What is Low-Code/No-Code/Pro-Code?

Low-Code No-Code (LCNC), or low code no code as it is sometimes written, refers to how to make an app – computer and mobile applications – that doesn’t require traditional programming skills (Pro-Code.)

Conceptually, using no code platforms, anyone can figure out how to create an app using a few clicks. With low-code solutions, power users and subject matter experts (citizen developers) can build applications using a business-friendly expression language, and, of course, pro-code solutions utilize programming languages like JavaScript, Java, Python and C# where professional development teams are the app creator.

Healthcare automation needs have become so critical and pervasive that to address these concerns head-on, a community of practice, BPM+ Health, has been created. BPM+ Health was established based on the use of open, standards-based notations including BPMN™ (workflow management) DMN™ (decision management), CMMN™ (case management), and other open IT standards which allows for all types of health organizations, professional societies, and vendors to document their care pathways and workflows, so they are sharable, discoverable, and automatable.

In this age of digital transformations, software is becoming increasingly strategic ad pervasive. Both new care settings and continuously changing medical and pharmaceutical advances are driving an explosion in the demand for new and updated applications yet professional programmers who can build and maintain this software has reached a critical shortage. Other industries are already adopting lowcode and nocode platforms to speed the creation of applications, reduce the backlog, and make application development more affordable. Because professional software developers are an increasingly scarce and expensive resource, everyday employees are stepping up as “citizen developers.” These power users and SMEs already have the domain knowledge needed to rapidly compose their needed applications using low-code tools. The healthcare software revolution is behind the curve and low-code development is rapidly becoming the best option to catch up. However, even as low-code platforms advance, pro-code professional developers will still be needed to create the more complex features and integrations required in healthcare.

Most current Electronic Health Record systems (EHRs) are increasing the burden of work on doctors and other care team members primarily because they are neither agile nor provide for innovation capabilities. Surprisingly, while virtually every other business sector is utilizing these new technologies, little is developed with low-code or no code in healthcare. Low-code solutions would seem to lend themselves to patient portal apps, common patient care apps or even complex back-office systems. Using low-code, care givers and other subject matter experts (SMEs) don’t need to learn a professional programming language to create apps but only need to learn an app where they set configurations in a graphical user environment and sometimes a simple expression language. Low-code app development is therefore faster and far less expensive. Using low-code platforms, developers can use agile methods to test the new and changing needs of providers and patients directly during the development cycle. Since low-code platforms provide simple ways to invoke other applications or components via RESTful API calls, apps can easily integrate with existing IT systems and standards such as HL7®, FHIR®, CDS Hooks™, SMART™, and SMART on FHIR allowing new functionalities to be added to existing systems with little or no disruption to current operations.

A hallmark of the healthcare industry is the diversity and volume of data needed to provide the vast array of clinical, administrative, and insurance services patients and caregivers have come to expect while controlling the costs of those services. Just creating and maintaining a comprehensive data layer accessible to all is a major and ongoing undertaking. Add to that the hundreds, if not thousands, of applications, APIs, and interdependencies, the complexity is nearly overwhelming. Emerging standards like FHIR may help. Still, by using low-code composable apps along with FHIR and other data sources, organizations and their citizen developers may be able to modernize faster and more affordably by assembling their own vendor-neutral digital platforms.

Trisotech LCNC
in Healthcare

Trisotech is a founding member of BPM + Health which includes BPMN, as well as DMN and CMMN, as an integral standards technology. Trisotech healthcare clientele include international and U.S. acute care hospitals, healthcare insurance organizations, HMOs, renowned teaching hospitals, PPOs, and healthcare professional organizations.

The Trisotech Healthcare Feature Set (HFS) is an optional set of advanced low code development functionalities extending the Trisotech Digital Enterprise Suite with healthcare-specific additions. Through a combination of these new features and functions, healthcare organizations can now access FHIR®, SMART™, and SMART on FHIR capabilities as well as AI and Machine Learning (ML) in their modeling and automation of model-driven applications. Predefined FHIR Data types (simple, complex, and special purpose) are provided as no-code reusable drag and drop data structures that can be assigned as data objects in model-driven applications and autogenerated SMART on FHIR webapps can be created from automations stored in the Digital Enterprise Suite (DES) Service Library.

