, an electronic health record, as a set of screens but also the little dotted lines, those are screen-less tasks. These screens allow users to review data from previous patient encounters, to enter more data that will be useful in making decisions at later points, as well as order entry screens in which assessments and diagnosis and treatments such as things that’ll send prescriptions off to the pharmacy.
  • Now, the screen-less tasks are also saving a lot of time and effort and money in user dissatisfaction. They’re automatically going to see if there are clinical labs and downloading them and then putting a list, an item in a work list. They’re printing educational materials at the printer that’s closest to the person who’s responsible for the patient. They’re creating automatic reminders based on schedules interacting with business rules or clinical decision rules so that obviously saves a lot of time and effort.
  • Where did it come from this workflow that I’m talking about? Well, we’re going to grab a bunch of those and we’re going to create a workflow.
  • Over on the left hand side, we have … it’s only eight steps, a typical encounter might be twenty steps but we will see what these are because we can look at the pick list that represents the workflow.
  • We have “get patient,” so the nurse walks into the room, says, “I am bringing John Doe into room C,” and then the next couple of screens pop up automatically. The nurse doesn’t have to go and navigate some complicated and clumsy menu hierarchy.
  • We’re going to collect some vital signs….
  • …ask about allergies…
  • …ask about medications…
  • …We’re going to conduct a review assistance and that review assistance will be the right one based on whether it’s a child or an adult, whether that nurse likes … has a favorite review systems or it may be based on the physician that nurse works for and different specialists have different review systems. These systems can be very parameterized so that at each point of step and execution, they do the right thing.
  • The examination step can be an entire other workflow definition, such as a screen to enter history of present illness, a screen for physical exam observations, then assessments and order entry for treatments.
  • …Finally, you get down to the billing steps … [note that we skipped the Evaluation and Management coding step: users are not cogs in workflow machines, they can cancel workflows, skip steps, postpone them, forward them to other members of the care team and so on]
  • By the way, there’s something I call the litmus test for frozen workflow. After you see the demo of a system, say, “I’d like to see that demo again except I want you to make one change. I want you to bring up something that will allow you to edit the workflow.” It might look like that old-fashioned workflow editor with all the arrows and diagonal boxes or it might look like this or it might look like something else.
  • What I want you to do is go in there and change one thing, delete a step, change the order of a step and then I want you to go and do the demo again. If that system has an actual workflow engine that is consulting some kind of representation of workflow, it will do what you would expect it would do if it’s executing that recently edited model so in this case, it should skip the step of checking for allergies, asking the nurse ask the patient about allergies.
  • Okay. Let’s look at a non-point of care workflow automation example.
  • Here is a drag-and-drop hospital workflow definition editor and up here at the top is the beginning of the workflow, down at the bottom and at the end. It’s kind of like a cross between those two previous ones that we just looked at.
  • …okay, we want to drag and drop. We want to create a step which is to go and get a signature from someone. …
  • …Then when that happens, we want to forward it to a role or a group so anybody can look on this list of available tasks as kind of a pooling concept from computers and grab it and say, “Yes, quality assurance, everything has been done that I think should be done.” …
  • …Even the manager gets to see it. We have two levels of quality assurance so everything goes through the manager…
  • …Then finally, we see down here there’s like a little icon of a person and a arrow and going back to a question mark. We want to close the loop. We want to send back information to the person who ordered this workflow to say it was successfully accomplished…
  • …This is just a skeleton of a workflow. We want to go in and customize these steps further. Let’s say we want to go to the manager’s step and we want to give them an option to add a little note so we’ve got the little pen symbol…
  • …Now, suppose we want to make sure that every time that happens, an email gets sent to … maybe this is not the ultimate manager, maybe they’re filling in for someone or it needs to be copied to the other people who also have managing roles that are rotating through this department…
  • Well, now, we have the executable process model. It’s a process model. It’s a process definition. It’s a workflow definition. I’m using these so you get familiar with the terminology, which can vary.
  • The workflow engine looks at it and says, “Okay. I need to send a to-do item to this person. When they click on it, it’s going to pull up this form. It might be in a tablet as they’re wandering around the hospital.
  • Then, I want to forward the results of that into some pool where other people will grab it and do something with it.”
