Towards Improving Modeling and Simulation of Clinical Pathways: Lessons Learned and Future Insights

Mahmoud Elbattah, Owen Molloy


Clinical pathways (CPs) have been increasingly recognised as an instrumental evidence-based artifact that can support clinical decision making and care planning. However, research focusing on modeling and simulation of CPs is still sparse, despite significant individual endeavours. Initially, the paper conducts a systematic literature review with the aim of thoroughly inspecting the state-of-the-art in literature. Through the review, potential improvements are investigated with regard to the application of modeling and simulation within CPs. In view of that, we identify four thematic areas that emphasise how research in this space can be further developed. Specifically, we propose the following directions: i) Development of a conceptual reference model of CPs, ii) Adoption of a multi-perspective modeling approach that can integrate clinical, operational, financial and demographic information of CPs, iii) Development of a generic semantic-based model of CPs, and iv) Adoption of Linked Data concepts.


  1. Booth, Andrew, Diana Papaioannou, and Anthea Sutton. Systematic approaches to a successful literature review. Sage, 2011.
  2. De Bleser, Leentje, Roeland Depreitere, KATRIJN DE WAELE, Kris Vanhaecht, Joan Vlayen, and Walter Sermeus. "Defining pathways." Journal of nursing management 14, no. 7 (2006): 553-563.
  3. Renholm, Marja, Helena Leino-Kilpi, and Tarja Suominen. "Critical pathways: a systematic review." Journal of Nursing Administration 32, no. 4 (2002): 196-202.
  4. Every, Nathan R., Judith Hochman, Richard Becker, Steve Kopecky, and Christopher P. Cannon. "Critical pathways a review." Circulation 101, no. 4 (2000): 461- 465.
  5. Pearson, Steven D., Dorothy Goulart-Fisher, and Thomas H. Lee. "Critical pathways as a strategy for improving care: problems and potential." Annals of internal medicine 123, no. 12 (1995): 941-948.
  6. Vanhaecht, Kris, Massimiliano Panella, Ruben Van Zelm, and Walter Sermeus. "An overview on the history and concept of care pathways as complex interventions." International Journal of Care Pathways 14, no. 3 (2010): 117-123.
  7. Shannon, Robert, and James D. Johannes. "Systems simulation: the art and science." Systems, Man and Cybernetics, IEEE Transactions on 10 (1976): 723- 724.
  8. Gupta, Ashish, and Ramesh Sharda. "Improving the science of healthcare delivery and informatics using modeling approaches." Decision Support Systems 55, no. 2 (2013): 423-427.
  9. Yang, Xian, Rui Han, Yike Guo, Jeremy Bradley, Benita Cox, Robert Dickinson, and Richard Kitney. "Modelling and performance analysis of clinical pathways using the stochastic process algebra PEPA." BMC bioinformatics 13, no. Suppl 14 (2012): S4.
  10. Yao, Wen, and Akhil Kumar. "CONFlexFlow: Integrating flexible clinical pathways into clinical decision support systems using context and rules. " Decision Support Systems 55, no. 2 (2013): 499-515.
  11. Ye, Yan, Zhibin Jiang, Xiaodi Diao, Dong Yang, and Gang Du. "An ontology-based hierarchical semantic modeling approach to clinical pathway workflows." Computers in biology and medicine 39, no. 8 (2009): 722-732.
  12. Hashemian, Nima, and Syed Sibte Raza Abidi. "Modeling clinical workflows using business process modeling notation." In Computer-Based Medical Systems (CBMS), 2012 25th International Symposium on, pp. 1- 4. IEEE, 2012.
  13. Zhen, Hu, Jing-Song Li, Yu Hai-yan, Zhang Xiao-guang, Muneou Suzuki, and Kenji Araki. "Modeling of Clinical Pathways Based on Ontology." In IT in Medicine & Education, 2009. ITIME'09. IEEE International Symposium on, vol. 1, pp. 1170-1174. IEEE, 2009.
