Healthcare is ‘wasting’ away

I recently came across an article co-authored by someone I respect a great deal, Don Berwick, in which the authors address the current estimated annual US healthcare waste by category. I strongly recommend reading the article. What struck me the most was how many of the estimated waste categories can be significantly impacted by using sound business process management (BPM) principles and data analytics.

Then why aren’t they being applied more broadly? Healthcare workers are some of the brightest, most committed workers in any US industry. The major payers in the marketplace are starting to reward waste reduction and efficient, effective delivery of healthcare services. Accountable care mandates are coming. No matter how you feel about any of these options, there is a huge opportunity at the national level, system and facility level to do a better job in all these categories of waste; from support services to the direct delivery of patient care.

Framework urgently needed

I  don’t see how any of this can occur without a framework or road map to understand exactly what should occur and who is accountable for specific processes and activities across the continuum of care for any patient, group, or population. Failures in coordination, fraud and abuse, over treatment, and administrative complexity are ripe for cost savings. The power of using process frameworks, coupled with clear accountability, data analytics, and sound continuous improvement techniques becomes an apparent must for the healthcare industry. Not to mention the delivery of direct patient care services.

It’s clear that to get from the current state to a new way of operating we have to stop, start, and change many of the ways we work. The issue to me is how to ensure we are aligned during the transition. I say it is through adoption of a common process framework as we’ve seen work so well in other industries.

What say you?



Categories: Continuous Improvement, Data Analytics / Big Data, Frameworks, Healthcare, Process Management

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2 Comments on “Healthcare is ‘wasting’ away”

  1. June 18, 2012 at 3:19 am #

    Hi Ron,

    Here is my response to a similar question posed several years ago on the Process Excellence Network website (though I speak of cost, not waste) —


    “In the Healthcare environment, are there institutions using BPM software platforms in conjunction with ERP (fiscal) and EHR (medical) platforms?”

    (BPM stands for Business Process Management, a frequent topic on this blog.)

    Since no one answered it, I nominated myself.

    You can see my posted response at: (Short Link: )

    But below is a more readably formatted version.

    My answer:

    What a great question! EMR/EHRs, workflow systems, BPM, and financial applications are converging and we (patients, physicians, solution developers) should all be glad they are finally doing so.

    Process-aware technologies such as workflow management systems and business process management suites have matured and proven their worth in various industries. They will diffuse throughout healthcare. At the same time, traditional (that is, non-process-aware) electronic medical/health records (EMR/EHR) are coming under increased critical scrutiny. Many EHR implementations fail, estimates range from 30 to 70 percent. Government efforts to increase EHRs adoption by physicians paradoxically have had the opposite effect. A big part of the problem is that physicians realize that traditional EHR workflow is one-size-fits-all, and therefore does not fit them. In response, a growing number of EHR professionals are beginning to realize that physicians are not the problem; it is lack of usable and flexible EHR workflow.

    EMR/EHR productivity, usability, and workflow issues are effectively blocking adoption of a technology, which if it were to be adopted, would greatly improve (1) our knowledge of what works and what doesn’t (clinical outcomes research), (2) coordination of care between clinicians and clinicians and between clinicians and patients (interoperability), (3) real-time monitoring of patient care (alerts, reminders, compliance with care plans), and (4) means to systematically improve medical care effectiveness, efficiency, and patient and physician satisfaction.

    EMR/EHR productivity, usability, and workflow issues are inextricably intertwined, a Gordian knot of interdependencies. Process-aware technologies such as workflow engines, process definitions, and business process management techniques are promising ways to manage these interdependencies.

    Non-process-aware EHRs are difficult to optimize in a business process management sense. Their workflows and processes are too highly constrained by design and implementation decisions made by traditional programmers using third generation computer languages. A physician should not have to rely on a C# or Java programmer to tweak his or her workflow. Lack of easily changeable workflow/process definitions at points of care, and points between, makes systematic improving clinical workflow difficult, slow, and expensive.

