HEC-2016 Facilitating Clinical Pathway Standardization PDF

Facilitating Clinical Pathway Standardization and Adoption using a web-based Software Solution Björn Schwarza,1, Steffen Ruppa, Alexander Hinsmanna, Vivienne Djamila Mekhzouma, Anastasia Friesena, Thomas Friedla a THM Universi...

Facilitating Clinical Pathway Standardization and Adoption using a web-based Software Solution Björn Schwarza,1, Steffen Ruppa, Alexander Hinsmanna, Vivienne Djamila Mekhzouma, Anastasia Friesena, Thomas Friedla a THM University of Applied Sciences, Faculty of Health Sciences Abstract. While clinical pathways are an accepted tool for process optimization and quality management, their adoption into clinical routine is often lacking. This is often due to difficulties that arise when integrating process control into common electronic health records and administrative or diagnostic software. The solution presented here allows a standardized approach to modeling clinical pathways using the Business Process Model and Notation (BPMN) and integrates into existing software solutions. An intuitive interface supports pathway execution, and a feedback system allows to continually improve the processes. Keywords. Clinical pathway, BPMN, process optimization, healthcare, healthcare documentation, software 1. Introduction An ongoing trend in many branches of industry is the optimization of operations and processes to economize on time and expenses, which can be seen clearly over the last years, especially in the healthcare sector. This trend can be traced back to the introduction of Diagnosis Related Groups (DRG) for accounting, which presuppose a detailed documentation of patient treatment. Another reason is the growing competitive pressure, which enforces optimization of internal processes. Additionally, the technological development, for example in medical imaging, is creating a high demand for digital workstations combined with associated information systems. This leads to an expansion of infrastructure in healthcare institutions. In order to stay competitive in the future, internal processes and procedures have to be recorded and made readily available for staff and patients in a vivid, transparent manner. Due to the transparency of processes and the conditions attached to the activities and documentation, an increased long term quality of care and cost-effectiveness can be accomplished. Clinical Pathways offer healthcare facilities the opportunity to reduce the inpatient stays and consequently to save expenses [1,3]. In addition, studies have shown that the quality of treatment can be increased with the aid of clinical pathways. Therefore, tensions between cost and quality that are common to healthcare institutions can be reduced. While clinical 1 Corresponding Author. pathways are an accepted tool for quality management and process optimization , their adoption into clinical routine workflows is often difficult to achieve due to the lack of tools that incorporate them in a helpful yet non-intrusive way. The aim of this paper is the standardized modeling of administrative and care processes in order to capture all processes of a healthcare facility using standardized paths. Standardized modeling alone provides no benefit or interaction for the user and lacks active support of the individual process steps, merely providing another representation of existing workflows, processes or guidelines without providing the desired improvement of competiveness or optimization of processes. Therefore, a prototypically web-based application is presented which allows the standardized modeling of processes and is able to support their integration into clinical routine environments. The software solution allows importing the standardized process models, as well as processing them into an interactive clinical pathway representation. The digitalization of the processes into an interactive application makes it possible to support users by visualizing completed parts of the workflow and providing a quick overview about the process’ completion status at a glance. After the completion of sub-processes, a necessary validation of their clinical validity and applicability is possible. 2. Material and Methods Business Process Model and Notation (BPMN) has been established as a standard for modeling business processes in process management. The standardized notation of BPMN version 2.0 allows all stakeholders involved in a process management, depending on the area of responsibility, to interact on a professional or technical level. The BPMN standard provides a graphical notation for business experts and an Extensible Markup Language (XML-) based description of the model including the execution semantics. Therefore, the BPMN 2.0 notation encompasses a machine- readable process that enables direct execution of pre-structured sequences of individual process steps. Thus, the processes can be automated to some degree. For instance, certain process steps of the clinical pathway can be automatically enhanced with parameterized forms containing appropriate patient information. The automation of processes in a Clinical Information System or Electronic Health Record (EHR) can potentially achieved by accommodating BPMN based process models [8, s. 218 ff]. When integrating the model into an existing EHR the individual process steps should be expanded by including execution-relevant characteristics provided by the BPMN standard. These adjustments can be made directly within the XML schema. The BPMN XML-representation internally structures processes as directed graph. The structure contains nodes and an adjacency list that describes the graph’s edges by defining each node’s list of neighbors. In order to visualize the digital process models using the vis.js JavaScript library the XML-representation needs to be converted and stored as appropriate JavaScript Object Notation (JSON) documents, a task for which a parser was written. The vis.js library has an extensive range of functionality to facilitate interaction with the graph. The open source PostgreSQL database management system (DBMS) has been used for the persistence of customized models. PostgreSQL provides for structures that are stored in a JSON format, a corresponding JSON data type. This data type has the advantage of a flexible document-based layout and allows flexible adaption of the existing data structures without changing the database schema. The access to data stored within the JSON object is easily accessible via the data manipulation language (DML). The prototype application has been implemented using the web application framework Ruby on Rails. The framework supports an agile and structured approach to web development. The need to write boilerplate code is minimized. The user interface design is based on the Bootstrap framework which allows a rapid implementation of a consistent user experience, which is an essential part of usability. 3. Results The current prototypical web-application allows importing processes that have been modeled using external tools (Figure 1a) and editing them into an interactive pathway within the application. The adaptive editing of the process takes place at two different Figure 1. Clinical Pathway: Evolution from Model to interactive Application stages. First, the process can be graphically edited in a way that is similar to the large number of BPMN modeling software available. In addition to the modeling editor there is an interaction editor available, allowing to anchor additional information to the individual process steps, such as Documents that are associated with the specific step’s activities (Figure 1b). The individual process steps can be dynamically equipped with additional fields. In this prototype, these additional fields can be filled with information, which are used for completing the call to the document. While further automation of process execution was not looked at within the scope of this project due to the execution of any clinical pathway being tied closely to the EHR being used, we were able to show how the execution logic can be incorporated into the process model. In addition to editing individual process paths and their nodes, the editor allows to combine already-imported processes into a larger overall process, freely choosing which nodes should be merged and making it possible to use sub-process building block modules for recurring activities. In order to provide guidance when navigating the pathway the current progress on execution is visually tracked, the currently active step and all documents, information, and input fields are shown (Figure 1c). Decisions on pathway progression are entered by the user, who may assess individual steps afterwards using a simple rating system backed by extended comments. 4. Discussion The presented application solves problems commonly faced when adopting clinical pathways into routine workflows. Typical advantages of using clinical pathways are facilitated, such as improved documentation achieved by including documents directly with process steps. The feedback system allows to continually improve the pathways, which is an essential part of process quality management. The feedback may in addition be used to build a knowledge-base as foundation for an expert system, which may allow to provide recommendations for action in a later stage of the development process. Integrating addition information into the clinical pathway models may not only be used to combine the application with existing EHR software, but could possibly be extended to be a source of configuration for information systems which are prepared to be combined with the application. The ability to integrate with external tools, and to provide a standardized approach to modeling clinical pathways along with individually expanding the models to allow interactivity shows that the software application presented here can be used to incorporate clinical pathways into routine workflows. 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