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Friday, November 7, 2014

Clinical workflow: "YAWL," y'all?

OK, "y'all" (I'm a "Damn Yankee"), trying to shake off my post-midterms malaise.

Recent Health IT articles document continuing CIO displeasure with EHR "usability," with some expressing the view that it will likely continue to worsen. The recent Dallas ER Ebola dustup has quickly become totemic regarding poor usability and siloed workflows.

Some of my graphic riffs on workflow.

Figure 4

Dr. Carter has a good new post up over at EHR Science:
EHR Systems and Patient Safety: The Interplay of Workflow and Information Needs

...User interactions with software systems are workflows.  I doubt anyone would disagree with this.  However, what seems to be lacking in the general perception of workflow is that any workflow consists of not only a series of tasks, but also the information created and consumed by those tasks as well as the people and software systems that execute them.    Simply put, information needs are workflow needs, and the two cannot be separated...

Using workflow patterns, one can precisely capture the task to be completed, who will do it, and what information will be required. It is time to move away from workflows as simply something one captures in a swim lane or flow chart and accept that they are mathematical entities that can be captured and rendered unambiguously using workflow patterns. Workflow patterns can be rendered visually using tools such as YAWL, therefore they can be used for interactions with clinicians as well as developers...
"YAWL"? (Yet Another Workflow Language)

Open source, a freebie, with a 307 page manual (pdf).
Nowadays, organisations are challenged to continuously improve their efficiency and to respond quickly to changes in their environment, such as new business opportunities, competition threats, and evolving customer expectations. It is not surprising then that organisations are paying more attention to capturing, analysing and improving their work practices in a systematic manner. The methods, techniques and tools to do this are collectively known as Business Process Management (BPM).

For IT departments, BPM provides an opportunity to align IT systems with business requirements, and to re- organise existing application infrastructure to better support the day-to-day operations of the organisation. BPM initiatives often translate into requirements for IT systems. Here is where workflow technology comes into play. Business process models produced by business experts are taken as a starting point by software architects to produce a blueprint for a software application that co-ordinates, monitors and controls some or all of the tasks that make up these business processes. Such software applications are called workflows...
Many years ago, workflow was a bit of a dark art, practised by deep-pocketed companies that were able to afford expensive workflow management systems and highly specialised consultants. Today, workflow technology is widely available and its benefits and pitfalls are more widely understood. A word of warning though: while workflow doesn’t have to belong to arcane masters of lore, it’s also not something to trivialise. If a workflow application is not aligned with the business it’s been deployed in, it can be worse than a manual, paper-based bureaucracy. It is therefore important that both business and IT stakeholders follow a sound BPM methodology before attempting to deploy a workflow application..
Key observation here:
"If a workflow application is not aligned with the business it’s been deployed in, it can be worse than a manual, paper-based bureaucracy."
More from the YAWL manual.
3.3 Building a Simple Workflow Example
Designing a workflow typically begins with a process modelling exercise. A process modelling expert sits down with a domain expert, and picks their brains on “how things are done”. The knowledge gained on the sequencing and nature of the work done is then transformed into an executable workflow...
Given the irreducible hypercomplexity of clinical workflow, I have to have some concerns as to whether this app can scale up and model medical processes in a manner accessible to anyone outside of IT geekdom. Recall, a typical complete, certified ambulatory EHR contains close to 4,000 variables within its RDBMS schema, and a typical 99213 visit will likely have to hit on (view and/or update) hundreds of them (via multiple staffers) within in the time constraints of a 30-40 minute office visit.

Below, a "healthcare" example (pg 274):

Yeah, that's really clear. I'm havin' a swell UX.

See my post back in March, Chuck Webster's "Pragmatic Interoperability," continued...

My Garageband visual analogy.

Make it 3-d? How about one more visual analogy?

Where the inner insulation coverings stand for "data/communications siloing"?

Workflow apps that continue to focus on logic paths (e.g., "conditionals" branches and loops) will continue to miss the critical time element. And, it doesn't help that the visual illustrations are typically contorted to fill the dimensional constraints of the 8.5 x 11 page (whether portrait or landscape).

