FROM MEDICAL PROCESSES TO WORKFLOWS

Modeling of Clinical Pathways with the Unified Modeling Language

Christian Mauro, Tobias Happle, Ali Sunyaev, Helmut Krcmar

Information Systems, Technische Universitaet Muenchen, Boltzmannstr. 3, 85748 Garching, Germany

Jan Marco Leimeister

Information Systems, Universitaet Kassel, Nora-Platiel-Strasse 4, 34127 Kassel, Germany

Keywords: Clinical Pathways, Workflows, UML, Workflow Management Systems, Process Modeling.

Abstract: Clinical pathways describe treatment processes within a hospital. They can be used as process models,

which can be controlled by implemented workflow models in information systems. This enables (semi-)

automated processes, and they are therefore high potential for an improved quality management and

seamless IT support. Surprisingly, there are no published process models that describe the implementation

of clinical pathways in an information system while taking into account the characteristics of health care

specifics. We bridge this gap by proposing a process model using UML as modeling language.

1 INTRODUCTION

Clinical pathways specify concrete treatment

activities for patients with identical diagnoses or for

patients diagnosed differently but treated by

employing the same therapy (Engemann and Strobel,

2005). This standardization of the activities serves as

a cost saving factor because of its short delay time as

well as its quality assurance. Process descriptions

can be populated in hospital information systems or

in autonomous workflow management systems

(WfMS) (Allen and zur Mühlen, 2000) through

editors for effective information technology (IT)

support of the pathways. Hereby, essential parts of

the necessary communication and coordination

between the actors can be automated and the

effectiveness, as well as the efficiency of the

processes, can be improved.

Despite the advantages of this process control,

there is no process model published that describes

the implementation of clinical pathways in

information systems, considering the characteristics

of the clinical environment, such as the robust

clinical pathway structure in treatment phases. This

paper bridges this gap by introducing a process

model using the Unified Modeling Language (UML)

2.0, which is suitable for the implementation of

clinical processes (Becker, 2006), (Lang et al., 2006)

and is a widespread official standard of the Object

Management Group.

2 PROCESS MODEL

Models serve as a simplified description of reality.

In order to reduce complexity or to increase the

comprehensibility of the figures, one should employ

different views and modeling layers in the

representation of these systems (Gadatsch, 2005).

One is able to distinguish three modeling layers:

business process, functional workflow and technical

workflow, which are differentiated by their

proximity to the IT (Wittges, 2005). In contrast to

the business process which describes the activities to

be executed in a pure functional manner, the

functional workflow layer concentrates on the

description of work processes with regard to the

requirements that result from the technical support

of the execution of workflows by an information

system (Gadatsch, 2005), (Jablonski et al., 1997).

Due to the different focus of both modeling layers

(functional process vs. implementation supported by

IT), the use of successive modeling of a real process

is recommendable: first within the business process

layer and then in the workflow layer. In the end, the

functional and producer-independent workflow-

388

Mauro C., Happle T., Sunyaev A., Krcmar H. and Leimeister J. (2010).

FROM MEDICAL PROCESSES TO WORKFLOWS - Modeling of Clinical Pathways with the Uniﬁed Modeling Language.

In Proceedings of the Third International Conference on Health Informatics, pages 388-391

DOI: 10.5220/0002695103880391

 SciTePress

model is transformed by a workflow-editor into a

producer-specific model which can be automatically

executed (technical workflow layer). For the sake of

clarity, the process model for transformation of

clinical pathways will be divided hereafter into

modeling layers.

2.1 Modeling of Clinical Pathways in

the Business Process Layer

The modeling of clinical pathways in the business

process layer is organized in phases which will be

explained in the next sections.

2.1.1 Pathway Selection and Process

Analysis

The IT implementation of clinical pathways is, in

contrast to payment in kind processes, not always

accomplishable because of the high variation in the

process input factors (Gadatsch, 2005),

(Schneeweiß, 2002). The high variation of process

relevant properties, such as age, sex, or diverse

previous diseases, hinders the prediction and the

adherence of particular treatment processes and

treatment outcomes. In order to implement clinical

pathways in information systems, taking into

consideration the costs resulting from it, one can

employ only pathways with patients which promise

cost saving potentials because of their frequent

appearance and/or the corresponding treatment costs

or because of adequate homogenous patient groups,

whose processes differ insignificantly (Fischbach

and Engemann, 2006), (Thun, 2006).