  14. Li, Weizi, Kecheng Liu, Shuzhang Li, and Hongqiao Yang. "Normative modeling for personalized clinical pathway using organizational semiotics methods." In Computer Science and Computational Technology, 2008. ISCSCT'08. International Symposium on, vol. 2, pp. 3- 7. IEEE, 2008.
  15. Alexandrou, Dimitrios, Fotis Xenikoudakis, and Gregoris Mentzas. "SEMPATH: Semantic adaptive and personalized clinical pathways." In eHealth, Telemedicine, and Social Medicine, 2009. eTELEMED'09. International Conference on, pp. 36- 41. IEEE, 2009.
  16. Ozcan, Yasar A., Elena Tànfani, and Angela Testi. "A simulation-based modeling framework to deal with clinical pathways." In Proceedings of the Winter Simulation Conference, pp. 1190-1201. Winter Simulation Conference, 2011.
  17. Abidi, Samina Raza, and Syed Sibte Raza Abidi. "An ontological modeling approach to align institutionspecific Clinical Pathways: Towards inter-institution care standardization." In Computer-Based Medical Systems (CBMS), 2012 25th International Symposium on, pp. 1-4. IEEE, 2012.
  18. Du, Gang, Zhibin Jiang, and Xiaodi Diao. "The integrated modeling and framework of clinical pathway adaptive workflow management system based on Extended Workflow-nets (EWF-nets)." In Service Operations and Logistics, and Informatics, 2008. IEEE/SOLI 2008. IEEE International Conference on, vol. 1, pp. 914-919. IEEE, 2008.
  19. Michalowski, Wojtek, Szymon Wilk, Anthony Thijssen, and Mingmei Li. "Bayesian Belief Network Model of the Radical Prostatectomy Pathway." In System Sciences, 2006. HICSS'06. Proceedings of the 39th Annual Hawaii International Conference on, vol. 5, pp. 92a-92a. IEEE, 2006.
  20. Du, Gang, Zhibin Jiang, Xiaodi Diao, Yan Ye, and Yang Yao. "Modelling, variation monitoring, analyzing, reasoning for intelligently reconfigurable Clinical Pathway." In Service Operations, Logistics and Informatics, 2009. SOLI'09. IEEE/INFORMS International Conference on, pp. 85-90. IEEE, 2009.
  21. Combi, Carlo, Mauro Gambini, Sara Migliorini, and Roberto Posenato. "Representing business processes through a temporal data-centric workflow modeling language: An application to the management of clinical pathways." IEEE Transactions on Systems Man Cybernetics-Systems 44, no. 9 (2014): 1182-1203.
  22. Braun, Richard, and Hannes Schlieter. "Requirementsbased development of BPMN extensions: The case of clinical pathways." In Interrelations between Requirements Engineering and Business Process Management (REBPM), 2014 IEEE 1st International Workshop on the, pp. 39-44. IEEE, 2014.
  23. Zhang, Yunchuan, Kecheng Liu, and Guoxi Cui. "Consensus Forming in Clinical Pathway Development: Norm Based Modeling and Simulation." In Computational Intelligence for Modelling Control & Automation, 2008 International Conference on, pp. 931-936. IEEE, 2008.
  24. Young, Terry. "An agenda for healthcare and information simulation." Health care management science 8, no. 3 (2005): 189-196.
  25. Tako, Antuela A., Kathy Kotiadis, and Christos Vasilakis. "A participative modelling framework for developing conceptual models in healthcare simulation studies." In Proceedings of the Winter Simulation Conference, pp. 500-512. Winter Simulation Conference, 2010.
  26. Lehaney, Brian, and Vlatka Hlupic. "Simulation modelling for resource allocation and planning in the health sector." The Journal of the Royal Society for the Promotion of Health 115, no. 6 (1995): 382-385.
  27. Bolstorff, Peter. Supply chain excellence: a handbook for dramatic improvement using the SCOR model. AMACOM Div American Mgmt Assn, 2007.
  28. Huang, Samuel H., Sunil K. Sheoran, and Harshal Keskar. "Computer-assisted supply chain configuration based on supply chain operations reference (SCOR) model." Computers & Industrial Engineering 48, no. 2 (2005): 377-394.