To that end, one egregiously overlooked asset is sitting right there under the EHR hood in the now-requisite "audit log." to wit:
An EHR audit log is essentially an information workflow record that should be mined to analyze routine tasks times-to-completion and variability. Analysis can also reveal the "pain points," i.e., iterative, recurrent "flow" barriers. You then couple these data with data taken regarding concomitant physical tasks to flesh out a more useful picture for systematic improvement activities.

The very word 'workflow' has become a cliche. Rolls readily off the tongue with little thought given to what it entails. A more apt analogy might be a traffic copter shot of the jerky stop-&-go freeway traffic of rush hour. In most clinics, it's nearly ALWAYS rush hour...

A decade ago I was working in credit risk and portfolio management at a relatively small privately-held issuer of VISA/MC subprime credit cards (roughly a million active accounts). I had free run of most of the internal network. I got to looking at our in-house developed collections call center system (~1,000 collectors assiduously working the phones every day), and knew the source language and data tables architecture, so I started importing the data into SAS and mining them (it was basically a Collections "audit log," though I was the first to audit it, on my own initiative).

I was able to rather quickly show management that their staffing deployment and call volumes were egregiously misaligned. We were typically spending $1,000 to collect $50 (or less), hounding delinquent customers with sometimes up to 140 calls per month, at all hours of the day and night (the classic, hated subprime M.O.).

It was a lava flow of waste. I issued a snarky monthly report on these activities, dubbed "The Don Quixote Report."

On the basis of my rather simple call log analytics we were able to save the bank about $5 million a year in Collections Ops cost, dragging the VP of Collections kicking and screaming all the way (his annual bonus was tied in part to his budget, which was the largest in the company -- he did not become My Friend).

"Workflow" tactics deployed in healthcare remain stuck about 10-15 years behind the times, as they don't drill down into time consumed and error rates. Mining the EHR audit logs might be of great utility here -- though the datetime() stamps are gonna need to be more granular than just down to the second. SQL now supports time capture down to the microsecond, though tenths or hundreds might suffice.

Another barrier here in general might be "once you've seen one audit log data dictionary, you've seen one audit log data dictionary." Recall that we have at this point nearly 1,800 "complete Certified EHR systems" [March 2014]. How many differing audit log architectures we have is probably unknown outside of ONC CHPL -- if they even bother to look...
As I wrote back in March:
Lean / Six Sigma Process Improvement initiatives would likely focus principally (though not exclusively) on the "Physical Tasks" leg of clinical ops. Couple that with adroit analyses of HIT audit logs, and we might be able to better leverage significant improvement efforts. Time is, of course, the fundamental, inescapable constraint in any business. Saving time and reducing physical task and HIT inefficiencies and errors would leave more of it for improving the most important facet -- the cognitive.

So goes my theory, anyway.


With the mid-term elections out of the way, SCOTUS has quickly reversed itself and agreed to hear Burwell v. King, the case challenging the legality of the federal health insurance exchange subsidies under the PPACA. The suit is over one sentence in the consolidated 974 page law (pdf; not "2,700," 974).

Section 1311, page 72. "...established by a State." These litigants argue that the feds cannot extend insurance subsidies to lower income households, that such subsidy is solely the province of state-run exchanges. SCOTUS has to determine Congressional "intent," via "Ouija Board Jurisprudence," instead of just, -- well-- asking those who voted in the majority. (Depose them. Call them as witnesses. Under Oath. Ask for documentation. The victors know what they intended, irrespective of any bill drafting oversights.)

I know, I know. You can't do that. "Separation of Powers." Much better to spend millions quibbling over the ostensibly inscrutable contextual meaning of one sentence.

Fine, 1311(d). Aren't y'all just thrilled with yourselves.

However, the rightfully governing clauses follow shortly on its heels, on pages 85-86, in Section 1321.

(1) IN GENERAL.—The Secretary shall, as soon as practicable after the date of enactment of this Act, issue regulations setting standards for meeting the requirements under this title, and the amendments made by this title…

(A) a State is not an electing State under subsection (b); or
(B) the Secretary determines, on or before January 1, 2013, that an electing State—
(i) will not have any required Exchange operational by January 1, 2014; or
(ii) has not taken the actions the Secretary determines necessary to implement—
(I) the other requirements set forth in the standards under subsection (a); or
(II) the requirements set forth in subtitles A and C and the amendments made by such subtitles; the Secretary shall (directly or through agreement with a not- for-profit entity) establish and operate such Exchange within the State and the Secretary shall take such actions as are necessary to implement such other requirements.
(2) ENFORCEMENT AUTHORITY.—The provisions of section 2736(b) of the Public Health Services Act shall apply to the enforcement under paragraph (1) of requirements of subsection (a)(1) (without regard to any limitation on the application of those provisions to group health plans).

