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The Three Horsemen of the Coming Healthcare Apocalypse

April 8, 2016

Ok, so not really – It’s not about horsemen, it’s already partially here, and it won’t be an apocalypse either. It is however going to be a very big problem, it’s going to bankrupt some people, destroy some industries, and it’s going to put a massive hurt on almost everybody for many decades to come.

There are three healthcare issues that interact with each other, and which would have been a huge problem individually, but are going to slap us hard across the face when put together. I am talking about the Aging Population, Obesity, and Climate Change.

Aging Population

Here’s the thing. 10,000 Boomers are retiring per day, they did a horrible job of preparing the next generation to take the helm, and there are fewer of the next generation to do so anyway. We already have a looming shortage of nurses and doctors and medical technicians, and when a bolus of them retire and need medical help, we simply won’t have enough replacements to take care of the aging population. If your organization didn’t have a knowledge management, and training and recruitment plan already in motion ten years ago, the bottom line is that it’s too late. The chances are that you won’t save your organization from collapsing, and the best you can do is arrange a slightly more elegant landing than a straight-up belly flop from the highest diving board.

The medical schools have been focused on keeping profits high, the APA on keeping competition down, and who in heck knows what legislators were doing. Probably nothing. Maybe just pulling practical jokes on each other. So we have let the Magic Sparkle Fairy of the Invisible Market and siloed interests and perverse incentives drive how we scaled, staffed, and recruited for medical schools, and we are going to be massively, monstrously, marvelously short. We are already short, and it gets worse.

We are going to have the same problem across every part of healthcare, and our normal go-to plan of stealing skills from other countries isn’t going to work because they have the same problems.

That was the good news.

The bad news is it’s going to be much, much, much worse than I said. We didn’t invest in the infrastructure or save for this either, so this is going to be a huge, nasty drag on getting anything done in healthcare.


The entire world is getting heavier, and the US is one of those leading the charge. I mean of course the people are getting heavier. All ages, all genders, all races. All income groups. Some a bit more than others, but all of them are slowly getting heavier. Actually, not so slowly. Kinda fast. In fact, very fast – the rate has doubled globally since 1980. Obesity is now something that 35% of Americans can call their own, and the number is climbing.

With obesity comes a rapid increase in a whole raft of medical conditions, including diabetes, coronary disease, cancer, depression, and so on. All of them very expensive, chronic, and thoroughly entangled in social determinants of health and perverse incentives. One example is that we subsidize corn production. That creates cheap corn syrup. Corn syrup is added to every food and drink imaginable. It contributes to obesity, diabetes, stroke, and tooth decay. Wonderful stuff. So we fund a thing that kills us. Wonderful. We do that a lot.

We have entire industries whose focus is to craft very unhealthy food that is very appealing to our instincts, the way our brains work, and are kinda habit forming. The more money they make, the sicker we get, and they like making more money.

Climate Change

Despite Congress being really conflicted over whether it is happening, whether we are causing it, whether it is more important to bring out tortuous laws about gender assignment and public restrooms, Climate Change is increasingly a topic in healthcare. The anticipated effects of Climate Change of healthcare can be seen in research papers, conference sessions, and lectures at medical schools. The news isn’t very good. Well, actually not “good” as much as really bad.

There is almost no healthcare problem that is not made worse by Climate Change. On its own, Climate Change would be a darned pest. It will disrupt the agricultural supply chains, submerge some of our business transport links and cities, and increase damage to infrastructure through storm surges, hurricanes, tornados, and other forms of interesting peak weather. However, that’s just the entertaining stuff. It will also lead to resurgence of old medical enemies, shift vendors into novel regions, and hike up emergency visits for everything from asthma to zoonotic infections.


So even together these three aren’t an apocalypse, and won’t end the planet, our species, or even halt the amount of sports we watch. From the couch. With a Big Mac and Fries. And a soda. A big one. The super-slurp one that’s five times the size of our bladders and has enough corn syrup to kill off a platoon of insulin-producing beta cells. Not an apocalypse.

