Achieving task and workflow interoperability in healthcare

Being able to share data is not the same as cross-organizational coordination
By Chuck Webster, MD
08:03 AM
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I'm reminded of the famous first line in Charles Dickens' A Tale of Two Cities, "It was the best of times, it was the worst of times." Over the past decade we have spent billions to digitize healthcare, especially at the point-of-care in hospitals and medical clinics. So now we have unprecedented stores of patient data.

Nonetheless, in health IT imagination, healthcare interoperability is deep in Gartner's Trough of Disillusionment. We need interoperability to leverage these unprecedented resources. What will it take to climb from the Trough of Disillusionment onto the Slope of Enlightenment and then Plateau of Productivity? I will argue task interoperability and workflow interoperability – and both require workflow technology to be done right.

There's a level of interoperability above data interoperability. This is the workflow interoperability layer. Right now, if all of the data interoperability software works, we get to send some data from one system to another. But the mere ability to send data is not the same as being about to look into the workflows of another organization, and use that knowledge to better coordinate our internal workflow with their internal workflow. Only when we can do this, will we see dramatic improvement in the speed and quality of coordination of everyone and everything needed, so a patient can move seamlessly from home to medical office to hospital to rehabilitation and home again. This missing link is exactly what workflow interoperability provides. We are finally beginning to see the knitting together of separate specialists and organizations, each responsible for different aspects of patient care at different times and places during a patient's journey.

Ten years ago, at the HIMSS'05 conference in Dallas, I predicted the following:

"EHR workflow management systems will need to coordinate execution of workflow processes among separate but interacting EHR workflow management systems. For example, when a primary care EHR workflow management system (System A) forwards a document (such as a Continuity of Care Record) to a referral specialist, who is also using an EHR workflow management system (System B), System A should expect a referral report back from System B. When it arrives, it needs to be placed in the relevant section in the correct patient chart and the appropriate person needs to be notified (perhaps via an item in a To-Do list). If the expected document does not materialize within a designated interval, System A needs to notify System B that such a document is expected and that the document should be delivered or an explanation provided as to its non-delivery. System B may react automatically or eventually escalate to a human handler. If System B does not respond, System A needs to escalate to a human handler. Interactions among systems, a hierarchy of automated and human handlers, and escalation and expiration schedules will be necessary to achieve seamless coordination among EHR workflow management systems." (p. 14, EHR Workflow Management Systems in Ambulatory Care, HIMSS'05, February 14, 2005, Dallas)

Ten years ago there was very little task management in EHRs. The situation today is somewhat improved. However, most task management is based on what I call "frozen workflow." Ideally, users should not only get task management, they should get customizable task management, the workflows for which they can arbitrarily change, and not be hostage to some Java or C# programmer. Furthermore, healthcare IT users need distributed task management, in which workflows span boundaries between healthcare organizations. Healthcare workflows? Cross-organization workflows? Created and edited by non-programmer EHR users? In this, to date, today's EHR industry has not made much of a dent, if any at all.

The following is my diagram of the "Invoke," "Monitor," "Control," and "Get Result" workflow pattern between a primary care medical practice EHR and a referred to sub-specialist EHR. Note that while "A" and "B" in the above quote refer to EHR systems, "A" and "B" the diagram below refer to tasks within EHR systems.

The key concept I am promoting here is not just tasks being pushed back and forth between healthcare organizations. The key concept is tasks being pushed back and forth according to workflow definitions and business rules under control of non-programmer clinical and administrative users who best know their workflows and rules (plus a dollop of governance to avoid workflows "gone wild").

More recently, I've written about the importance of "pragmatic interoperability" in addition to syntactic and semantic interoperability. Syntactic interoperability is the ability of one EHR to parse (in the high school English class sentence diagram sense) the structure of a clinical message received from another EHR or health IT system (if you are a programmer think: counting HL7's  "|"s and "^"s, AKA "pipes" and "hats"). Semantic interoperability is the ability for that message to mean the same thing to the target EHR as it does to the source EHR or health IT system (think controlled vocabularies such as RxNorm, LOINC, and SNOMED).

Plug-and-play syntactic and semantic interoperability is currently the holy grail of EHR interoperability. We hear less about the next level up: pragmatic interoperability (AKA workflow interoperability). 

"Pragmatic interoperability (PI) is the compatibility between the intended versus the actual effect of message exchange." (Towards Pragmatic Interoperability in the New Enterprise -- A Survey of Approaches)

Issues of pragmatic interoperability manifest themselves as issues about coordination among EHR workflows. The most mature technology for implementing pragmatic interoperability is workflow technology.

Sophisticated workflow technology (see my five-part tutorial) is coming to healthcare and health IT. Every year, for the past five years, I search every HIMSS conference exhibitor website for workflow and workflow technology-related words and phrases. The percentage of HIMSS exhibitor websites mentioning, even emphasizing, workflow and workflow technology has doubled every year since 2011, from less than two percent to over a third of HIMSS exhibitor websites. Sophisticated workflow technology is diffusing into healthcare and health IT at a rapid rate. However, in absolute terms, healthcare is a large industry.  Many workflow-oblivious legacy EHRs and health IT systems are in place. They won't be ripped-and-replaced in the foreseeable future. How can we optimally workaround and compensate for these vestiges of health IT past?

The key is workflow interoperability. And a key milestone on the way to workflow interoperability is task interoperability. I'll delve into that in Part 2 of this series.