  • It needs … ultimately, everything … the manager has to sign off on everything because in this place, they have two levels of quality assurance
  • …and finally, we want whoever initiated this needs-to-know that it was done so we’re closing the loop….
  • [and the workflow terminates]
  • All right. Now, I don’t have enough time. This is cat, dog, tree version of business process management but I did want to pull out an example number from a case study. There was a paper manual process for creating … generating the patient admissions packet in a hospital. It cost $2.40, it was estimated. Then, after the workflow was automated using a workflow engine and process definition and so forth, the cost per packet dropped to $0.45. This is on the border of increase in productivity of three or four hundred percent.I’ve seen this before and what’s fascinating is, I’ve seen many manual paper processes automated that did not use workflow automation, did not use true workflow automation with the workflow engine doing all that work. Guess what? Those end up reducing productivity. People have to click a lot because if there is no workflow engine in the computer, the human has to do all that work and they got to click, click, click and they complain about that. Other things … the other dimensions of increased productivity are things like if you greatly reduce the cycle time so if all the steps are not having to wait around for someone to pick up the baton and move it to the next person, flow is going to happen more quickly. When you get a shorter cycle time, you get higher throughput and for the given amount of resources, you’re going to be able to scale up or you’re going to achieve the same amount with reduced resources.
  • All right. If my enthusiasm, my animations and this data has convinced you, “Maybe I ought to investigate this further,” this is my workflow of where to go. You might call it meta-meta workflow, the workflow of workflow of workflow. We’re learning right now. That’s what we’re doing right here. Well, you kind of … this is called a split, by the way and it is a … both of these happen in parallel and you look at your environment and you say, “Well, what are the high value workflows? What are the things …” and we’ll … on the next slide, we’ll talk about what is a high value workflow an those workflows, the details about those workflows will inform you about a set of requirements so that you can compare workflow products or workflow platforms or vendors.
  • Let’s look at workflow value. Workflow value is a function of a number of users. The more users that are use it, well, then the more valuable it’s going to be, more happy people, the greatest good for the greatest many. The more frequently the workflow is executed, the more valuable it will be. If it’s executed every fifteen minutes, it’s going to be a lot more valuable than if it’s executed every couple of weeks. The financial value is important. Is there something writing a check at the end of the successful workflow? Then finally, the difference between a better workflow and the current painful workflow, the current ineffective, inefficient and unhappy user workflow, the bigger that is, the more the workflow value is going to be.
  • Okay. Well, once you’ve done that, you need to winnow down those workflows a little bit further. What you need to do, because you need to walk before you run, you need to say, “Well, what are the low complexity workflows? What are the workflows that will be easiest to accomplish? Because a lot of people are going to be watching and you want to plan for success and so you want to do the things that are going to give you the biggest bang for the buck and then people are going to line up because of the latent demand for fixing workflow problems.
  • What is workflow complexity? It is also the number of users because users are different so you have a lot of users and they’re all different. Well, guess what, that causes complexity. Now, you’ve got the number of steps. The more steps that you have to model and to execute, the more complicated the workflow definition, the more complicated the executable process model will be. The more other systems that the system has to touch, the emails that need to be sent automatically, the data that needs to be downloaded from a clinical laboratory or the prescription that needs to be sent someplace or the database in the medical records department that has patient demographics and forms content, the more complicated the workflow is going to be.Then finally, the more logically complex the decision making and the problem solving across that workflow, the more complicated the workflow. The simpler the decision making, the more likely you can create an business rule someplace, but some business rules are more complicated, the more you’re going to require human intervention and that equals complexity.
  • You scan your environment and you say, “Here’s all the workflows.” You grade them according to high value versus low value, low complexity versus high complexity and while you probably don’t want to bother with low value, anything, low value, low complexity, low value … certainly not low value high complexity…
  • …but you want to start with a success because people are watching. You choose that and when you’re successful, you then start to move up into more complex but also higher value.
  • Now, we finally made it down to actually tackling that workflow. Where is the knowledge that is going to make you successful? Well, business process management, especially in healthcare and workflow automation, workflow management systems technology, case management systems, the terminology hasn’t yet been standardized and the best practices have not been standardized. You kind of need to go native with the vendor.