  29. Hermann, Jeffrey W., Edward Lin, and Guruprasad Pundoor. "Supply chain simulation modeling using the supply chain operations reference model." In ASME 2003 International Design Engineering Technical Conferences and Computers and Information in Engineering Conference, pp. 461-469. American Society of Mechanical Engineers, 2003.
  30. Persson, Fredrik, and Mirko Araldi. "The development of a dynamic supply chain analysis tool-Integration of SCOR and discrete event simulation." International Journal of Production Economics 121, no. 2 (2009): 574-583.
  31. Hu, Zhen, Jing-Song Li, Tian-Shu Zhou, Hai-Yan Yu, Muneou Suzuki, and Kenji Araki. "Ontology-based clinical pathways with semantic rules." Journal of medical systems 36, no. 4 (2012): 2203-2212.
  32. Yang, Hongqiao, Weizi Li, Kecheng Liu, and Junping Zhang. "Knowledge-based clinical pathway for medical quality improvement. " Information systems frontiers 14, no. 1 (2012): 105-117.
  33. Daniyal, Ali, and Syed Sibte Raza Abidi. "Semantic Webbased modeling of Clinical Pathways using the UML Activity Diagrams and OWL-S." In Knowledge representation for health-care. Data, processes and guidelines, pp. 88-99. Springer Berlin Heidelberg, 2010.
  34. Abidi, Samina Raza. "A conceptual framework for ontology based automating and merging of clinical pathways of comorbidities." In Knowledge Management for Health Care Procedures, pp. 55-66. Springer Berlin Heidelberg, 2009.
  35. Studer, Rudi, V. Richard Benjamins, and Dieter Fensel. "Knowledge engineering: principles and methods." Data & knowledge engineering 25, no. 1 (1998): 161- 197.
  36. Pol, Louis G., and Richard K. Thomas. The demography of health and health care. Springer Science & Business Media, 2000.
  37. Campbell, Harry, Rona Hotchkiss, Nicola Bradshaw, and Mary Porteous. "Integrated care pathways." BMJ: British Medical Journal 316, no. 7125 (1998): 133.
  38. Zander, Karen. "Integrated care pathways: eleven international trends." Journal of Integrated Care Pathways 6, no. 3 (2002): 101-107.
  39. Fieschi, M., J. C. Dufour, P. Staccini, J. Gouvernet, and O. Bouhaddou. "Medical decision support systems: old dilemmas and new paradigms? Tracks for successful integration and adoption." Methods of information in medicine 42, no. 3 (2003): 190-198.
  40. Karsh, Ben-Tzion. "Clinical practice improvement and redesign: how change in workflow can be supported by clinical decision support." Agency for Healthcare Research and Quality, US Department of Health and Human Services. Publication 09-0054 (2009).
  41. Kawamoto, Kensaku, Caitlin A. Houlihan, E. Andrew Balas, and David F. Lobach. "Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success." Bmj 330, no. 7494 (2005): 765.
  42. Wears, Robert L., and Marc Berg. "Computer technology and clinical work: still waiting for Godot." Jama 293, no. 10 (2005): 1261-1263.
  43. Vanounou, Tsafrir, Wande Pratt, Josef E. Fischer, Charles M. Vollmer, and Mark P. Callery. "Deviation-based cost modeling: a novel model to evaluate the clinical and economic impact of clinical pathways." Journal of the American College of Surgeons 204, no. 4 (2007): 570-579.
  44. Porter, Geoffrey A., Peter WT Pisters, Carol Mansyur, Annette Bisanz, Kim Reyna, Pam Stanford, Jeffrey E. Lee, and Douglas B. Evans. "Cost and utilization impact of a clinical pathway for patients undergoing pancreaticoduodenectomy." Annals of Surgical Oncology 7, no. 7 (2000): 484-489.
  45. Huber, Thomas S., Lori M. Carlton, T. R. Hrward, Mildred M. Russin, Paul T. Phillips, Betty J. Nalli, Timothy C. Flynn, and James M. Seeger. "Impact of a clinical pathway for elective infrarenal aortic reconstructions." Annals of surgery 227, no. 5 (1998): 691.
  46. Pritts, Timothy A., Michael S. Nussbaum, Linda V. Flesch, Elliot J. Fegelman, Alexander A. Parikh, and Josef E. Fischer. "Implementation of a clinical pathway decreases length of stay and cost for bowel resection." Annals of surgery 230, no. 5 (1999): 728.
