What BPM Technology Can Do for Healthcare Process Support [original]

What BPM Technology Can Do

for Healthcare Process Support

Manfred Reichert

Institute of Databases and Information Systems, Ulm University, Germany

[email protected]

Abstract. Healthcare organizations are facing the challenge of deliver-

ing personalized services to their patients in a cost-eﬀective and eﬃcient

manner. This, in turn, requires advanced IT support for healthcare pro-

cesses covering both organizational procedures and knowledge-intensive,

dynamic treatment processes. Nowadays, required agility is often hin-

dered by a lack of ﬂexibility in hospital information systems. To over-

come this inﬂexibility a new generation of information systems, denoted

as process-aware information systems (PAISs), has emerged. In contrast

to data- and function-centered information systems, a PAIS separates

process logic from application code and thus provides an additional

architectural layer. However, the introduction of process-aware hospi-

tal information systems must neither result in rigidity nor restrict staﬀ

members in their daily work. This keynote presentation reﬂects on recent

developments from the business process management (BPM) domain,

which enable process adaptation, process ﬂexibility, and process evolu-

tion. These key features will be illustrated along existing BPM frame-

works. Altogether, emerging BPM methods, concepts and technologies

will contribute to further enhance IT support for healthcare processes.

1 Introduction

Business process support has been a major driver for enterprise information sys-

tems for a long time. Its overall goal is to overcome the drawbacks of functional

over-specialization and lack of process control. Technology response to this busi-

ness demand was met with a suite of technologies ranging from oﬃce automation

tools to workﬂow systems to business process management technology.

Just as database management systems provide a means of abstracting appli-

cation logic from physical data aspects, workﬂow management systems separate

coordinative process logic from application code [1, 2]. Although workﬂow tech-

nology has delivered a great deal of productivity improvements in industry, it

has been mainly designed for the support of pre-speciﬁed and repetitive busi-

ness processes requiring a basic level of coordination between human performers

and required application services. More recently business process management

(BPM) has been used as broader term to reﬂect the fact that business processes

may or may not involve human participants, cross organizational boundaries,

and require a high degree of ﬂexibility [3, 4].

M. Peleg, N. Lavraˇc, and C. Combi (Eds.): AIME 2011, LNAI 6747, pp. 2–13, 2011.

Springer-Verlag Berlin Heidelberg 2011

What BPM Technology Can Do for Healthcare Process Support 3

Currently, there is a widespread interest in BPM technologies in a variety

of domains, especially in the light of emerging software paradigms surrounding

service-oriented computing and its application to dynamic service orchestration

and choreography. In this context, the notion of PAIS (Process Aware Infor-

mation System) provides a guiding framework to understand and deliberate on

the above developments [5]. As fundamental characteristic, a PAIS provides the

basic means to separate process logic from application code. Furthermore, it

has to cover all phases of the process lifecycle; i.e., process design, process im-

plementation, process conﬁguration, process enactment, process monitoring and

diagnosis, and process evolution [6]. At build-time the process logic has to be ex-

plicitly deﬁned based on the constructs provided by a process modeling language.

In this context, a variety of workflow patterns (e.g., control and data patterns,

resource patterns, time patterns) have been suggested enabling the comparison

and evaluation of existing modeling languages and tools [7–10]. Other works, in

turn, target at improved process model quality and understandability [11–13]. At

run-time a PAIS executes the processes according to the deﬁned logic (i.e., pro-

cess model) and orchestrates required application services and other resources.

Examples of PAIS-enabling technologies include process management systems

like ADEPT2 [14], AristaFlow [15], and YAWL [16] as well as case handling

frameworks like FLOWer [4] and PHILHarmonic Flows [17].

In spite of several success stories on the uptake of PAISs in industry and the

growing process-orientation of enterprises, BPM technologies have not had the

widespread adoption in the healthcare domain yet [18]. A major reason for this

has been the rigidity enforced by ﬁrst generation workﬂow management systems,

which inhibits the ability of a hospital to respond to process changes and ex-

ceptional situations in an agile way [19]. When eﬀorts are taken to improve and

automate the ﬂow of healthcare processes, however, it is extremely important

not to restrict physicians and nurses. Early attempts to change the function-

oriented views of patient processes have been unsuccessful whenever rigidity

came with them. Variations in the courseofadiseaseoratreatmentprocess

are deeply inherent to medicine, and the unforeseen event is to some degree

a “normal” phenomenon. Therefore, healthcare process support craves for ad-

vanced BPM technologies enabling flexible,adaptive and evolutionary processes

in large scale.