While it won’t be an apocalypse, each one will be a bit like getting a backhander through the face. On a cold morning. With a fish. A large wet fish. The three together will be like getting three individual fishy-slaps through the face, followed by another, bigger fish. With spines and slime. And frozen. A hearty backhander though the face on a cold morning with a large frozen fish, wielded by an Olympic medalist in fish throwing.

A bit like that.

Are you ready?

BPM & CM – My takeaway from the Global Summit

July 20, 2015

Thanks to Dr. Charles Webster (@wareflo), I attended the 2015 BPM & CM global summit in Pentagon City last month.
During the three-day summit, Dr. Webster interviewed me and several other attendees, and broadcast live over Periscope.
His intention was to find out what we each hoped to get out of the sessions, and then to follow up afterwards to find out what we saw as the major takeaways.

It has taken me nearly a month to settle on what I took away from the seminar, but here is my answer to his question:

  1. There was an elephant in the room
  2. The field has achieved a great deal of progress, but still has a long way to go
  3. There is a huge opportunity to improve healthcare

Before I talk about those, here are my top three favorite sessions

  1. Chuck Webster’s session on wearable workflow featuring @MrRimp. (It’s not every day you get that level of geekiness crammed into a presentation)
  2. Anne Rozinat’s session on process mining using Disco
  3. Aaron Drew, U.S. Department of Veterans Affairs & Business Architecture Leadership Panel, who spoke about the future of the VA’s VistA EHR design

Chuck thrilled us all with MrRimp, and hinted at a future in which wearable technology would form part of seamless workflow. From door to doc and beyond, wearables are going to play a major role in healthcare, and will shift the patient to the center of a care team, rather than simply being the topic of clinician discussions. Wearable workflow also has the promise of having adaptive business processes in which the currently error-prone activities of basic data capture are shifted from clinicians to machines. Shifting this burden will free up hours per day per clinician, while increasing data reliability.

Anne eloquently stepped us through the concepts and technology behind process mining, and gave examples that were clear and compelling. Process mining is a big deal in healthcare, as I discuss in a whitepaper on process discovery in quality improvement. The big deal is that current methods to discover the as-is workflow are resource intensive and slow. Variation in healthcare settings is high, and processes may vary not just from hospital to hospital, but ward to ward, and even shift to shift.

If you have a healthcare system with dozens or hundreds of care facilities, scaling this is close to impossible, and even in a single facility with a small number of wards, can be daunting and expensive. Process mining does not entirely overlap with observational methods of process discovery, but it comes close enough to bring real-time process discovery within the reach of small and large healthcare systems alike.

Aaron described a future in which BPM is built into the EHR, and where patient centered care teams could interoperate seamlessly without the EHR creating obstacles and pitfalls. The original VHA EHR was built to solve the problem of running a single medical facility and managing diverse treating specialties within a single environment. Since then it has been pressed into service as a means to do care and bed management across the nation as well as handle medication ordering, medical imaging, and disaster planning.

This venerable but dated EHR has architectural limitations that are no longer up to the challenges and demands of the modern care environment. The VistA Evolution project details a ground-up rebuild of the architecture and technology, and will put VHA back in the lead with a groundbreaking EHR.

That’s my top-three picks for sessions.

Now for the elephant

During one of the sessions, the presenter was explaining how he wished that US management and C-Suite were as tuned into the need for efficient and effective BPM as the executives he encountered in Germany. What followed was, from my perspective, a remarkable response from the audience. As a qualitative researcher and quality improvement practitioner in healthcare, whenever an audience is animated it’s important to pay attention.

Nowhere on the agenda was a discussion related to management itself, none of the sessions involved management best practices, and no speaker directly addressed the topic of executive sponsorship and behavior. Governing policies regarding process improvement and quality weren’t a listed topic. However, what came thick and fast, in raised voices, were accounts and agreements that US business practices were a major impediment to improving processes.

One person gave an account of how short-term focus and lack of forward vision was crippling attempts to improve workflow in the business operation. Another described how quarterly metrics resulted in punitive reactions to improvements, and that improving a process for long-term success were often cancelled by management because of a short-term focus. Somebody else gave a personal account of management cancelling projects that were designed to improve quality and efficiency. The projects couldn’t deliver within a financial quarter, and so they were terminated.