(d) NO INTERFERENCE WITH STATE REGULATORY AUTHORITY.—Nothing in this title shall be construed to preempt any State law that does not prevent the application of the provisions of this title...
1321(1)(c)(1)(ii)(I and II) 

What part of "the Secretary shall (directly or through agreement with a not- for-profit entity) establish and operate such Exchange within the State and the Secretary shall take such actions as are necessary to implement such other requirements" do people fail to comprehend?

This is nothing more than a cowardly, disingenuous tactical attempt to scuttle the PPACA by pricing millions of lower income earners out of the health insurance market in Red states that have refused to set up HIXs.

A week ago, SCOTUS announced they would not hear the case. Now, with the mid-terms out of the way, they're quickly green-lighting it. Hmmm... why would that be?

BTW, if you insist on the long-winded, scholarly version of divining Congressional intent with respect to the PPACA and this latest challenge, see  
Amici curiae are a group of 49 distinguished professors and internationally recognized scholars of economics who have taught and researched the economic forces operating in the health care and health insurance markets. The Economic Scholars include economists who have served in high-ranking positions in the Johnson, Ford, Carter, George H.W. Bush, Clinton, George W. Bush, and Obama administrations; two Nobel Laureates in Economics; two recipients of the John Bates Clark medal, which is awarded biennially to the American economist under 40 who has made the most significant contribution to economic thought and knowledge; one of only two social scientists awarded the Alan T. Waterman Award, usually reserved for physical and chemical scientists; six recipients of the Arrow award for best paper in health economics; and two recipients of the American Society of Health Economists Medal for the best American health economist aged 40 and under. A complete list of the Economic Scholars is provided in the Certificate as to Parties, Rulings, and Related Cases at the front of this brief.

believe that reform of the health care system is essential to constraining the growth of health care spending and to extending health insurance coverage, and that such reforms cannot succeed without premium subsidies for people with low or moderate incomes. 
Amici submit this brief to explain the economic reasons why premium subsidies are essential to achieving the reforms of the health care system that Congress seeks through the Affordable Care Act (“ACA”), and to urge that the ACA cannot conceivably achieve those reforms if it is interpreted in the manner proposed by the Appellants. Congress – correctly – structured the ACA as a series of interlocking reforms, of which premium subsidies are essential components. If those subsidies are unavailable to the many who will buy insurance on the federal Exchange, the other components of the ACA will not work, and the legislation will fail to achieve its goal of expanding coverage...
 "...and the legislation will fail to achieve its goal..."

Precisely what opponents of the PPACA want. By any means necessary.

More (pp 25-27)" 
According to Appellants’ construct, Congress knew that § 1401 of the ACA limited availability of premium subsidies to residents of states that established their own exchanges. As Appellants see it, Congress was willing to exclude from the promise of affordable health insurance any low-or moderate-income family or individual who happened to be unfortunate enough to live in a state that refused to set up its own Exchange. Congress, Appellants assert, intentionally conditioned federal assistance to make health insurance affordable for these families and individuals on each state’s willingness to undertake the thankless job of establishing and operating Exchanges. According to Appellants’ theory, states will eventually buckle under the pressure of their uninsured citizenry and create their own exchanges.

But the tale told by Appellants is entirely at odds with what Congress knew and intended when it enacted the ACA. First, as explained above, Congress fully understood the economic need for the ACA to rest on the three interlocking reforms, of which subsidies were one primary component. Nothing in the record suggests that Congress intended the economically disastrous approach of dramatically limiting subsidies only to participants in state exchanges. Second, the Congressional Budget Office never entertained the possibility that subsidies would not be available across all Exchanges. See supra. Members of Congress consulted regularly with the CBO, yet not one of them indicated that the CBO’s work was at odds with congressional intent. Third, initial versions of the ACA indicate that premium subsidies were understood to be available for enrollees buying insurance on the federal Exchange. Premium tax credits were included in the House bill even though that bill provided for a single Federal exchange rather than state exchanges. Affordable Health Care for America Act, H.R. 3962, 111th Cong. tit. III, § 301 (2009) (establishing single, federal exchange); id. tit. III, § 343 (providing for “affordability premium credit”). In the endgame debate in which the House debated Senate language, it is inconceivable that the House would have accepted a change sure to cripple the federally-run Exchange. Appellants point to nothing in the legislative record to support their economically implausible argument that the purpose of the subsidies changed from the initial House proposal to the final Act. Instead, as Judge Edwards put it, Appellants peddle a “narrative concocted to provide a colorable explanation for the otherwise risible notion that Congress would have wanted insurance markets to collapse in States that elected not to create their own Exchanges.” Halbig, 758 F.3d at 416 (Edwards, J., dissenting).