For many years the BPM community has recognized that a PAIS needs to be

able to cope with real-world exceptions, uncertainty, and evolving processes [20].

To address respective needs a variety of process support paradigms like adaptive

processes,case handling,andconstraint-based processes have been suggested and

been applied in practice. Basically, these paradigms allow for coordinated pro-

cess support (involving human actors) and application service orchestration on

the one hand, while enabling process ﬂexibility, process adaptation, and process

evolution on the other hand. For example, adaptive PAISs allow dynamically

changing the process model of an ongoing process instance during run-time [21],

while constraint-based paradigms enable loosely speciﬁed process models, which

can be dynamically reﬁned at the process instance level obeying pre-deﬁned

4 M. Reichert

constraints [22]. Taking these technological developments from the BPM area,

new perspectives for the realization of ﬂexible, process-aware hospital informa-

tion systems emerge.

This keynote presentation elaborates on advanced BPM methods, concepts

and technologies developed during the last decade. Emphasis is put on key

features enabling process ﬂexibility, process adaptation, and process evolution.

Based on them advanced PAIS can be realized being able to ﬂexibly cope with

real-world exceptions, uncertainty, and change. Respective methods, concepts

and technologies will foster the development of a new generation of process-

aware healthcare information systems.

Section 2 draws a realistic picture of the environment in which a process-aware

hospital information systems must run. Section 3 discusses core contributions

from the BPM domain enabling ﬂexible and dynamic process support. Finally,

the paper concludes with a short summary and outlook in Section 4.

2 Hospital Working Environment

This section motivates the need for healthcare process support and discusses

the conditions under which a process-aware hospital information system must

operate [18, 19].

Generally, in hospitals, the work of physicians and nurses is burdened by

numerous organizational as well as medical tasks. Medical procedures must be

planned and prepared, appointments be made, and results be obtained and eval-

uated. Usually, in the diagnostic and treatment process of a particular patient

various, organizationally more or less separate units are involved. For a patient

treated in a department of internal medicine or surgery, for example, tests and

procedures at the laboratory and the radiology department may become neces-

sary. In addition, specimen or the patients themselves have to be transported,

physicians from other units may need to come and see the patient, and reports

have to be written, sent, and evaluated. Thus, the cooperation between orga-

nizational units as well as the medical staﬀ is a vital task with repetitive, but

nevertheless non-trivial character. Processes of diﬀerent complexity and dura-

tion can be identiﬁed. One can ﬁnd short organizational procedures like order

entry and result reporting for radiology, but also complex and long-running (even

cyclic) treatment processes like chemotherapy for in- and out-patients.

Physicians have to decide which interventions are necessary or not - under the

perspective of costs and invasiveness - or which are even dangerous because of

possible side-eﬀects or interactions. Many procedures need preparatory measures

of various, sometimes considerable complexity. Before a surgery can take place,

for example, a patient has to undergo numerous preliminary examinations, each

of them requiring additional preparations. While some of them are known in ad-

vance, others may have to be scheduled dynamically, depending on the individual

patient and her state of health. All tasks may have to be performed in certain

orders, sometimes with a certain time distance between them. After an injec-

tion with contrast medium was given to a patient, for example, some other tests

What BPM Technology Can Do for Healthcare Process Support 5

cannot be performed within a certain period of time. Usually, physicians have to

coordinate the tasks related to their patients manually, taking into account all

the dependencies existing between them. Changing a schedule is not trivial and

requires time-consuming communication. For some procedures, physicians from

various departments have to work together; i.e., coherent series of appointments

have to be arranged and for each step actual and adequate information has to

be provided. Typically, each unit involved in the treatment process concentrates

on the function it has to perform. Thus, the process is subdivided into partial,

function- and organization-oriented views, and optimization usually stops at the

border of the department. For all these reasons many problems result:

–Patients have to wait, because resources (e.g., physicians, rooms or technical

equipment) are not available.

–Medical procedures may become impossible to perform, if information is

missing, preparations have been omitted, or a preceding procedure has been

postponed, canceled or requires latency time. Depending procedures may

then have to be re-scheduled as well resulting in numerous phone-calls and

time losses.

–If any results are missing but urgently needed, tests or procedures may have

to be performed repeatedly.