Whether the specific projects were viable or not, is something we can never know. What was clear is that the tone and degree of participation in this session, and on this specific topic, were remarkable. The topic evoked a far higher degree of audience participation, and the degree of vociferous agreement stood out. The thing that nobody was talking about, but was evidently on everyone’s mind, was that US business models are a significant cause of bad business processes.

That bears some thinking, especially in the US healthcare market, where the cost of bad processes is paid in blood and death.

BPM & CM advancement

With the release of BPMN v2.0, and the advent of DMN v1.0, the field now has an accepted set of standards that can be used to model business processes. This is great news for fields that include quality improvement, business reengineering, and business design. This means that a wide variety of workflow and process design tools will produce interoperable if not entirely interchangeable process models. It also opens the door to being able to build processes that can be directly embodied in business logic in the workplace.

What is less stellar is that while over 80% of all process models are created and reside in Microsoft Visio, the model you created in Visio only pretends to be a BPMN model. It’s like a picture of a dollar bill – it looks like one, and it can be named “dollar bill”, but you can’t buy anything with it. You can’t just flow your business data through the Visio diagram to see if something is wrong.

Perhaps with time that will change, but it isn’t a pretty picture right now.

Opportunities in Healthcare

Putting this together, if there is one industry where wearable workflow, process mining, and BPM standards could benefit operations, it is healthcare.

  1. Healthcare costs in the US, account for up to 60% of bankruptcies
  2. Preventable medical mistakes are the third highest source of untimely death
  3. Incompatible processes are the daily reality for patients and providers alike


Improving the performance and conformance of business processes, placing patients at the center of their care team, engineering humans out of data entry, and standardizing processes across points of care could save lives and money. It could shift US healthcare from being the most expensive in the world to being at least on par with the OECD averages. It could move US healthcare outcomes from the doldrums to being in the top five percentile.

That’s my story, and I’m sticking to it!

Utilization Management and Climbing Healthcare Costs

January 14, 2015

With all the attention that the soaring cost of healthcare has been getting over the last few election cycles, it’s easy to assume that this is a new phenomenon, and that back in the “old days”, it wasn’t a concern.

Quoting my own previous papers on the topic: The actual  history of healthcare and cost is different, however, and the rising cost of healthcare has been an issue in the US since the early 1920’s, and led to the formation in 1927 of the Committee on the Costs of Medical Care.
Although health insurance firms had been concerned over high medical costs which they identified as being at least partly the result of unnecessary procedures and hospital stays, it was the creation of the Social Security Act of 1965 for Medicare and Medicaid Title XVII and XIX that provided the impetus for a focus on methods to standardize admission and hospital stay decisions.

During this time, there was significant variation between physicians, hospitals, and regions on the use of procedures or inpatient admissions, and it was typical for patients to be admitted for weeks or even months for observation or for procedures that would currently require less than a week or even be performed on an outpatient basis.

The Social Security provisions required clinical evaluation and review, but did not set criteria. In the early 1970’s a Congressional subcommittee estimated that were over two-million unnecessary surgeries per year across the US. As a result, there was a growing requirement for standards regarding procedures and inpatient admissions. [1]

To give a context of scale, physicians who fail to follow evidence-based clinical criteria add a $500 billion cost burden to U.S. healthcare by providing overly aggressive or ineffective care. [2] In a study of contribution to cost by cases that do not meet clinical guidelines, Cutler et al found that patient demand was not a significant contributor, but that physician preferences unsupported by clinical evidence accounted for 36%  of end-of-life spending, and 17% of total health care spending. [3]

One approach to reducing costs and controlling the “exuberance” of a free market that would naturally tend towards increasing use of medical products and services, is to have clinical episode of care criteria. Utilization Management criteria can be used prior to encounters  (prospective review), as part of the triage and episode of care decisions (concurrent review), or as a quality improvement tool to assess episode of care after the case (retrospective review).

With this backdrop of cost burden, it is clear that UM plays a critical role in provision of appropriate care. UM adds value by reducing the incidence of unnecessary care, and by placing the patient at the most appropriate level of care with the least possible delay. Effective UM supports efficient scheduling of inpatient admissions and procedures by reducing the number of unnecessary admissions, and providing an evidence-based mechanism for admission decisions. Modern UM balances Cost vs. Care through a systematic process and evidence-based criteria.