If anything, the record establishes that Congress created the state Exchanges not because it intended the federally-run Exchanges to be dysfunctional, but simply to provide States the option of creating their own exchanges. The federally-run Exchanges remained available to those States that lacked the resources, expertise, or desire to build their own.
The one plausible reason for SCOTUS even hearing this case?


You will see media references to PPACA Section 1401 citing the contentious phrase "established by the state." Yeah, but take note of what it cites (page 110).

Again, 1311 is governed by Section 1321 in the event of state inaction or refusal (see above).

Moreover, at the risk of belaboring what ought be obvious with respect to "legislative construction," the very header at the top of page 110 says
"Subtitle E--Affordable Coverage Choices for All Americans."
Not "Affordable Coverage Choices for Only Those Americans Living in States That Follow PPACA Legislative Intent and Establish Health Insurance Exchanges."

Seriously, people? We really need legions of $500 per hour lawyers spewing forth lengthy "briefs" over something that simply jumps right off the page?


Indeed. This comes down to Chief Justice Roberts, given that four of SCOTUS have already vote to strike down the PPACA in toto. Should he provide the 5th vote to strike down federal HIX subsidies, given the dispositive countervailing evidence of legislative intent, it will scream partisan political corruption inside SCOTUS loud and clear.

Supreme Court already said DC Court was wrong on Obamacare subsidies

...Sophisticated textual analysis of complex laws like this one requires attention to the statutory text as a whole, in context, and not in isolation. That’s how the Virginia appeals court read the ACA today, and the Supreme Court itself offered the same admonition last month, through an opinion by Justice Antonin Scalia in the EPA case.

In fact, it was Justice Scalia himself, together with Justices Anthony Kennedy, Clarence Thomas, and Samuel Alito, who interpreted the health reform statute precisely this way in the 2012 health reform case—holistically, and assuming the statutory text makes subsidies available on state and federal exchanges alike.

In their joint dissent, they wrote:

“Congress provided a backup scheme; if a State declines to participate in the operation of an exchange, the Federal Government will step in and operate an exchange in that State.”

And then: “In the absence of federal subsidies to purchasers, insur­ance companies will have little incentive to sell insurance on the exchanges. … That system of incentives collapses if the federal subsidies are invalidated.”

The dissenters also assumed: “By 2019, 20 million of the 24 million people who will obtain insurance through an exchange are expected to receive an average federal subsidy of $6,460 per person”—numbers that only make sense if the federal exchanges are included.

So there you have it.

While one never can be certain about what the Supreme Court will do if it takes a case, the four Justices who held that the mandate was unconstitutional in 2012 then understood the Affordable Care Act to provide subsidies for insurance bought through the federal and state exchanges...

More to come...


  1. My GPO copy of the law has just 906 pages.

    Just sayin

  2. "just sayin"?

    Sayin' what? That you "got" me? The PPACA Consolidated law is 974 pages, the 906 plus some addenda.

  3. ACA is an interesting attempt. From the perspective of an Internal Auditor, I believe the lawmakers with novice healthcare awareness, thought somebody must be making costs go up and get rich, however in reality the regulation of the industry and the fact that the Government already pays 40% of the bills, it was makes it expensive. Markets reach high quality and low cost when their is carful regulation that rewards these behaviors, and adequate consumer information. It is these missing market components that have the industry broken... 1/3 of ACA can help, but the insurance exchanges are/were and unfortunate miscalculation of politicians, and will likely only add total industry cost and complexity.

  4. Thanks, Daniel. I'm not a big PPACA fan.