    EMR/EHRs built on workflow management system/business process management suite foundations are the next logical evolutionary step of EHR technology. They are essentially a new class of clinical information systems, existing at the intersection between two great software industries: electronic medical/health record systems and process-aware workflow management systems/business process management systems. The hybrid EMR workflow systems that will result will be more usable and more systematically optimizable than traditional EMRs with respect to user and patient satisfaction, clinical performance, and hospital and medical practice financial viability.

    That’s the vision, at least. The reality is that I am aware of one well-known EHR workflow management system/business process management suite on the hospital side and one such system on the ambulatory, medical office side. I am also aware of a number of document imaging/scanning workflow systems used by healthcare payers and in non-clinical hospital departments; however I don’t “track” them. Without structured syntax and semantics of patient-specific data, the following important activities will not be possible: clinical outcomes research, institution-to-institution coordination of care, real-time patient care activity monitoring, and the process mining that will be necessary to improve the these activities.

    Fortunately, I am seeing an uptick in interest by healthcare organizations and health information technology vendors in process-ware/workflow management system/business process management approaches to problems that traditional EMRs have failed to solve. This interest is evinced in trade publication articles about the potential for BPM in healthcare, press releases about new initiatives to use a BPM system in a healthcare venue, blog posts and comments (see below), occasional job announcements, and excellent questions such as yours.

    For example, the following is a randomly picked blog comment (not my blog or comment, see, written by someone familiar WfM/BPM but directed toward the physician blog author):

    “Most existing EMR systems are a combination of data collection and storage (the facts) and the workflows associated with these facts (e.g. the follow-ups, ticklers. Etc.) The facts can be standardized but the workflows vary from practice to practice and physician to physician….Most existing EMRs handle workflow as if every physician/practice were identical…There is a whole separate class of software products with names like workflow management or business process management which is focused on how facts flow between people and what happens when flows are interrupted…Once you’ve seen a general workflow system in action you never want to go back.”

    You also mentioned integration of fiscal applications into the EMR/EHR BPM mix. As great a picture as I have painted, the picture that results when you add financial data is even more extraordinary. I used to work in a hospital MIS department (wow! when I think about that potential!). However for the last decade I’ve worked in the primary care industry. So in my following comments about combining clinical cost and clinical workflow data I will stick to what I know. However, I think you can extrapolate to other specialties and institutional venues.

    One of the great promises of EHR workflow management systems in general, and primary care EMR workflow systems in particular, is the pairing of activity-based costs with process definitions. Since each step in a patient encounter process definition is time stamped as to when it is available to be accomplished, when it starts to be accomplished, and when it is actually accomplished and who (cost per minute) and where (rent per minute) is the resource used during each task, the total cost of each patient encounter can be calculated. With the revenue per pediatric encounter that is available from the practice management system (a fiscal application), the profit per each encounter can be calculated.

    By comparing encounter profitability across similar medical practices, specific reasons for decreased profitability can be located: (1) a step is more expensive per minute than it should be (that is, it is accomplished by less expensive resources at other medical practices), (2) a step takes longer to accomplish than it should (compared to other practices), and (3) a step is executed more frequently than it should (compared to other practices). The win-win-win analytic result is to find those too expensive and too long steps being executed too often and change the workflow to increase encounter profitability.

    That’s just one example of the power of combining EHRs, BPM, and cost data.

    So, to answer your question: “In the healthcare environment, are their institutions using BPM software platforms in conjunction with ERP (fiscal) and EHR (medical platforms)?”:

    There are a couple of mature existence proofs that EMR/EHR workflow systems/BPM platforms work well and have excellent potential. A metaphorical light bulb is turning on over the collective heads of the healthcare IT industry. And there are excellent questions like yours. Thank you for asking it!

  2. Ron Webb
    June 18, 2012 at 9:23 am #

    Dr. Webster, thanks for sharing that related blog post. I definitely see the applicability and think it offers great insight into the current state of the industry in healthcare. While process management (BPM) is a key to the solution, I agree, technology is going to have to play a huge role. The processes within (and between) care provider networks and systems are extermely complex and need a high degree of coordination. Technology will have to play that role, and there is currently a pretty big gap there.

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