1. Field, M. J. (1989). Controlling costs and changing patient care?: the role of utilization management. National Academies.
2. Goldberg, C. ‘Cowboy’ Doctors Could Be A Half-A-Trillion-Dollar American Problem, 2014.
3. Cutler, D. Skinner, J. Stern, D. and Wennberg, D. “Physician beliefs and patient preferences: a new look at regional variation in health care spending,” National Bureau of Economic Research, 2013.

Electronic Health Records: Where they should be Going but aren’t

January 9, 2015

The past few years, mostly because of the Affordable Care Act, the adoption of Electronic Health Record (EHR) systems in the USA has seen a dramatic growth. Because of the rapid climb, EHR vendors have been trousering some pretty large amounts of revenue, billions of dollars, in fact. This is not a bad thing per se’, but as Congress suddenly realized this year, all that cash didn’t translate into giant leaps in innovation, as they predicted. Some of this is the result of a captive market, some because of psychosocial artifacts of clinicians, and some to do with that markets aren’t necessarily innovative.

One of the ways in which one can see the lack of innovation, or even basic maturity, is the degree to which clinicians have to type the same data over and over in different electronic forms. Not only do the EHR systems not interoperate very well between vendors, some don’t even interoperate with themselves! So it is a common sight to see a nurse type in records from a sheet of paper, then if they are lucky, copy and paste them into another form. If they are unlucky, they get to retype the same data multiple times in different EHR screens. If they are doubly unlucky, the system is also somewhat fragile, which isn’t unusual, and it aborts the session before the data is saved. In that case, they get to retype it all again when the system comes back to life. Sometimes this happens several times a day – in one case that I encountered, the clinician had to try fourteen times before the system recorded the data!

This is obviously a pretty abominable situation, and to get even the most basic degree of workflow into this is going to take a lot of effort and money. Luckily, the EHR vendors are flush and positively glowing pink with all that Meaningful Use cash in their fists.

The Goal

What I want to see isn’t beyond current technology or in the realm of science fiction, and not even where we ultimately want to be, but it shows where the thinking needs to head (In my opinion, that is).

What I want to see is the removal of the human from any data capture that doesn’t actually require their expertise.
Not really a big ask, given that we can put intelligence in spectacles and the average smartphone has more brains than it knows what to do with.

So let’s say a patient arrives for a consultation.

When they enter the waiting room, I want them to get a transponder sticker. These are dirt cheap, pretty reliable, and can be scanned without actual contact. At the reception desk, the clerk reads the sticker and associates it with the patient record. Now I can tally who left without being registered (elopement), how long it took (primary wait time), and at which stage of the encounter all the patients are (census).

When the patient is called, they are read leaving the waiting room, and again when they enter the examination room. The nurse or nurse practitioner scans them, and the patient record is already onscreen in the room when the nurse scans their ID on the workstation. Each vital sign collected goes directly into the patient record because the instruments are vaguely intelligent. Blood pressure, pulse-oximetry, weight, height, respirations, temperature, etc. are all directed from the device to the EHR simply by using them on the patient. These are all time-stamped, have the ID of who was using them, the ID of the device, and are shown as machine entries in the patient record.

Verbal notes can already be captured through speech recognition, but let’s say that the nurse actually has to enter this themselves. They don’t have to search for the patient record or the screen, those are already there, and they simply need to verify that the patient record is correct. (Although unless the patient swapped armbands with somebody, we are pretty sure who they are).

When the process has reached a certain point, the EHR can buzz the physician that the patient is close to ready. So no long wait while the nurse has to write things down or type in much, and no need for them to go find the physician.

A similar scenario unfolds when the physician enters: the room, patient, and physician are associated in an entry event because all three have transponder identities. Relevant patient data is already displayed when the physician scans their ID at the workstation to login, and again, any use of instruments captures data. Listening to the patients lungs with an intelligent stethoscope can capture the sounds, timestamp them, and put them into the correct place in the patient’s record. Even more wonderful, if the patient has any electronic records pertinent to the encounter, these can be transmitted from a smartphone Personal Health Record (PHR) app.