  • The vendor has a track record of success. They know what works. They’re invested in your success and so you need to spend the amount of time they think you need to spend the amount of time on training and so forth and so on. In a sense, you’ve got to pick the right Kool-Aid and then you’ve got to drink that Kool-Aid. You’ve kind of got to go native in order to bring the workflow mindset, the workflow culture from the vender over into your organization.
  • Okay. We’re closing here and I just want to show that big data slide. We’ve got this wave. It’s in the headlines but I am firmly convinced that even more important than big data is big workflow. Big workflow requires big data. It requires the data necessary to systematically improve workflow based on analytics that are hooked to things like cycle time, throughput, patient safety and so forth and so on.
  • I’m very, very cheerful and optimistic about more and more of this kind of technology, workflow engines, process definitions, workflow management systems, workflow automation, business process management, case management, these are all kind of mixed together in amalgam. I call it “healthcare business process management”. Now, some people have a problem with the word “business” in healthcare and so you’ll also sometimes see healthcare process management or care process management but if you drill down and you look in the footnotes, you’ll typically see workflow engines, models, executable models of work.I’ve created a website at, for healthcare business process management dot com. Hope you’ll stop by. I’ve got lots of content there and links off to case studies and so forth.
  • One more thing, I love hearing workflow success stories regardless of whether they involved workflow engines or not. I’ve created a directory on my kind of Twitter account website which is at, POWHIT, P-O-W-H-I-T, links on the next slide too. POWHIT, that stands for people and organizations improving workflow with health information technology. POWHIT is kind of like those call outs that you’d see during a fisticuffs scene in the old Batman series, just trying to give it a little zip.
  • Okay. Finally, we’ve come to the end here. I think we’ll probably be holding questions until after Shawn has his chance to present. I do want to mention again, my blog, my Twitter account at I think I’m pretty interactive and I want to thank the folks down here at the bottom, Brown Selasie, Professor BPM in the Netherlands, Ryan Lucas, M Luxton’s a great guy, you should follow him. They’ve been re-Tweeting links about this seminar and they have been Tweeting me and saying, “How are the slides coming along?” It’s a very jovial community. It’s a good community to join if you want to learn about this kind of stuff.
  • [I answered each of these questions to the best of my ability, extemporaneously , with in extreme time constraints. Each deserves at least a complete blog post…what a great idea!]Well, I’m not even sure that the idea of a workflow champion necessarily makes sense to me. I think that if you give people the tools to improve the workflow around them, they will tend to want to do it, especially if you can demonstrate to them. I guess you do need a champion for that first workflow, whoever owns the high value, low complexity workflow, that’s the champion. In fact, I didn’t show all of the dimensions. There’s actually about three or four dimensions to both value and complexity and one of the values, one of the dimensions was … had to do with executive sponsorship and/or a champion. It’s a little bit like looking for your keys under the lamp post because that’s where you can see, so as you look As you scan the environment, one of the three or four or five things that will determine whether a workflow is a high value workflow or not is whether there’s a natural champion who can help shepherd the project. So, the answer to who is going to be the champion has to be answered on a case by case basis.[That said, I do think there is also the role of champion for workflow technology, for bringing business process management software into a healthcare or clinical environment. I’ve seen CIOs perform this function, but also management engineers and CMIOs (Chief Medical Informatics Officers).]
  • [I answered each of these questions to the best of my ability, extemporaneously , with in extreme time constraints. Each deserves at least a complete blog post…what a great idea!]It tends to be very, very sort of domain-specific. Are we talking about the medical records department? Are we talking about the ambulatory? are we talking about managing some kind of process in the executive suite? Probably, for good, specific examples in this case, Shawn might be the best source.Shawn Curtiss (of FormFast, who hit’s the ball out of the park!): Yeah, we typically talk with our customers about their high volume forms, and there are a lot of things that aren’t that complex. A lot of them … a lot of the processes don’t have a definition around them today even so things like employee on-boarding and all the things that are spurred around that, requesting access to systems from IT, requesting security badges and clearances from the security department so as you on-board an employee, those are simple processes but maybe you don’t have full control over those. Kind of the other side of this too is, what’s the impact of not having full control over these processes? When that employee terminates, do you know what systems they have access to? Do you know what security passes they have on them? Do you know what equipment has been issued to them? Being able to take those processes from the simple aspect of, “Geez, we just hired somebody, they need these items,” and then turning that into, “Now we have an inventory of what every employee has,” and extending it because now we can leverage technology rather than crap knowledge to do that. Another high volume application that a lot of our customers are using are employee change orders so when they transfer from department to department or change a rate or hours, those are very high volume transactions in those processes, especially in some of the larger organizations. There are a lot of employees to do deal with. There are all kinds of processes that can be automated and of course, the number one process would be admissions, generating the right content at the time of admissions and making sure you get that right so that patient care flows properly and so that billing flows properly. It affects a lot of things, getting that right, getting signatures in place. That’s one of the core processes of automation. That’s a low-hanging fruit as well.