Building low-code healthcare apps requires access to advanced computational and logical capabilities. Trisotech supports the only international standard expression language perfect for low-code developers – FEEL (Friendly Enough Expression Language) published as part of the DMN (Decision Model and Notation™) from OMG, an international standards body.

Another no-code feature is the Attended Tasks extension. The Trisotech Attended Task feature allows for validation and confirmation of the inputs and/or outputs of any automated task by the care provider user or any other designated performer. This feature ensures that a knowledgeable human expert can correct/modify information in real time during apps execution.

Trisotech also provides nearly 1,000 pre-built evidence-based workflow and decision models including care pathways, clinical guidelines, and healthcare calculators using the the BPM+ Health standard. These models can be quickly and easily modified to fit the exact nature of anorganization’s policies and procedures. Healthcare organizations can also create their own apps from scratch with the easily understood visual Workflow Modeler (BPMN) that can be shared by IT, practitioners, SMEs, and business people – LCNC citizen developers.

What Are Business Rules and Decision Management?

To meet the demand for enterprise automation over the last few decades, computer programs have become larger and more complex.

To simplify the building and maintenance of those programs, new programming paradigms have evolved. One central method of simplification has been to extract and standardize common computing tasks from the body of application programming source code. One of the first major abstractions was to replace custom data management in programs with Data Base Management Systems (DBMS). The next big movement replaced the step-by-step embedded procedure logic in individual programs with that of Business Process Management Systems (BPMS). Next came the abstraction of business rules which automated the policies by which organizations operated with Business Rule Management Systems (BRMS). The latest evolution is the replacement of BRMS with Decision Management Systems (DMS).

Business rules systems work on the principle of rules statements – a trigger then action paradigm – typically in the If->Then->Else style and usually defined in a proprietary “language” along with decision tables. Those rules are then processed when the trigger occurs by a Business Rules Engine (BRE). The tools to define the rules, version, deploy, execute, monitor, and manage them plus the engine are normally bundled together in a Business Rules Management System (BRMS). These systems are highly technical in nature and are usually owned and maintained by IT resources. Direct business subject matter expert involvement is usually quite limited. Instead, subject matter experts (SMEs) harvest or mine (discover) business rules from within the organization and define them as requirements specifications. IT then translates those requirements into rules statements.

Decision Management Systems work on the principle of defining business decisions where the decision answers a specific business question providing the result (output) of the decision based on the values of pre-defined input variables to the decision logic – typically in the Input(s)->Decision Logic->Answer (output) style. The most commonly used decision management technique is Decision Model and Notation (DMN) an international standard published and supported by OMG, an international, open membership, not-for profit technology standards consortium. DMN focusses on decisions – higher level business asset artifacts – that are meaningful to business subject matter experts (SMEs). DMN also provides the Friendly Enough Expression Language (FEEL), a simple but powerful way to provide logical, textual, mathematical, list processing, interval, date/time and other functions business people need to make decisions.

Decision Management differs from rules management in significant ways. The most important is that rather than just a collection of rules statements, decisions are specific, reusable business logic modules usually created and maintained by business subject matter experts. The DMN standard utilizes visual models which are standardized, verifiable, and where the model serves as the documentation and as the executable source for the Decision Automation Engine. Visual modeling by SME’s eliminates one of the major sources of business rules errors, the “translation” of SME-defined rules (requirements) to IT-created rules. With DMN both the SMEs and IT personnel are working with the same decision model.

Why Are Business Rules and Decision Management Used?

Busines Rules and Decision Management systems are used to free business people and subject matter experts from needing to know and use complex IT programming languages for creating and maintaining the automated policies and logic used to make operational decisions that run their business. By abstracting these rules and decisions from conventional IT application programs and processes, rules and decision systems allow non-IT personnel to create a reusable “single version of the truth” while working directly with existing systems and IT. This abstraction facilitates not only more direct access by business people but also enhances the separation of concerns by making sure the correct people have access to the organization’s policies while providing IT access to the more technical implementation and integration requirements. Business Rules and Decision Management systems abstraction also provides ways to greatly speed up and simplify the creation of and changes to operational decisions resulting in better business agility.