The only parts the physician play in capturing data is when expertise is required or when the machines can’t (yet) do it themselves. There is no reason on earth why a scale, blood pressure cuff, or pulse-oximetry device can’t transfer the data to the EHR themselves. Only the most antiquarian of medical offices don’t already have devices that display the data digitally, it’s just that we then typically ask a human to write it down or type it into the EHR manually. That is a bad use of resources, and opens up opportunities to get it wrong.

With time stamped machine data, the practice can start monitoring movement and wait times, and would be enabled to make adjustments to their workflow to optimize patient flow, and reduce unnecessary steps or waits. Staffing rosters and equipment placement can be evidence based rather than rely on guesswork, and bottlenecks in the processes will be far more visible.


The basic theory is similar to industrial engineering – don’t ask a human to do something that the machine can do. Free up clinician time, reduce transcription errors, and allow the clinician to focus on where their expertise lies – not in being low-level data capture clerks.

We should be demanding that equipment manufacturers and EHR vendors get their act together, and stop making clinicians do their dirty work.

That’s my story, and I’m sticking to it!

Learning from the Past – Risk Management at National Scale Using PHR

July 23, 2014


The 2014 World Development Report from the World Bank sketches how confronting risks, preparing for them, and adopting appropriate coping strategies can make a vast difference in outcomes, sometimes at an epic scale. In 2010, both Haiti and Chile were victims of large natural disasters of similar destructive capacity. Both countries experienced serious earthquakes, the larger of which struck Chile. However, while Chile suffered a loss of 300 lives as a result, Haiti lost in the order of 250,000 lives.

The World Bank attributes this to several causes, one of which is the degree to which Chile learned from a previous experience and invested in insurance, undertook preparation to reduce risk, and improved their capacity to cope with the aftereffects of future disasters. Chile confronted the lessons of the previous disaster, there was a national awareness, and as a result, building codes were changed, and the country took insurance both against damage and in terms of divestiture of investments and commerce. These changes allowed Chile to suffer less damage to people and infrastructure, recover faster from the shock economically, and to learn from what worked and what did not. Without these investments, it is believed that Chile’s death toll in the 2010 earthquake would have been of an even greater magnitude than that of Haiti.

The WDR2014 report is an evolution from early risk management approaches, and instead of the highly technical perspective taken in earlier years, the report views risk management as a long-term and strategic process. The WDR2014 report sketches two principles in risk management: To be realistic, and to build foundations. In the former, they are recommending that risk reduction attempts be pragmatic and simple rather than theoretical and extensive, and in the latter case, they are advising that risk reduction efforts build on each other and take a long-term view. To comply with this advice and to manage risk effectively requires that the efforts take into account several obstacles, such as the information requirements of the population involved, human behavior and change, resources available, and the uncertainty of risk.

Risk Management in the WDR2014 report thus rests on four “pillars”

  • Knowledge
  • Insurance
  • Protection
  • Coping

The focus of this article takes a cue from the two principles, and offers a narrow perspective on a single issue, that of the health records of people forced to migrate because of shocks such as natural disasters. This focus addresses the knowledge needs when receiving healthcare organizations must care for refugees and people affected by shocks such as natural disasters, but could hold true for any form of shock in which healthcare delivery was disrupted. The paper addresses a form of insurance in the shape of planning for eventualities, protection from medical delays and mistakes, and a coping strategy for dealing with migrant patients or disrupted healthcare delivery.

Case: Typhoon Haiyan 2013

In November of 2013, typhoon Haiyan reached the Philippines with the strongest winds ever recorded. As a result, the infrastructure was severely damaged, a large proportion of the population was displaced, and over six-thousand people died. The Philippines comprise over 7,000 islands, and few hospitals or health care providers (HCP) have Electronic Health Records (EHR). One highly specific problem was that people’s health records became unavailable both for those who fled and to those who stayed but were unable to reach their HCP.

For this article, a local doctor providing endocrine care was interviewed on Twitter using the hashtag #wdrrisk.