  • Aaron:Another question that we got via the chat states, “How would you manage the ‘But we’re special,’ pushback,” most BPM theory gets from clinical care teams? Chuck, do you see that type of pushback?[see next slide]
  • Aaron:Another question that we got via the chat states, “How would you manage the ‘But we’re special,’ pushback,” most BPM theory gets from clinical care teams? Chuck, do you see that type of pushback?[see next slide][I answered each of these questions to the best of my ability, extemporaneously , with in extreme time constraints. Each deserves at least a complete blog post…what a great idea!]Chuck: Yeah. Yes, I do and I think … and again, you only have enough time to cover what you can cover and I think I was pretty organized and spoke pretty quickly but if you go back to … I think, can you put me back on the [third slide] slides? Okay, the fifth one down, Adaptive Case Management Global Excellence Awards. I’m actually a judge on that. You saw the quote from Wil van der Aalst, in which he said that healthcare is more chaotic and more unstructured. Within the business process management community, there has been a similar reaction to overly rigid process models and part of the tribe of rebels, they’re into something they call adaptive case management. These systems, they come out of the business process management community but they very much diminish emphasis on that network diagram that says this has to happen and this has to happen. In fact, what they do is they represent very high level goals, like this case is 25% done or we have obtained the signature. It doesn’t say how to get the signature. Anybody can get the signature but what they do emphasis is visibility. Visibility:here are the set of goals. Anybody can accomplish it based on certain constraints. I mean you have to have the authority and so forth. Then everybody sees as the case moves along, what’s being accomplished and then people jump in more dynamically. What these systems emphasize and represent is *what* needs to be done, not *how* it needs to be done. There are some very interesting adaptive case management systems that I think would be great to show to those folks who look at a traditional BPM system and look at that workflow and say, “Well, we can’t imagine ourselves fitting ourselves into such a rigid structured workflow.”
  • [I answered each of these questions to the best of my ability, extemporaneously , with in extreme time constraints. Each deserves at least a complete blog post…what a great idea!]I’m interested in workflow across organizations. In fact, integration engines and interface engines, where various kinds of messages to be passed through from organization to organization have a lot of business process management-like qualities and a lot of BPM engines also have adapters that allow them to transform and transport messages. There’s actually a lot of overlap. I focus workflow within the organization partly because I don’t think you can have great workflow between organizations if the organizations themselves don’t have great workflow inside. I don’t think you can build a strong bridge out of mediocre materials. That’s just a personal ax I have to grind but there are lots of orchestration engines out there in healthcare that have business process management-like characteristics and so I do see kind of a great convergence. A rose by any other name, as long as it models the process and whether it’s inside the organization or outside the organization, if it provides transparency, scalability, flexibility, that’s great.
