Jerome Carter, MD  November 29, 2015

Traditionally, clinical professionals dealt with patients in semi-isolation.  The concept of the patient as the center of attention of a tightly-interacting team of clinicians is relatively new.  With the advent of care coordination as both meme and policy, the value of managing a variety of intertwined processes as they relate to a single patient has become more obvious and compelling.  It is time to consider clinical process management (CPM) as a structured approach to understanding and delivering high quality care.  

The business community long ago recognized the need for a holistic approach to managing the many aspects of business — manufacturing, shipping, inventory, etc.— as essential to efficient and productive organizations.  Automation was a key driver for business process management (BPM).  As in health care, businesses were struggling to align information systems with traditional ways of doing things.  Few businesses can survive without other businesses— bakers need flour, construction companies need steel, grocery stores need produce.  Communicating across boundaries is a major aspect of BPM.

“Business process management” is more than a buzzword. It is a structured approach to understanding how organizations function as they deliver products and serve customers.   Gartner offers the following definition of BPM.

Business process management (BPM) is a discipline that uses various methods to discover, model, analyze, measure, improve, and optimize business processes.  A business process coordinates the behavior of people, systems, information, and things to produce business outcomes in support of a business strategy. Processes can be structured and repeatable or unstructured and variable. Though not required, technologies are often used with BPM. BPM is key to align IT/OT investments to business strategy.

Central to the idea of managing processes is acknowledgement of the amount and depth of thought required—discovery, modeling, analysis, measurement, improvement, optimization—to actually manage processes.      As we have learned from the EHR incentive programs, implementing an EHR does not lead to automatic gains in productivity or efficiency.  Rather, a good deal of analysis is required to optimize a practice after implementation.  When that analysis is absent or sub-par, clinicians complain and care quality suffers.   

EHR systems affect clinical processes, both direct and indirect.  Direct care processes are those that occur as a result of patient care activities (e.g., taking a history, writing a Rx, ordering labs, blood draws).  Indirect care processes are those that make direct care processes possible (e.g., registration, appointment scheduling, billing) and are often administrative in nature.  Since direct and indirect care processes must interact at some point, understanding how care delivery organizations function and how to optimize their products (outcomes) and serve their customers (patients) requires a structured approach to clinical processes.

BPM is a significant advancement for businesses, and BPM methods hold great promise for health care as long as we never forget that people are not widgets.  Widgets should never vary—one batch should be identical to the next.    People, however, necessarily vary; that is what makes them special and interesting.  Clinical care can never be one-size-fits-all; there can be no cookbook. 

Health care has had its share of process initiatives, even if they are not explicitly referred to as such.  Decision support, quality improvement, and medical homes are different approaches to altering or shaping clinical processes.  Each has shown varying levels of success.   However, unlike BPM, these clinical process initiatives lack an underlying theory or approach that ties them together, and this is where clinical process management comes in.  

Clinical process management, as here envisioned, consists of a coherent and consistent set of methods and tools for discovering, modeling, analyzing,  measuring, improving, and optimizing direct and indirect care processes.    Many of the methods used in BPM can be adapted for CPM.  BPM emphasizes the proper use of information technology to improve efficiency and productivity.  To that end, many BPM automation tools exist that allow one to build and execute BPM models (i.e., workflows).  

The growing interest in clinical workflow disruptions and clinical workflow analysis evinces the growing recognition within the healthcare community that processes are important.   However, health care currently lacks a mature process/workflow theory, culture, or body of knowledge that those newly-interested in workflow issues can apply.   BPM offers tools, with moderate effort, can be applied to health care. 

BPMN is a workflow modeling notation that can be used to create executable systems (i.e., real applications). BPM software is readily available, and many open source systems are feature-rich.   BPMN is easy to learn.  For purists, YAWL is a great research tool for creating models, especially if one is interested in the underlying mathematics of clinical workflows.  The tools needed to move CPM forward are widely-available, and often free.   

Moving to a new era in health care where care coordination and information sharing are valued, one where patients are treated holistically and not by body part or location, requires a fundamental rethinking of what we in health care do and why.  Better, safer care requires a deeper understanding of the processes we perform—the steps involved,  the information they use, and how clinicians interact with computers,  patients,  and one another.  Clinical care is replete with processes and moving forward requires that we recognize and manage those processes with patients as the intended beneficiaries.  Clinical process management is an idea whose time has come…

Suggested BPM Resources
van der  Aalst W, Stahk C. Modeling Business Processes: A Petri Net-Oriented Approach. Cambridge, MA: The MIT Press; 2011
Van Der Aalst, W. M., & Ter Hofstede, A. H. (2005). YAWL: yet another workflow language. Information systems, 30(4), 245-275.
The Healthcare Business Process Management Blog