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Interoperable Health IT and Business Process Management: The Spider In The Web

Posted on June 10, 2014 I Written By

Chuck Webster, MD, MSIE, MSIS has degrees in Accountancy, Industrial Engineering, Intelligent Systems, and Medicine (from the University of Chicago). He designed the first undergraduate program in medical informatics, was a software architect in a hospital MIS department, and also VP and CMIO for an EHR vendor for over a decade. Dr. Webster helped three healthcare organizations win the HIMSS Davies Award and is a judge for the annual Workflow Management Coalition Awards for Excellence in BPM and Workflow and Awards for Case Management. Chuck is a ceaseless evangelist for process-aware technologies in healthcare, including workflow management systems, Business Process Management, and dynamic and adaptive case management. Dr. Webster tweets from @wareFLO and maintains numerous websites, including EHR Workflow Management Systems (, Healthcare Business Process Management ( and the People and Organizations improving Healthcare with Health Information Technology ( Please join with Chuck to spread the message: Viva la workflow!

This is my second of five guest blog posts covering Health IT and EHR Workflow.

If you pay any attention at all to interoperability discussion in healthcare and health IT, I’m sure you’ve heard of syntactic vs. semantic interoperability. Syntax and semantics are ideas from linguistics. Syntax is the structure of a message. Semantics is its meaning. Think HL7’s pipes and hats (the characters “|” and “^” used as separators) vs. codes referring to drugs and lab results (the stuff between pipes and hats). What you hardly every hear about is pragmatic interoperability, sometimes called workflow interoperability. We need not just syntactic and semantic interop, but pragmatic workflow interop too. In fact, interoperability based on workflow technology can strategically compensate for deficiencies in syntactic and semantic interoperability. By workflow technology, I mean Business Process Management (BPM).

Why do I highlight BPM’s relevance to health information interoperability? Take a look at this quote from Business Process Management: A Comprehensive Survey:

“WFM/BPM systems are often the “spider in the web” connecting different technologies. For example, the BPM system invokes applications to execute particular tasks, stores process-related information in a database, and integrates different legacy and web-based systems…. Business processes need to be executed in a partly uncontrollable environment where people and organizations may deviate and software components and communication infrastructures may malfunction. Therefore, the BPM system needs to be able to deal with failures and missing data.”

“Partly uncontrollable environment where people and organizations may deviate and software components and communication infrastructures may malfunction”? Sound familiar? That’s right. It should sound a lot like health IT.

What’s the solution? A “spider in the web” connecting different technologies… invoking applications to execute particular tasks, storing process-related information in a database, and integrates different legacy and web-based systems. Dealing with failures and missing data. Yes, healthcare needs a spider in the complicated web of complicate information systems that is today’s health information management infrastructure. Business process management is that spider in a technological web.

Let me show you now how BPM makes pragmatic interoperability possible.

I’ll start with another quote:

“Pragmatic interoperability (PI) is the compatibility between the intended versus the actual effect of message exchange.”

That’s a surprisingly simple definition for what you may have feared would be a tediously arcane topic. Pragmatic interoperability is simply whether the message you send achieves the goal you intended. That’s why it’s “pragmatic” interoperability. Linguistics pragmatics is the study of how we use language to achieve goals.

“Pragmatic interoperability is concerned with ensuring that the exchanged messages cause their intended effect. Often, the intended effect is achieved by sending and receiving multiple messages in specific order, defined in an interaction protocol.”

So, how does workflow technology tie into pragmatic interoperability? The key phrases linking workflow and pragmatics are “intended effect” and “specific order”.

A sequence of actions and messages — send a request to a specialist, track request status, ask about request status, receive result and do the right thing with it — that’s the “specific order” of conversation required to ensure the “intended effect” (the result). Interactions among EHR workflow systems, explicitly defined internal and cross-EHR workflows, hierarchies of automated and human handlers, and rules and schedules for escalation and expiration are necessary to achieve seamless coordination among EHR workflow systems. In other words, we need workflow management system technology to enable self-repairing conversations among EHR and other health IT systems. This is pragmatic interoperability. By the way, some early workflow systems were explicitly based on speech act theory, an area of pragmatics.

That’s my call to use workflow technology, especially Business Process Management, to help solve our healthcare information interoperability problems. Syntactic and semantic interoperability aren’t enough. Cool looking “marketectures” dissecting healthcare interoperability issues aren’t enough. Even APIs (Application Programming Interfaces) aren’t enough. Something has to combine all this stuff, in a scalable and flexible ways (by which I mean, not “hardcoded”) into usable workflows.

Which brings me to usability, tomorrow’s guest blog post topic.

Tune in!

ICD-10 Benefits – Where are they?

Posted on March 8, 2012 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

One of the interesting topics of discussion at HIMSS was around the delay of ICD-10. However, I have yet to find an answer to what I think is probably the most important question around ICD-10. I posted the question and some other thoughts related to the question on the EHR Guy’s passionate post about ICD-10. Here’s my question and comments:

“What are the true benefits to using ICD-10?”

I’ve read story after story about ICD-10 (including this post) and so far I’ve only seen people giving general lip service to the basic idea that more specifically quantified data will somehow have a benefit to the healthcare system. Darren in the comment above says, “The fact that ICD-10 helps so many electronic and quality initiatives right now, or as pointed out above, are, in fact, required to achieve them”

What are the electronic and quality initiatives to which he speaks? What are the true benefits that we’ll get if we go to ICD-10? I haven’t seen enough of these examples.

We could also look at this same question another way. The rest of the world has been using ICD-10 for a lot longer than us. What have been the benefits that the rest of the world has seen from their use of ICD-10 that we haven’t seen in the US since we’re still on ICD-9?

I’m not trying to say that there aren’t benefits. I’m just saying if there are, then why aren’t we hearing more stories with concrete examples of the benefits? If there are, I’d love to see them and make them more widely known.

The EHR Guy offered this reply:

What you are asking for is reasonable and fair.

I will post, in a future blog, examples of why migrating to ICD-10 has beneficial clinical quality outcomes other than the intended reimbursement aspect of it which has been the main purpose of implementing it here in the United States.

But in essence a deep specificity would eliminate the erroneous coding accompanied by bulk documentation to justify the claim to be reimbursed.

Achieving semantic interoperability with erroneous coding is impossible. I’ve been in aggregation projects where abstracting information from HL7 messages was futile because no one in the healthcare organization seemed to understand what was contained in them.

This will be a very lively topic for months to come. I look forward to your participation in the discussions.

I look forward to the EHR Guy offering some more concrete examples in future blog posts. Although, I think this question deserves much more attention. I’ll admit to not being an expert on ICD-10. I know enough to be dangerous. So, I’d love to hear some of the real life benefits that ICD-10 has provided other countries and/or the benefits the US will get from ICD-10 implementation.

If we don’t have more stories and example of these benefits, then instead the stories related to the cost and inconvenience of ICD-10 (which are easy to find) will dominate the conversation. If that’s the case, then we can be sure that ICD-10 will be delayed.