  • [I answered each of these questions to the best of my ability, extemporaneously , with in extreme time constraints. Each deserves at least a complete blog post…what a great idea!]Yeah, very sympathetic to that. I’ve worked in a hospital MIS department and we did an environmental scan and we ended up with, I don’t know, a hundred information systems and this was 20 years ago. None of them talked to any of the others and now some of them talk to each other. I guess there’s some progress there. One of the measures of complexity in ranking workflows was how many systems does it touch or need to integrate with. If it needs to integrate with a bunch of systems or it needs to integrate with a system that you cannot integrate with, that makes it highly complex. I think you need to start with the workflows that can be successful because if they’re successful and people understand the benefits of a process-aware philosophy and of using workflow engines and so forth, then that’s going to put pressure to open up other systems to they can participate in this larger workflow highway that’s being created. I know that doesn’t really address a particular system but it does give you a route forward,to strategically bring in trueworkflow automation into a hospital environment. [It’s also worth a quote here, from Wil van der Aalst “WFM/BPM systems are often the “spider in the web” connecting different technologies”So, in other words, BPM may be useful in connecting workflows between previously unconnected hospital systems. For more… ]
  • [I answered each of these questions to the best of my ability, extemporaneously , with in extreme time constraints. Each deserves at least a complete blog post…what a great idea!]I used to give a three-hour tutorial on workflow automation and healthcare at the old TEPR Conference (Toward the Electronic Patient Record), which is gone. I did that for three of four years running and I turned those into blog posts. I actually have a blog post, if you’ll leave me a comment or contact me to a contact form, in which I talk about non-value added versus value-added activities in a workflow automation context. If you give Lean and Six Sigma professionals, you’ve give them trulyplastic, instrumented, malleable healthcare workflow information management tools, I think you’re going to turbo-charge and give a great deal of help to those Lean and Six Sigma activities. In fact, the BPM professionals, they don’t necessarily know the healthcare domain that well. It’s be great to better marry healthcare domain content expertise, the Lean and Six Sigma health professional, to the software that increasingly mediates healthcare workflow.[Wrap up!]I’d like to thank everybody who attended but especially everybody who I interact with on Twitter. If you’re not on Twitter, come and get and interact because it’s a fun community and a great way to learn about this stuff.
  • The Power Of Process: Workflow, BPM, and Healthcare

    1. 1. With CompleteSpeaker’s Notes!The Power ofProcessWorkflow Automation,BPM* and Healthcare*Business Process Managementv.12http://ChuckWebster.comhttp://EHRworkflow.com
    2. 2. http://ChuckWebster.comhttp://EHRworkflow.com• BPM Background• Healthcare needs BPM• Other industries• Point-of-care• Non-point-of-care• Next steps2
    3. 3. http://ChuckWebster.comhttp://EHRworkflow.com Webster,MD, MSIE, MSIS• Accy, Industrial Engineer, AI, Medicine• Hospital MIS, Professor, EHR vendor• Designed first undergrad medicalinformatics program• Workflow: 200+ blogs, 20,000 tweets• Adaptive Case Management GlobalExcellence Awards• IEEE Task Force on Process Mining3
    4. 4. http://ChuckWebster.comhttp://EHRworkflow.com Webster,MD, MSIE, MSIS• Accy, Industrial Engineer, AI, Medicine• Hospital MIS, Professor, EHR vendor• Designed first undergrad medicalinformatics program• Workflow: 200+ blogs, 20,000 tweets• Adaptive Case Management GlobalExcellence Awards• IEEE Task Force on Process Mining4
    5. 5. http://ChuckWebster.comhttp://EHRworkflow.com Webster,MD1, MSIE2, MSIS3, BSA45Pre-medAccountancy4ArtificialIntelligence3IndustrialEngineering2Medicine1Cost WorkflowComputers HealthcareHCBPM
    6. 6. http://ChuckWebster.comhttp://EHRworkflow.com Online Resources6
    7. 7. http://ChuckWebster.comhttp://EHRworkflow.com
    8. 8. http://ChuckWebster.comhttp://EHRworkflow.com 8
    9. 9. http://ChuckWebster.comhttp://EHRworkflow.com Definition of WorkflowSeries of steps,consuming resources,achieving a goal.9
    10. 10. http://ChuckWebster.comhttp://EHRworkflow.com of WorkflowWorkflow10
    11. 11. http://ChuckWebster.comhttp://EHRworkflow.com of WorkflowWorkflowEven BetterWorkflowWorkflow of WorkflowBetterWorkflowWorkflow of Workflow11
    12. 12. http://ChuckWebster.comhttp://EHRworkflow.com Dog. Tree.12???