Because of this, from the patient as well as from the hospital perspective un-

pleasant and undesired eﬀects occur: Hospital stays can be longer than necessary

and the costs or even the invasiveness of the patient treatment may increase. In

critical situations, missing information may lead to late or even wrong decisions.

Investigations have shown that medical personnel is aware of these problems

and that computer systems helping to make appointments and providing the

necessary information would be highly welcome by nurses and physicians. In an

increasing way it is being understood that correlation between medicine, orga-

nization and information is high, and that current organizational structures and

hospital information systems oﬀer sub-optimal support. This is even more the

case for hospital-wide and cross-hospital processes and for health care networks.

The roles of physicians and nurses complicate the problem. They are respon-

sible for many patients and they have to provide an optimal treatment process

for each of them. Medical tasks are critical to patient care and even minor errors

may have disastrous consequences. The working situation is further burdened

by frequent context switches. Physicians often work at various sites of a hospi-

tal in diﬀerent roles. In many cases unforeseen events and emergency situations

occur, patient status changes, or information necessary to react is missing (up

to: “where is my patient?”). In addition, the physician is confronted with a mas-

sive load of data to be structured, intellectually processed, and put into relation

to the problems of the individual patient. Typically, physicians tend to make

mistakes (e.g., wrong decisions, omissive errors) under this data overload.

From the perspective of a patient, a concentration on his treatment process

is highly desirable. Similarly, medical staﬀ members wish to treat and help pa-

tients and not to spend their time on organizational tasks. From the perspective

6 M. Reichert

of health care providers, the huge potential of the improvement of healthcare

processes has been identiﬁed: length of stay, number of procedures, and number

of complications could be reduced. Hence there is a growing interest in pro-

cess orientation and quality management. Medical and organizational processes

are being analyzed, and the role of medical guidelines describing diagnostic and

treatment steps for given diagnoses is emphasized [23–25].

3 IT Support for Healthcare Processes

3.1 Flexibility Demands of Healthcare Processes

Obviously, the IT support for healthcare processes must not introduce rigidity

or restrict medical staﬀ members in their daily work. Generally, physicians and

nurses must be free to react and are trained to do so. In an emergency case,

for example, physicians may collect information about a patient by phone and

proceed with the treatment process, without waiting for the electronic report

to be written. Furthermore, medical procedures may have to be aborted if the

patient’s health state gets worse or the provider ﬁnds out that a prerequisite is

not met. Such deviations from the pre-planned process are frequent and form a

key part of process ﬂexibility in hospitals. Any computer-based system which is

used to assist physicians and nurses in their daily work, therefore, must allow

them to gain complete initiative whenever needed. In particular, process-aware

hospital information systems must be easy to handle, self-explaining, and - most

important - their use in exceptional situations must be not more cumbersome

and time-consuming than simply handling the exception by a telephone call to

the right person. Otherwise the PAIS will not be accepted by hospital staﬀ.

In summary, process-aware hospital information system must be able to cope

with exceptions, uncertainty, and evolving processes.

3.2 Pre-specified vs. Loosely Specified Process Models

In the predominant process support paradigm, PAISs require the apriorispec-

iﬁcation of all process details. The resulting pre-speciﬁed process models are

then used as schema for process execution. Typically, such a pre-specified pro-

cess model deﬁnes all activities to be executed, their control ﬂow and data ﬂow

dependencies, organizational entities performing the activities, the data objects

manipulated by them, and the application services invoked during their execu-

tion. In this context, a variety of modeling patterns has been suggested [7–10],

which can be used as building blocks for creating process models and which allow

adding some build-in-ﬂexibility to these models (i.e., flexibility-by-design).

However, IT support for healthcare processes demands a more agile approach

recognizing the fact that in dynamic environments pre-speciﬁed processes are

outdated fast and thus require closer interweaving of modeling and execution.

Consequently, any PAIS relying on pre-speciﬁed process models not only needs to

be able to adequately cope with real-world exceptions [26], to adapt the execution

of single process instances (i.e., business cases) on-the-ﬂy [27], to eﬃciently deal

What BPM Technology Can Do for Healthcare Process Support 7

with uncertainty [20], and to cope with variability [28], but must also support

the evolution of business processes over time, e.g., due to changing regulations

or organizational changes [29, 30]. Respective features are provided by adaptive

PAISs [21, 27] that have emerged in the BPM area during the last years.