One-person interviews with selected

professionals involved in the process (from nursing,

medical or administrative departments) are

documented in order to collect information about the

current treatment processes. Organizational delays

often cause at least a two-day duration of the

interviews. Both rounds of talks should be at least

three working days away from each other since

during this time period the start of the modeling

should be planned. Thus, knowledge gaps in the

process execution can be identified and prompted in

the following interviews. The interviews must be

recorded on audio tapes because the complexity of

the processes makes written documentation difficult

during long talks. Documents relevant for the

process execution should also be provided to be

analyzed.

2.1.2 Cases – Preliminary Design

Since with a single clinical pathway different disease

patterns can possibly be treated and these variations

can be demanded during the process execution,

different alternatives of the pathway must be

distinguished and modeled separately. Therefore,

one can discern cases which summarize patient

groups of one pathway, for whom an identical

treatment process is obligatory. Business partners

(for instance, general practitioners or medical

specialists) initiate the cases which, in order,

determine to a greater extent, the starting point of

the model. Activity diagrams and standard elements

in UML 2.0 are used for modeling of the various

cases.

Treatment processes in the clinical field exhibit

robust structure of the activities to be executed into

treatment phases; especially in post-operative

treatment processes, the activities are also structured

into treatment days. The treatment phase in which a

process is being executed has an impact on the

concrete execution of some diagnostic processes too.

Therefore, the activity diagrams necessary for the

modeling are, at first, divided into treatment days

and phases in order to ease the further matching.

Since UML 2.0 provides no suitable elements for

visualization of time spans within an activity

diagram, and isolated modeling of the days and

phases (for example in separate activity diagrams) is

usually not possible because of the large number of

interdependencies, day and phase changes are

presented as a Fork/Join element. The naming of the

activities and the actions are expressed from a

clinical institution's point of view (Oestereich et al.,

2003). For instance, “dispense medicaments” would

be used instead of “receive medicaments.”

In the context of examination and approval

processes, information flows are presented as

Send/Receive UML objects. When using

Send/Receive objects, one must note from which

organizational unit the signal originates and for

which one it is intended. Both objects are connected

through an information flow. Because of the acute

cases of emergency and the chronic overload of the

clinical personnel, an important condition for the

composition of clinical treatment processes is their

flexible and appropriate adaptation. Thus, the

workload of the necessary resources determines, to a

greater extent, the time for the execution of activities

that are not critical (especially in post-operative

phases). In order to achieve the necessary flexibility

in the form of a modeling paradigm, one would

better use parallelization of actions and activities

instead of sequential arrangement if the latter is not

compulsory because of the corresponding

interdependencies.

Knowledge gaps in the process execution are

FROM MEDICAL PROCESSES TO WORKFLOWS - Modeling of Clinical Pathways with the Unified Modeling

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389

noted during the modeling as notices in the activity

diagram and in a notice list. These gaps are handled

as checklists during the talks that follow.

2.1.3 Final Case Design and the Role Model

During the modeling of the case preliminary design,

organizational and role models are produced

simultaneously, for which the relevant

organizational units within a class diagram are

modeled by using an organigram. After all

interviews are completed, an actor model is

developed within a use case diagram. The model

contains all identified roles and additional features

for which an assignment from activities to people is

required. The modeled organizational units are

detailed by the identified actors.

Subsequently, the pathway on the business

process level is completed after the modeling of the

case final design. For that purpose, activities are

consolidated, the process logic is specified, and the

roles and functions contained in the process are

displayed by Swimlanes, which represent the

schedule of responsibilities. In case different actors

can process activities or decisions about the process

sequence, they are placed on the strip line of the

Swimlanes, or if there are more than two different

actors, tags are intended to represent them. Tags can

also serve, for instance, as containers for additional

information describing the content of the activities.