    13. 13. http://ChuckWebster.comhttp://EHRworkflow.com Dog. Tree.13
    14. 14. http://ChuckWebster.comhttp://EHRworkflow.com
    15. 15. http://ChuckWebster.comhttp://EHRworkflow.com Definition.15
    16. 16. http://ChuckWebster.comhttp://EHRworkflow.com Definition. Editor.16
    17. 17. http://ChuckWebster.comhttp://EHRworkflow.com Power of (executable)Process (models)17Executed By CreateWorkflow DefinitionProcess Definition
    18. 18. http://ChuckWebster.comhttp://EHRworkflow.com 18UnderstoodByThe Power of (executable)Process (models)CreateWorkflow MapProcess Map
    19. 19. http://ChuckWebster.comhttp://EHRworkflow.com 19Business Process Management???
    20. 20. http://ChuckWebster.comhttp://EHRworkflow.com 20Business Process Management
    21. 21. http://ChuckWebster.comhttp://EHRworkflow.com 21Workflow of Workflow"processoptimizationprocess”
    22. 22. http://ChuckWebster.comhttp://EHRworkflow.com of Workflow"processoptimizationprocess”
    23. 23. http://ChuckWebster.comhttp://EHRworkflow.com (plan–do–check–act/adjust)Workflow of Workflow"processoptimizationprocess”
    24. 24. http://ChuckWebster.comhttp://EHRworkflow.com BPM Market Size$0$1$2$3$4$5$6$7$82012 2013 2014 2015 2016 2017 2018Billions24Annual Growth Rate ≈ 18%
    25. 25. http://ChuckWebster.comhttp://EHRworkflow.com BPM Market Size$0$1$2$3$4$5$6$7$82012 2013 2014 2015 2016 2017 2018Billions25Annual Growth Rate ≈ 18%Health IT (magnitude larger): Annual Growth Rate ≈ 7%
    26. 26. http://ChuckWebster.comhttp://EHRworkflow.com
    27. 27. http://ChuckWebster.comhttp://EHRworkflow.com is estimated to wastemore than $765billion/year on healthcarespending, one third of thetotal $2.5 trillion dollarhealthcare industry27
    28. 28. http://ChuckWebster.comhttp://EHRworkflow.com Does HealthcareCost So Much?• Unnecessary services• Defensive medicine• Unnecessary use of high-cost services• Administrative waste• Duplicative costs ofadministering differentplans• Unproductivedocumentation• Inefficiently deliveredservices• Medical errors• Uncoordinated care28• Inefficient operations• Too-high prices• Prices higher thancompetitive levels• Excessive variation inservice prices• Medicare/Medicaid fraud• Insufficient investment todetect fraud• Missed preventionopportunities• Poor delivery of clinicalprevention services
    29. 29. http://ChuckWebster.comhttp://EHRworkflow.com 29“We have a particularinterest in healthcarebecause processes aremuch more chaoticthan in many otherindustries, andpotential savings areenormous….healthcare is a verychallenging, andtherefore interesting,application domainfor BPM.”
    30. 30. http://ChuckWebster.comhttp://EHRworkflow.com From The Headlines!30
    31. 31. http://ChuckWebster.comhttp://EHRworkflow.com IssuesTip of IcebergEHR31
    32. 32. http://ChuckWebster.comhttp://EHRworkflow.com IssuesTip of IcebergEHREHR & non-EHR ITEffectiveness,Efficiency,UserSatisfaction,Issues32
    33. 33. http://ChuckWebster.comhttp://EHRworkflow.com IssuesTip of IcebergEHREHR & non-EHR ITEffectiveness,Efficiency,UserSatisfaction,Issues33
    34. 34. http://ChuckWebster.comhttp://EHRworkflow.com IssuesTip of IcebergEHREHR & non-EHR ITEffectiveness,Efficiency,UserSatisfaction,Issues“BPM is a systematicapproach to making anorganizations workflowmore effective,more efficient, andmore capable ofadapting to an ever-changingenvironment.” 34
    35. 35. http://ChuckWebster.comhttp://EHRworkflow.com IssuesTip of IcebergEHREHR & non-EHR ITEffectiveness,Efficiency,UserSatisfaction,Issues“BPM is a systematicapproach to making anorganizations workflowmore effective,more efficient, andmore capable ofadapting to an ever-changingenvironment.” 35
    36. 36. http://ChuckWebster.comhttp://EHRworkflow.com and HealthcareProcess Improvement36My MSIE
    37. 37. http://ChuckWebster.comhttp://EHRworkflow.com and HealthcareProcess Improvement37EHRsHealth ITMedicalInformaticsTQMSixSigmaLeanMy MSIE
    38. 38. http://ChuckWebster.comhttp://EHRworkflow.com and HealthcareProcess Improvement38EHRsHealth ITMedicalInformaticsTQMSixSigmaLeanHealthcare BPMMy MSIE
    39. 39. http://ChuckWebster.comhttp://EHRworkflow.com’s Healthcare?39InsuranceManufacturingAssociationHospitalityTransportationEnergyBanking
    40. 40. http://ChuckWebster.comhttp://EHRworkflow.com’s Catching Up!40InsuranceManufacturingBankingAssociationsHospitalityTransportationHealthcareEnergy
    41. 41. http://ChuckWebster.comhttp://EHRworkflow.com 41Healthcare’s Catching Up!