Throughout the typhoon, many Tacloban residents went to Manila either to escape danger or join family or friends who had left, and of these were people who were already ill with current or long-term chronic illnesses such as cancer, or became ill while away from their homes in Tacloban. Few people had made provision to take their medical records with them, and valuable medical information such as test results was lost or otherwise not available to HCPs in Manila.

The doctor interviewed for this paper is an endocrine specialist based in Manila, and saw many patients who were refugees from Tacloban. Patients typically had no documentation of their medical history, and no ability to access the facilities in Tacloban where their records were kept. Because few medical facilities in the region use electronic records available through the cloud, even those patients whose providers were on an EHR lacked the ability to access their records. Patients typically have only a vague recollection of what tests or procedures they have previously undergone, when these were carried out, and what the results were. As a result, patients without medical records experienced increased risks, delayed care, and additional burden of repeated tests. Where patients were on medication, a lack of a definitive history regarding dosages, patient reactions, and allergies required that HCPs started drug regimens from base dosages and take a conservative and cautious approach in order to avoid potential overdose or adverse reactions. As a result, many patients may have experienced sub-optimal results until the drug selection and dosages were calibrated to their individual needs and responses.

The doctor reported that repeating tests delayed treatment, increased patient risk, and raised the cost of care, but some tests cannot be repeated at all because the results are based on historical progression of a condition. The doctor was unable to fill in the blanks in some cases, and was left with an incomplete clinical picture that increased patient risk. For example, for some chronic patients the doctor needed histology test results that are helpful in cancer staging and which could not be reconstructed. Without these historical data, the doctor had uncertainty and had to make best estimates that may have increased patient risk or resulted in sub-optimal care. The lack of a longitudinal view of these patient’s history and healthcare journey, lost or missing data, and gaps in patient history increased the risk of inappropriate or ineffective care.

Personal Health Records

In order to provide effective healthcare, clinicians and other providers need information related to the patient’s present condition, past medical history, and core health records such as medication use, existing conditions and treatment, and medical images, prescriptions, and procedures. These are usually kept by the person’s primary care facility, and may be kept either as physical records such as patient files, x-ray plates, and the like, or as electronic records and images. However, when the patient migrates or their provider’s infrastructure is disrupted, these records may be unavailable. Personal Health Records (PHR) are an alternative that gives individuals the ability to either carry their health records on removable storage such as thumb drives, DVD, etc. or to link to them on the web using a secure repository, e.g. Microsoft HealthVault.

PHR puts the patient’s medical history in their own hands in a way that is likely to be transportable during a disaster, and unlike paper records, can be encrypted and secured in order to maintain patient privacy. The downside is that PHR relies on a certain level of technology and computer literacy on the part of the patient to realize the full benefits. However, simply providing the patient with their records in the form of an encrypted memory stick requires minimal computer literacy on the part of the patient, and is more likely to accompany the patient and be available during disasters than paper records.

The advantages of having PHR are:

  • Faster triaging leading to fewer delays in care
  • Definitive drug and test data, enabling better targeting of treatment
  • Longitudinal views of illness progression, allowing more appropriate treatment and drug dosing
  • Documented endorsement back to their home town HCP, allowing better continuity of care


Tacloban had been hit previously by natural disasters, and although many aspects of the four pillars of Knowledge, Insurance, Protection, and Coping had been addressed with regard to physical infrastructure and administrative processes, the need for maintaining the fidelity of medical histories was not adequately addressed. Lack of learning from those events with regard to medical records resulted in preventable morbidity and mortality across the region, but there is hope for improvements due to new frameworks. The PHR framework for the Philippines described by Dr. Alvin Marcelo outlines a way in which lessons from Haiyan and other natural disasters in the Philippines could be put to use in creating a way to utilize PHR to avoid losing valuable medical data, and reduced cost, patient risk, and delays in provision of care during disasters.


This paper was developed as a result of interactions with the participants of the #HealthXPh tweetchat where the issue was first discussed. Further thanks go to #HCLDR, #BioEthx, and #HCSM tweet groups. A special thank you is due to Dr. Iris Thiele Isip Tan for her willingness to be interviewed online for this paper and for providing insight into the effects of not having access to patient history during disasters. Doc Iris also provided the links to the PHR framework created by Dr. Marcelo.

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