  47. Pitt, Henry A., Kevin P. Murray, Helen M. Bowman, JoAnn Coleman, Toby A. Gordon, Charles J. Yeo, Keith D. Lillemoe, and John L. Cameron. "Clinical pathway implementation improves outcomes for complex biliary surgery." Surgery 126, no. 4 (1999): 751-758.
  48. Collier, Paul E. "Do clinical pathways for major vascular surgery improve outcomes and reduce cost?." Journal of vascular surgery 26, no. 2 (1997): 179-185.
  49. Maliapen, Mahendran, and B. C. Dangerfield. "A system dynamics-based simulation study for managing clinical governance and pathways in a hospital." Journal of the Operational Research Society 61, no. 2 (2010): 255- 264.
  50. Cole L and Houston S. “Structured care methodologies: evolution and use in patient care delivery”. Outcomes Management for Nursing Practice 1999; 3(2): 88-94.
  51. Bizer, Christian, Tom Heath, and Tim Berners-Lee. "Linked data-the story so far." (2009).
  52. Robak, Silva, Bogdan Franczyk, and Marcin Robak. "Applying big data and linked data concepts in supply chains management." In Computer Science and Information Systems (FedCSIS), 2013 Federated Conference on, pp. 1215-1221. IEEE, 2013.
  53. Lowery, Julie C., Brian Hakes, Lou Keller, William R. Lilegdon, Kal Mabrouk, and Frank McGuire. "Barriers to implementing simulation in health care." In Proceedings of the 26th conference on Winter simulation, pp. 868-875. Society for Computer Simulation International, 1994.
  54. Lowery, Julie C. "Introduction to simulation in health care." In Proceedings of the 28th conference on Winter simulation, pp. 78-84. IEEE Computer Society, 1996.
  55. Harper, P. R., and M. A. Pitt. "On the challenges of healthcare modelling and a proposed project life cycle for successful implementation&star." Journal of the Operational Research Society 55, no.6 (2004):657-661.
  56. Brailsford, Sally. "Overcoming the barriers to implementation of operations research simulation models in healthcare." Clinical and investigative medicine. Medecine clinique et experimentale 28, no. 6 (2005): 312-315.
  57. Eldabi, Tillal. "Implementation issues of modeling healthcare problems: misconceptions and lessons." In Winter Simulation Conference, pp. 1831-1839. Winter Simulation Conference, 2009.
  58. Feinstein, Alvan R. "The pre-therapeutic classification of co-morbidity in chronic disease." Journal of Chronic Diseases 23, no. 7 (1970): 455-468.
  59. Abidi, Samina, Jafna Cox, Syed Sibte Raza Abidi, and Michael Shepherd. "Using OWL ontologies for clinical guidelines based comorbid decision support." In System Science (HICSS), 2012 45th Hawaii International Conference on System Sciences, pp. 3030-3038. IEEE, 2012.

Paper Citation

in Harvard Style

Elbattah M. and Molloy O. (2015). Towards Improving Modeling and Simulation of Clinical Pathways: Lessons Learned and Future Insights . In Proceedings of the 5th International Conference on Simulation and Modeling Methodologies, Technologies and Applications - Volume 1: SIMULTECH, ISBN 978-989-758-120-5, pages 508-514. DOI: 10.5220/0005568405080514

in Bibtex Style

author={Mahmoud Elbattah and Owen Molloy},
title={Towards Improving Modeling and Simulation of Clinical Pathways: Lessons Learned and Future Insights},
booktitle={Proceedings of the 5th International Conference on Simulation and Modeling Methodologies, Technologies and Applications - Volume 1: SIMULTECH,},

in EndNote Style

JO - Proceedings of the 5th International Conference on Simulation and Modeling Methodologies, Technologies and Applications - Volume 1: SIMULTECH,
TI - Towards Improving Modeling and Simulation of Clinical Pathways: Lessons Learned and Future Insights
SN - 978-989-758-120-5
AU - Elbattah M.
AU - Molloy O.
PY - 2015
SP - 508
EP - 514
DO - 10.5220/0005568405080514