    42. 42. http://ChuckWebster.comhttp://EHRworkflow.com
    43. 43. http://ChuckWebster.comhttp://EHRworkflow.com
    44. 44. http://ChuckWebster.comhttp://EHRworkflow.com
    45. 45. http://ChuckWebster.comhttp://EHRworkflow.com Case ≈???A use case is a listof steps … defininginteractionsbetween a role …and a system toachieve a goal.(Wikipedia, 2013)45
    46. 46. http://ChuckWebster.comhttp://EHRworkflow.com Case ≈???A use case is a listof steps … defininginteractionsbetween a role …and a system toachieve a goal.(Wikipedia, 2013)A workflow is a seriesof steps, consumingresources, achievinga goal. (Webster,2013)46
    47. 47. http://ChuckWebster.comhttp://EHRworkflow.com Case ≈Workflow DefinitionA use case is a listof steps … defininginteractionsbetween a role …and a system toachieve a goal.(Wikipedia, 2013)A workflow is a seriesof steps, consumingresources, achievinga goal. (Webster,2013)47≈ +A definition is a shortdescription of a thingby its properties.(Johnson, 1755)
    48. 48. http://ChuckWebster.comhttp://EHRworkflow.com Workflow Editor1. Triage Patient2. New neuro check?3. Nurse TPAassessment4. Thrombolysiscandidate?5. STAT CVA Eval6. CVA Confirmed?7. CT Head r/o CVA8. Hemorrhage absent?9. Physician TPAdecision12 3 4 5 678948
    49. 49. EHR DataReview &Entry &Order EntryScreens
    50. 50. ScreenlessTasks: Checkfor Labs,Print Ed.Materials,SendReminders
    51. 51. http://ChuckWebster.comhttp://EHRworkflow.com
    52. 52. http://ChuckWebster.comhttp://EHRworkflow.com and DropHospitalWorkflowDefinitionEditor63
    53. 53. http://ChuckWebster.comhttp://EHRworkflow.com 64Drag and DropHospitalWorkflowDefinitionEditor
    54. 54. http://ChuckWebster.comhttp://EHRworkflow.com 65Drag and DropHospitalWorkflowDefinitionEditor
    55. 55. http://ChuckWebster.comhttp://EHRworkflow.com 66Drag and DropHospitalWorkflowDefinitionEditor
    56. 56. http://ChuckWebster.comhttp://EHRworkflow.com 67Drag and DropHospitalWorkflowDefinitionEditor
    57. 57. http://ChuckWebster.comhttp://EHRworkflow.com 68Drag and DropOptions andActions toIndividualWorkflowSteps
    58. 58. http://ChuckWebster.comhttp://EHRworkflow.com 69Drag and DropOptions andActions toIndividualWorkflowSteps
    59. 59. http://ChuckWebster.comhttp://EHRworkflow.com 70Drag and DropOptions andActions toIndividualWorkflowSteps
    60. 60. http://ChuckWebster.comhttp://EHRworkflow.com EngineExecutes WorkflowDefinition71
    61. 61. http://ChuckWebster.comhttp://EHRworkflow.com EngineExecutes WorkflowDefinition72
    62. 62. http://ChuckWebster.comhttp://EHRworkflow.com EngineExecutes WorkflowDefinition73
    63. 63. http://ChuckWebster.comhttp://EHRworkflow.com EngineExecutes WorkflowDefinition74
    64. 64. http://ChuckWebster.comhttp://EHRworkflow.com EngineExecutes WorkflowDefinition75
    65. 65. http://ChuckWebster.comhttp://EHRworkflow.com EngineExecutes WorkflowDefinition76
    66. 66. http://ChuckWebster.comhttp://EHRworkflow.com per PatientAdmissions Packet$0.00$0.50$1.00$1.50$2.00$2.50$3.00Manual Paper Process Workflow Automated Process$2.40$0.4577