In addition to pre-speciﬁed processes, which provide a reliable schema for

process execution and thus are well suited for automating repetitive and rather

predictable processes, existing approaches also allow process designers to only

provide a loosely specified process model [31, 32] which can then be reﬁned by end-

users during run-time taking predeﬁned constraints into account (e.g., mutual

exclusion of two activities or activity orders to be obeyed).

In practice, there also exist processes that can neither be adequately captured

in pre-speciﬁed models nor in constraint-based ones. In particular, it has been

recognized that knowledge-intensive processes (e.g., treatment processes) cannot

always be “straight-jacketed” into activities. Prescribing an activity-centric pro-

cess model for them would lead to a “contradiction between the way processes

can be modeled and the preferred work practice” [33]. As shown in the con-

text of the PHILharmonicFlows project a major reason for this deﬁciency stems

from the unsatisfactory integration of processes and data in existing activity-

centric PAISs [34, 35]. To remedy this deﬁciency, [36] analyzed various processes

from diﬀerent domains which are not adequately supported by existing PAIS.

As a major insight it was found out that in many cases process support requires

object-awareness. In particular, process support has to consider object behavior

as well as object interactions, and should therefore be based on two levels of gran-

ularity. Besides this, object-awareness requires data-driven process execution and

integrated access to processes and data. PHILharmonicFlows has identiﬁed ba-

sic properties of object-aware processes as well as fundamental requirements for

their operational support. The developed PHILharmonicFlows framework [17]

addresses these requirements and enables object-aware process management in a

comprehensive manner distinguishing between micro and macro processes. For

example, a micro process may coordinate the processing of a particular medical

order, whereas a macro process may comprise all micro processes related to a

particular entity (e.g., patient) as well as their coordination dependencies.

3.3 Dealing with Exceptions, Uncertainty and Evolving Processes

For more than a decade the BPM community has recognized that PAISs need

to provide diﬀerent kinds of build- and run-time ﬂexibility [20]. Consequently,

a variety of techniques have been developed ranging from fully pre-speciﬁed

processes with certain built-in ﬂexibility to ad-hoc adaptations of pre-speciﬁed

processes during their execution to loosely speciﬁed processes (that have to be

concretized during run-time). Generally, existing approaches can be character-

ized along three fundamental dimensions, namely IT support for adaptation,

ﬂexibility, and evolution:

– Adaptation represents the ability of the implemented processes to cope

with exceptional circumstances [27]. On the one hand, existing PAISs like

8 M. Reichert

YAWL [16] provide support for the handling of expected exceptions, which

can be anticipated and thus be pre-speciﬁed in the process model. Comple-

mentaty to this, adaptive PAISs like ADEPT2 [37] enable the handling of

unanticipated exceptions, e.g., through structural ad-hoc adaptations of sin-

gle process instances (e.g., by adding, deleting or moving process activities

during run-time). Thereby, users are assisted in deﬁning ad-hoc adaptations

and in reusing knowledge gathered in similar problem context in the past

[6, 38]. Clearly, dynamic process adaptations necessitate a comprehensive

framework ensuring correctness and robustness of the PAIS. The ADEPT2

framework, for example, provides sophisticated methods, concepts and tools

for achieving these goals. In particular, ADEPT2 enables instance-speciﬁc

changes of a pre-speciﬁed model in a controlled, correct and secure manner

[27, 39]. This, in turn, can be considered as fundamental driver enabling ﬂex-

ible and dynamic processes in complex application environments. Note that

when providing support for ad-hoc adaptations users are no longer forced

to bypass the PAIS when unplanned exceptions occur. Instead, single pro-

cesses instances can be dynamically adapted to the real-world situation if

required. Finally, deviations from the pre-speciﬁed model are documented in

respective change logs [40].

– Flexibility represents the ability of a process to execute on the basis of

a loosely or partially speciﬁed model which is completed at run-time and

may be unique to each process instance [31, 32]. Due to the high number

of choices, not all of which can be anticipated and hence be pre-speciﬁed

in a process model, frameworks like DECLARE [31] and Alaska [41] allow

deﬁning process models in a more relaxed manner; the model can be deﬁned

in a way that allows individual instances to determine their own (unique)

