Jerome Carter, MD    March 7, 2016

Prepare for a bit of culture shock. Anyone with a background in clinical workflow analysis or human factors methods, such as cognitive task analysis, will find Business Process Model and Notation (BPMN) a little jarring initially. BPMN 2.0, the current standard, is the result of efforts by the business community to improve and automate its key processes -- inventory management, order fulfillment, procurement, etc. -- things few in the clinical domain ever encounter or likely conscientiously avoid.

Pre-2.0 versions of BPMN were mainly visual tools for building process models -- what we in the clinical community would call workflows. BPMN caught on, and the most recent specification was released in 2010. With BPMN 2.0 a major change occurred: BPMN went from being primarily a modeling tool to being one that could be used to create executable applications, making BPMN 2.0 an application development tool. It is this ability to create visual models that can then be turned into real applications that makes BPMN 2.0 interesting to me and, I think, potentially a great tool for building clinical applications. I say potentially because there is a huge chasm between the way clinical professionals and business professionals see the world. Since BPMN 2.0 is a business tool with deep acceptance and support within the business community, making use of BPMN means becoming familiar with business process management jargon, which can be a challenge.

One can only read so many documents that say something akin to, “creating dynamic synergies across the enterprise to promote third-quarter upside market expansion,” before the mind simply shuts down. I am not denigrating business jargon, only pointing out that if one is not used to it, an adjustment period is required. BPMN resources are not THAT bad, but still… A major goal of this tutorial series is to create a Rosetta stone of sorts that will allow those with backgrounds in clinical care to translate BPM-speak into clinical-speak.

As I mentioned earlier, the focus of BPM/BPMN is process improvement and automation (i.e., using information technology optimally to further the business goals of the organization). The EHR incentive programs had the same basic goal for clinical care when they were initiated in 2009. However, automation of clinical processes (workflows) has not gone as well as everyone expected. In many ways, EHRs are better than paper, but usability, safety, and productivity concerns are a few of the unintended consequences of using EHR systems to automate clinical processes. Why is this??? EHR systems were not designed to support processes, but rather to record and present data gathered from patients.

Unlike business processes, there is little experience in automating clinical processes. Within health care, there are two main categories of processes: those that involve patient care (direct) and those that support care delivery (indirect). Direct care is what clinicians do on behalf of patients. Direct care is comprised of clinical processes, which include everything from creating nursing care plans to doing procedures and reviewing lab results. Indirect care processes are administrative, legal, or regulatory in nature. Thus, all clinical processes are healthcare processes, but not all healthcare processes are clinical processes; this is an important distinction when process automation is the objective.

Many indirect care processes have been automated outside of health care. For example, registration, whether for a hotel or a doctor’s office, has many things in common, such as verification of identity, payment form, and requested service. Of course, each business site will have elements that are peculiar to it, but the basic processes are similar. The decisions that guide indirect care processes tend to be relatively easy to reduce to business rules. For example, if no major credit is used, service is refused; one must be over 25 to rent a car. Such rules are readily built into information systems. Direct care processes, on the other hand, are guided by the expertise of the clinician. Clinicians interview, diagnose, treat and assess based on their experience and expertise. One does not automate clinical processes; rather, the goal has to be supporting clinicians as they take care of patients. EHR systems mainly record the results of clinical processes. As a result, EHR systems may increase data entry requirements without providing much help for direct care processes other than making patient data available. There is more to supporting a clinical process than simply providing data.

In order to support clinical processes, a detailed understanding of those processes is required. Care coordination has different process requirements than does results management; prescribing a new medication differs from both. Creating HIT tools that help clinicians requires a way of representing clinical processes in sufficient detail for specifying an application. Flowcharts, the traditional process mapping tools used in healthcare settings, are not good tools for capturing information for application design. Not only can BPMN 2.0 model a process, but it can also create an application to support that process.

Since BPMN can be used for application development, BPMN process maps have to be detailed and correct. BPMN is a standard with a well-defined syntax. BPMN symbols have defined semantics. Done properly, a BPMN process map should have only one interpretation. For those used to clinical workflow analysis (CWFA) using flowcharts, BPMN can seem overly exacting (BPMN has 90+ symbols). I came to BPMN from Petri nets, and I find that all of the symbols still get on my nerves. Fortunately, as with any language, it is possible to start out simply and attack more complex problems as experience increases.

Another possible speed bump for those moving from flowcharts to BPMN is the way the flow of activities (tasks, steps) is controlled using events and gateways. Gateway and event symbols are easy to misuse. Concepts such as exclusive-OR splits and AND merges, have to be mastered in order to create BPMN process maps (see series Workflow Patterns: A Pattern-Based View of Clinical Workflows).

Moving from flowcharts to BPMN requires adjusting to new ways of saying familiar things. For example, the word “activity” in BPM jargon is used in different ways by different authors. A process consists of a series of directed activities. In CWFA, “task” is often used to mean what the BPM world calls an activity. CWFA modelers would call a BPMN process map a workflow diagram or model, and a BPM “process” would be a referred to as a “workflow.”

Healthcare BPMN
Task, Step Activity
Workflow Process
Workflow Model Process Map
Workflow Analysis Process Analysis

  Healthcare to BPMN 2.0

Since there is no BPMN specifically for clinical care, terms will be introduced as needed for modeling clinical concepts. Here are the terms that will be used when discussing for clinical workflow concepts.

Clinical Workflow Terms
Clinical Work - Actions performed by clinicians to assess, change, or maintain the health of a patient.
Clinical Workflow - The directed series of steps comprising a clinical process that 1) are performed by people or equipment/computers and 2) consume, transform, and/or produce information. (Note that patient outcomes count as information.)

Clinical Process - Clinical work undertaken by one or more clinical professionals that has a specific start point, endpoint, and an expected clinical outcome.

Information Metabolism - The movement of information in and out of clinical processes.
Clinical Workflow Model - A human-readable, visual representation of a clinical workflow that can be executed by a workflow engine.

Clinical Workflow Analysis - Methods/tools/techniques used to deconstruct clinical processes in order to determine their exact steps, control-flow, participants, resources, and information metabolism.

Modeling tools
Reading a tutorial without trying out the concepts discussed is not an effective way to learn a new skill. BPMN is a widely-adopted standard, so many tools are available, and many are free. There are two types of modeling tools that one could use: standalone or one that is part of a BPM suite. (A BPM suite is a full-blown application development/delivery environment along with an execution engine that allows one to run applications). For Windows users, Visio provides BPMN modeling capability as does Bizagi Modeler.  I use a Mac and like Camunda Modeler and Bonita Community Edition  (a BPM suite).   

That’s all for now. In the next article, we will look at BPMN symbols and basic modeling methods.   For those who would like more background on BPM, I suggest A Computer Scientist's Introductory Guide to Business Process Management (BPM).  The author provides a clear explanation of the key concepts with only enough jargon to get the point across