While Business Rules Management Systems continue to be used, their shortcomings have become more pronounced over time. Among these shortcomings are a lack of standardization which forces customers into IT driven vendor-specific proprietary systems and requires higher cost, difficult to find technical personnel to operate. Most recently the advent of cloud computing and customer personalization requirements has disrupted most businesses causing an explosion of rules that has made rules logic more difficult to understand and maintain and that severely restrict agility. Because large business rules repositories contain many thousands of individual rules, they are notoriously difficult to validate and test so heavy step-by-step IT technology involvement is needed and that continuously widens the gap between IT and business subject matter experts.

Decision Management systems based on the DMN standard are, on the other hand, visual model driven, verifiable, standardized, are easily shared between business subject matter experts and IT personnel. A business decision is a reusable tangible business asset that can be automated directly from the visual model without IT translation. Comprehensive visual models in DMN are readable by both IT and business people, serving as a decision specification, the decision logic, the decision documentation, and the automation code – all in a single visual artifact.

Large-scale healthcare organizations are often linked businesses combining and networking physicians, acute care hospitals, long term care facilities and insurance organizations. All these organizations need secure standards-based software to help them store and retrieve data as well as standardize and centralize workflows and decision making across all parts of their business.

Healthcare is also a highly dynamic sector with constant change being generated from regulatory requirements, new procedures, new medicines, new insurance rules and rapidly evolving technologies. Every healthcare organization must be able to quickly set guidelines and policies associated with their data and tailored to their respective delivery systems and business models against which quality of service, cost containment, and patient satisfaction can be directly measured and continuously improved.

Business rules and decision management systems have been used to improve clinical guidelines, care management, prior authorization, billings and payments, off-label prescription policies, fraud management, actuarial and risk management insurance calculations, call center scripting, incorporating AI/Machine learning into decision making, complex process automation pathing and many other applications. Decision Modeling and automation, in conjunction with clinical decision support (CDS), is being used to deliver real-time clinical decision support (CDS Hooks) for providers during their patient encounters. As a result, the providers are able to consider alternative diagnoses, treatments, and potential cost-saving measures for their patients.

Other examples include hundreds of healthcare calculators like BMI, FEV/1, LACE, PEARL, DECAF, Framingham Diabetes Risk, etc. and outside agency preauthorization requirements like Medicare Home Oxygen reimbursement, conventional insurance pre-authorization for Total Knee Arthroplasty (TKA), and internal organizational policies on off-label drug use evaluation and approval. Models like these require multiple decisions, often needing specific patient data. Some of these decisions are based on preset external requirements like Medicare policies and some are specific to the decision-making organization’s policies. One size does not fit all, so the models, to be effective, must be well documented and easy to change to reflect changing policies. Business rules and decision management system solutions allow healthcare organizations to easily define and deploy these examples and many more solutions tied to evidence-based best practices.

Healthcare automation needs have become so critical and pervasive that to address these concerns head-on a community of practice, BPM+ Health™, has been created. BPM+ Health was established based on the use of open, standards-based notations including DMN (decision management) and other open IT standards which allows for all types of health organizations, professional societies, and vendors to document their care pathways and workflows so that they are sharable, discoverable, and automatable.

Trisotech is a founding member of BPM + Healthcare and Trisotech healthcare clientele include international and U.S. acute care hospitals, healthcare insurance organizations, renowned teaching hospitals, and healthcare professional organizations.

The Trisotech Decision Modeling and the Decision Automation Engine provides healthcare providers with centralized, easy-to-understand and change standard process and decision methodologies. These tools adhere to international standards for building processes and decisions and support other standards like FHIR® (HL-7®) for data storage and retrieval, CDS Hooks for real-time decision support at the point of care and PMML execution for the inclusion of AI and Machine learning into automated decision models.

Trisotech also provides nearly 1,000 free pre-built evidence-based workflow and decision models including care pathways, clinical guidelines, and healthcare calculators in the BPM+ Health standard that are being put into practice every day. These models are human-readable, machine automatable, and embeddable in most medical encounter systems. Healthcare organizations can use these models, created under the direction of Trisotech CMO John Svirbely, as they are, or quickly and easily modify them to fit the exact nature of their organization’s policies and procedures. Healthcare organizations can also, of course, create their own processes and decisions from scratch since the easily understood visual models can be built and shared by practitioners, IT and business people.

What is Business Process Management?

What is BPM?

All businesses have processes. Processes are typically differentiated from projects because processes are predictable and repeatable. They are the building blocks of operating a business.