processes. In particular, declarative approaches allow for loosely speciﬁed

process models by following a constraint-based approach. While pre-speciﬁed

process models deﬁne exactly how the overall task has to be accomplished,

constraint-based process models focus on what should be done by describing

the set of activities that may be performed as well as the constraints prohibit-

ing undesired process behavior. Therefore, constraint-based approaches pro-

vide more build-in ﬂexibility when compared to completely pre-speciﬁed pro-

cess models. Potential advantages include the absence of over-speciﬁcation

and the provision of more maneuvering room for end-users. Generally, loosely

speciﬁed models raise a number of challenges including the ﬂexible conﬁgu-

ration of process models at design time or their constraint-based deﬁnition

during runtime. Due to the high number of run-time choices, in addition,

more sophisticated user support (e.g., recommender systems) becomes nec-

essary when compared to PAIS relying on fully pre-speciﬁed models. Finally,

the integration of pre-speciﬁed and constraint-based processes constitutes an

emerging area which is particularly important for the healthcare domain. In

particular, well established criteria are needed to be able to decide which

approach to take in which scenario and how to combine the two paradigms

in the best possible way.

What BPM Technology Can Do for Healthcare Process Support 9

–Evolutionrepresents the ability of a process implemented in a PAIS to

change when the business process evolves, e.g., due to legal changes or pro-

cess optimizations [30, 42]. The assumption is that the processes have pre-

speciﬁed models, and a change causes these models to be modiﬁed. The

biggest challenge then is the handling of the potentially large number of long-

running process instances, which were initiated based on the old model but

are required to comply with the new speciﬁcation from now on. Approaches

like WASA2, ADEPT2 and WIDE allow process engineers to migrate such

process instances to the new model version, while ensuring PAIS robustness

and process consistency (see [43, 44]). Moreover, pre-speciﬁed process models

often have to be changed to cope with model design errors, technical prob-

lems or poor model quality. In the latter context process model refactorings

have been suggested to foster internal process model quality and to ensure

maintainability of the PAIS over time [11, 45].

3.4 Dynamic Processes and Process Learning

In practice, there often exists a signiﬁcant gap between what is prescribed in a

model and what actually happens. Generally, a PAIS records the actual execution

behavior of a collection of process instances in an execution log.Furthermore,

adaptive PAISs document deviations from pre-speciﬁed models in change logs.In

this context process mining strives to deliver a concise assessment of the organi-

zational reality by mining these logs of dynamic processes [46]. Process discovery

algorithms, for example, analyze execution logs and derive process models from

them reﬂecting the actual process behavior best. Conformance testing, in turn,

analyzes and measures discrepancies between the original model of a process

and the actual execution of its instances (as recorded in execution logs). Finally,

log-based verification checks the execution log for conformance with desired or

undesired properties; e.g., process instance compliance with corporate guidelines

or global regulations. Furthermore, change mining not only considers execution

logs of process instances, but additionally analyzes the structural changes ap-

plied during the execution of process instances; i.e., they allow visualizing and

analyzing dynamic deviations from pre-speciﬁed processes [47]. Finally, process

variants mining [48, 49] allows discovering an optimal reference process model

being “close” to a given collection of process variants; e.g., process instances

derived from the same model, but structurally diﬀering due to ad-hoc changes

applied to them.

4 Summary and Outlook

When targeting IT support for healthcare processes it is important to distin-

guish the patient-speciﬁc medical treatment processes from the organizational

procedures (e.g. order handling and result reporting) that generally coordi-

nate the cooperation between staﬀ members and organizational units within

a hospital [18]. While the former are knowledge-intensive and highly dynamic

10 M. Reichert

processes, the latter constitute repetitive processes that capture the organiza-

tional knowledge necessary to coordinate daily tasks among staﬀ members and

between organizational units (e.g., wards and medical departments). Basically,

BPM provides methods, concepts and tools for supporting both categories of pro-

cesses. In particular, the described technological developments will allow provid-

ing the required process dynamics and ﬂexibility, and thus foster the realization

of a new generation of process-aware hospital information systems.

Still there is a gap between technology-driven approaches developed by the

BPM community and methodological-based approaches suggested in the medi-

cal informatics ﬁeld (e.g., clinical guideline support). Besides there still exists a

number of challenges to be tackled in order to provide support for both organi-

zational procedures and complex patient treatment processes. Amongst others

these challenges include the process-oriented integration of heterogeneous sys-

tems, the embedding of IT process support into routine work practice, the learn-

ing from past process executions, the evolution of process knowledge over time,

the real-time tracking of healthcare processes, and the coordination of inter-

related processes (e.g., corresponding to the same patient). These issues are

unlikely to be solved in near future, but indicate that interdisciplinary research

is needed to further enhance IT support for healthcare processes.

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