    67. 67. http://ChuckWebster.comhttp://EHRworkflow.com Steps78Learn (doing that now!)CompareWorkflowProductsList HighValue Workflows
    68. 68. http://ChuckWebster.comhttp://EHRworkflow.com Value# of UsersFinancialImpact CurrentPainExecutionFrequency79
    69. 69. http://ChuckWebster.comhttp://EHRworkflow.com Steps80Learn (doing that now!)CompareWorkflowProductsList HighValue WorkflowsList LowComplexityWorkflows
    70. 70. http://ChuckWebster.comhttp://EHRworkflow.com Complexity# of Steps LogicalComplexity# of Interfaces81# of Users
    71. 71. http://ChuckWebster.comhttp://EHRworkflow.com ValueLow Complexity,Workflows FirstValueComplexity 82XXXXXXXXXXX XXXXX X
    72. 72. http://ChuckWebster.comhttp://EHRworkflow.com ValueLow Complexity,Workflows FirstValueComplexity 83XXXXXXXXXXX XXXXX XSooner Later
    73. 73. http://ChuckWebster.comhttp://EHRworkflow.com Steps84Learn (doing that now!)CompareWorkflowProductsList HighValue WorkflowsList LowComplexityWorkflowsTackle High Value,Low ComplexityWorkflowVendor-SpecificBest Practices
    74. 74. http://ChuckWebster.comhttp://EHRworkflow.com PracticesYour workflow vendor knows best.85
    75. 75. http://ChuckWebster.comhttp://EHRworkflow.com
    76. 76. http://ChuckWebster.comhttp://EHRworkflow.com Future is Bright!87HCBPMhttp://HCBPM.COMHealthcareBusinessProcessManagementHealthcareProcessManagementCareProcessManagement
    77. 77. http://ChuckWebster.comhttp://EHRworkflow.com 88What’s Your Story?
    78. 78. http://ChuckWebster.comhttp://EHRworkflow.com You!*Questions &*Thanks to @BrownSelasie @ProfBPM @dz45tr@mloxton @iHT2 @FormFast @KittermanMG@janicemccallum @MightyCasey @INFORMS@jeanmariegrange @BPMbooks fortweets re this presentation!89
    79. 79. http://ChuckWebster.comhttp://EHRworkflow.com #1Who needs to be the championof workflow? Is it the physician,the nurse, administration, IT,what’s your thought?90
    80. 80. http://ChuckWebster.comhttp://EHRworkflow.com #2Are there specific examples ofhigh value, low complexityworkflows that you can think ofas low-hanging fruits?91
    81. 81. http://ChuckWebster.comhttp://EHRworkflow.com #3How would you manage the‘But we’re special,’ pushback,”most BPM theory gets fromclinical care teams?92
    82. 82. http://ChuckWebster.comhttp://EHRworkflow.com Webster,MD, MSIE, MSIS• Accy, Industrial Engineer, AI, Medicine• Hospital MIS, Professor, EHR vendor• Designed first undergrad medicalinformatics program• Workflow: 200+ blogs, 20,000 tweets• Adaptive Case Management GlobalExcellence Awards• IEEE Task Force on Process Mining93
    83. 83. http://ChuckWebster.comhttp://EHRworkflow.com #4Could you comment on thesimilarities and differences atBPM within organizations versusacross organizations?94
    84. 84. http://ChuckWebster.comhttp://EHRworkflow.com #5How do we use [BPM] in inpatientflow management when theapplications like ER systems, bedmanagement systems andutilization management systemsare all un-integrated?95
    85. 85. http://ChuckWebster.comhttp://EHRworkflow.com #6Is Lean as a good first pass forhealthcare entities looking toexplore BPM?96