In addition, the creation of specific stereotypes,

which change the visualization of the activities,

depending on the tags, might be reasonable. Finally,

a glossary of the used technical terms is created.

2.2 Modeling of Clinical Pathways on

Workflow Level

After the pathway has been modeled on the business

process level, its modeling on technical workflow

layer follows. The modeling of single cases is

implemented in separate activity diagrams, whereas

the modeling is focused on the organizational,

operative, and data-oriented content (Lang et al.,

2006). Organizational aspects are very significant

because of the highly specialized job descriptions in

health care (Ziegenbein, 2001). The important

meaning of the data-oriented aspects results mainly

from extensive documentation requirements and the

generally high information requirements of patients'

treatment processes.

2.2.1 Representation Elements

A central element of the representation within the

technical workflow layer is the work item – a

stereotype of the UML class Action that

encapsulates the interaction of a system with human

actors in a black box. The element work item can be

interpreted as an IT representative of an activity to

be processed in a work list handler, and it enables

the interaction between a user and the information

system. The work item conceals the concrete

technical implementation of the communication, but

despite that, allows a simple representation of

interactions which control the execution of the

pathway. Generally, three basic use cases of an

interaction are possible: a notification about the

present tasks without additional presentation and/or

documentation of data, the optional, and the required

presentation and/or documentation of information.

The actors, who process the work item, are modeled

explicitly and attached to it. Moreover, for each of

them the corresponding organizational unit is

indicated.

2.2.2 Modeling in the Technical Workflow

Layer

The modeling in the technical workflow layer is

basically divided into three phases. In the first one,

the sub-processes which are to be implemented on

the system are selected and holistically modeled.

Very suitable for implementation on this layer are

diagnostic methods, periodic or recurrent processes

(such as measurement and documentation of vital

parameters) and common administrative processes,

in whose execution a multitude of actors participates

and which possesses a sufficiently high grade of

structuring of the work processes.

During the implementation of multiple pathways,

these sub-processes are separated and categorized

into delimitable use cases and specific variants in

order to develop standardized processes that can be

reused in a variety of pathways. However, these

process libraries that originate from them are not the

subject of this brief paper. If, however, only one

pathway is transferred into an information system,

then the development of standards and variants is

not urgently required but still reasonable because

such complex pathways can be structured

systematically.

After the creation of a domain model or a state

model, the complete pathway including the

necessary process logic is modeled into an activity

diagram. Thereby, the subdivision into phases

should be kept because this structure is used, for

example, for the assignment of success factors, and

the following treatment steps are activated partly on

presentation of particular success factors, whereby

this structure is exceptionally suitable for control of

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the treatment progress or for regulation and enabling

the following treatment phases.

3 SUMMARY AND OUTLOOK

A process model was presented which describes the

implementation of developed (paper-based)

pathways in an information system. Unified

Modeling Language 2.0 was used as a modeling

language. Initially, clinical pathways were modeled

in their functional sequence (business process layer),

afterwards selected subsequences were implemented

in the second modeling layer in regard to IT

requirements (functional workflow layer).

The effort during the implementation of numerous

pathways in an information system can be

considerably reduced by the employment of patterns

for subsequences and for the sequential structure of

the whole pathway. Due to space restrictions, the

approach for the identification and systematization

of clinical processes in a process library is not part

of this paper. The efforts implied by the

implementation of clinical pathways can be

considerably reduced by the procedure model and

the approach for development of a process library.

In the present research paper, problems with

respect to the implementation of clinical pathways in

an information system have been examined but not

the technical capabilities of such implementation.

Therefore, further research must clarify which

requirements need to be met by such an information

system and especially by a workflow editor within

the information system, i.e., which technology

solutions are suitable for the implementation of

process control in the clinical field. This research

paper has shed light on the significance of

comprehensive pathway templates; however, it must

be clarified in further research how such pathway

templates can be identified and delimited. The

verification of the approach methodology described

here on other clinical pathways is also a goal of

further research.

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