While many organizations have similar fundamental processes, the unique parts of their processes, dictated by their specific business methods, form the basis of the organization’s competitive advantage and often their “culture.” A process can be defined as a series of steps leading to identified outcomes. Common business processes are often named with descriptions like Opportunity-to-Order, Order-to-Cash, or Employee Onboarding. The sequence of work and steps performed can vary from instance to instance based on inputs, decisions, timing, dates, etc. However, regardless of the value of these variables, to properly define a process one must know all the possible paths and outcomes in advance i.e., predictability.

Business Process Management is a management discipline with the key goals of discovering, modeling, analyzing and optimizing business processes. While some BPM solution providers might include business process automation – a BPM engine or automation platform – as part of BPM, Trisotech defines process automation as a separate discipline. As a methodology, BPM can be thought of as similar to (and sometimes encompassing) other methodologies like continuous improvement (CI) or total quality management (TCM).

Why is BPM Used?

Once a predictable process has been defined through process discovery, it can be optimized – often called process improvement – and performed over and over in a standard way i.e., repeatability. By the act of discovering and defining a process, the resulting process documentation becomes a valuable organizational asset. The use of BPM can improve business operations’ performance and agility, lower costs and add value to customer products and services. Often cited specific benefits include higher efficiency and productivity, reduced costs, increased revenue, better agility, operational consistency, greater customer service focus, better regulatory compliance, increased security, and higher operational visibility.

Process-driven healthcare organizations can create standardized clinical guidelines that facilitate consistent organizational policy, patient diagnosis, treatment, and reporting for both individuals and populations. Business processes can also provide real-time feedback and recommendations to providers, be embedded in most patient encounter systems, and integrate the use of standards like FHIR® and CDS Hooks.

Business processes are not just valuable in the clinical setting, however. They are also extensively used in healthcare insurance and patient services settings. Examples of these types of processes include claims processing, pharmaceutical and durable medical equipment (DME) pre-authorizations and patient, provider, and facility scheduling.

I came into the process automation industry by way of content-driven workflow: the scanning of a paper document – such as an application form – triggered a workflow that was focused on manual data entry of the information on this document into a transaction processing system. I became more interested in how to design and optimize the process side of things, but never lost sight of the fact that unstructured content (documents, emails, media) is an integral part of many processes. What became increasingly apparent is that in order to have properly-governed content-rich processes, process must control access to content, in addition to whatever controls are in place in the content management systems themselves.

This is especially true of complex customer-facing processes such as insurance underwriting and claims, where the underlying purpose of the process is to collect sufficient information in order to make a decision (whether or not to insure, or whether to pay a claim) and set a value associated with that decision (the premium or claim amount). Some of that information comes in the form of data, captured from the customer in a web form or manually entered from their submitted application, but some will be unstructured content: property evaluations, photos, proof of income, medical reports, and more. This content may need to be accessed by anyone involved in the process, including the underwriter, claims manager, other internal workers, third parties, and even the customer themselves.

However, you can’t just give all of these people open access to the content: there must be limits set on who can see what content, and at what point in the process. This is where process and rules come into play, plus some clever handling of the content itself.

First of all, there’s the question of whether someone should be able to see a piece of content at all: this is usually based on their role and the particular task that they are performing within the process, but may also be filtered by the specific case or customer. For example, a junior underwriter may be able to see all content related to all of their customer cases and also access similar cases for context, but must be prevented from accessing content related to high-profile customers such as politicians or their own company executives. A third party, such as a property evaluator, may require access to some of the content in order to determine the scope of their evaluation, but only for the cases assigned to them. And the customer should be able to see the documents that they submitted as well as some of the underwriter’s work in progress, although not anything that would violate company confidentiality or that of other customers.

Next, there’s the question of whether someone should be able to see all of the information within a particular piece of content. This is especially true of content such as application forms, which may contain private customer information such as banking details. Even if someone has access to the content based on their role in the process, some part of the content may need to be redacted to ensure customer privacy.

A good content management system will apply both access control and redaction based on the specific user, but that misses two key things: first of all, the same user may take on different roles in the context of different processes, and thereby require different types of access. Secondly, most companies don’t keep all of their information in a good content management system: instead, it’s spread across an ad hoc collection of content management systems (some of them dating back decades) and network file shares. Internal employees have too much access, and can directly access any content that is available on their internal network. External third parties and customers aren’t given enough access, since they can’t see any of the internally-stored content even if they need it for their own work.

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