A Layered Model Approach for Care Process Monitoring Mohamed Anis Mokahhal1, Aladdin Hussein Baarah2, Liam Peyton1

1University of Ottawa, Ottawa, Canada, 2Hashemite University, Zarqa, Jordan m.mokahhal@gmail.com, aladdin.baarah@hu.edu.jo, lpeyton@uottawa.ca

Abstract—In this paper, we present a layered

model-based approach to Care Process Monitoring (CPM). Business Process Management (BPM) technology is used to manage the care process online with an explicit business process model. The business process model is structured into three layers (organizations, processes, and interfaces) and uses vertical swim lanes with tracking points to identify where to monitor care process. An existing cardiology care process case study from a Canadian hospital is used to evaluate the approach. Transitions between different departments in a hospital are often problematic and a source of bottlenecks, so a technique of integrating event messages with a flexible triggering mechanism is also presented.

I. INTRODUCTION There is pressure on health organizations in

Canada, and other countries, to effectively and efficiently improve care process monitoring (CPM) to support operational decisions, improve delivery of care and reduce wait times to ensure timely delivery of service. The Ontario Ministry of Health and Long-Term Care in Canada announced that reducing wait times in emergency rooms is its top health care priority [1]. Wait times negatively affect both patient safety and the quality of health care delivery [2].

The traditional approach to CPM in many hospitals uses data warehouses to integrate data from different operational systems from different departments in the hospital [3]. This approach is labelled “Departments to Data Warehouse” in Figure 1. It does not often provide enough fine-grained details and analytics regarding the bottlenecks that may occur in the care processes. It can take days or even weeks after the fact to provide performance monitoring reports [4].

More recently, there has been work on leveraging new technologies such as Complex Event Processing (CEP) [5][21], Real-time Locations Systems (RTLS) [6], and Business Process Management (BPM) [7] to process fine-grained events from care processes while they are taking place online. Typically, in these approaches, separate CPM applications, in addition to the existing operational systems, are built to collect, correlate and process data from different sources in real-time and feed the data into the data warehouse for reporting [8]. This approach is labeled “BPM/RTLS/CEP to Data Warehouse in Figure 1. This provides fine-grained granularity and delivers reports in a timely fashion, but there is a significant cost and complexity in implementing applications using diverse technologies.

BPM is a technology for mediating between the business architecture layer of an organization and its Service Oriented Architecture (SOA) in order to centrally model and manage processes across diverse operational systems and across departments within an organization [9]. However, to date, there has been little guidance on how to incorporate performance monitoring into business process models in a systematic manner.

Fig. 1. Different Approaches to CPM

In this paper, we present a layered model-based

approach to Care Process Monitoring (CPM). Business Process Management (BPM) technology is used to manage the care process online with an explicit business process model. This is labelled “BPM Integrated Monitoring” in Figure 1. The business process model is structured into three layers (organizations, processes, and interfaces) and uses vertical swim lanes with tracking points to identify where to monitor care process. An existing cardiology care process case study from a Canadian hospital is used to evaluate the approach. Transitions between different departments in a hospital are often problematic and a source of bottlenecks. A technique of integrating event messages with a flexible triggering mechanism is also presented to address such transitions.

II. BACKGROUND BPM is defined as “the art and science of

overseeing how work is performed in an organization to ensure consistent outcomes and to take advantage of improvement opportunities” [10]. The concepts, methods and techniques established in BPM support the design, execution, management and analysis of business processes by using model-based tools and methods [11][12].

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Business Process Model and Notations (BPMN) is designed to allow process models to be understandable and readable by business people [13]. Business Process Execution Language (BPEL) is an XML based language designed to execute business process models and enable task-sharing across multiple organizations using a combination of web services and human interfaces [14].

According to Gartner group, business activity monitoring “describes the processes and technologies that enhance situation awareness and enable analysis of critical business performance indicators based on real time data” [15]. It is used to align a business process with its overall business objectives and ensure the quality of process, using metrics like wait times which are reported online dynamically using charts and dashboards [10] [16].

There are many vendors of BPM technology (including IBM, Oracle, Microsoft, Cordys). In our case study we worked with IBM BPM 8.5 [17]. IBM BPM is a rich set of tools for BPM with a well-defined methodology for developing business processes [9]. It has been used in [7] to improve clinical quality using best practices for business process management. The methodology is an iterative cycle of well-defined steps to plan, implement, deploy, and manage and optimize a business process model. Unfortunately, it is silent on how to structure and integrate care process monitoring into the business process model. Nor does it give specific guidance on the specific metrics such as wait times that are critical for CPM.

Other technologies such as CEP and RTLS have also been investigated to address business activity monitoring. RTLS has been defined by [18] as “local systems for the identification and tracking of the location of assets and/or persons in real or near-real-time”. RTLS is used to support operational decision making [19].

RTLS applications are used in healthcare system to track personnel, patients, and assets during medical emergency. RTLS technology is typically implemented using unique wireless tags that transmits data to readers including an identification number attached to each patient. It can enable personnel to monitor the handoffs between different departments. Thus, the hospital management staff can determine how many patients are located where in order to allocate staff and determine where the bottlenecks are in a hospital [20] [18].

Figure 2 shows a proposed integrated CPM architecture as reported in [8] that integrates BPM, RTLS, CEP and other technologies. It integrates event data from BPM, RTLS and other systems and streams them through a Message Broker to a CPM

application that uses CEP technology for inferring patient states so that wait times can be reported in a Real-Time Dashboard as well as stored in a data warehouse for historical reporting.

The key point is that the care performance monitoring application is defined separately from the business process model. However, there is complexity in the sheer amount of technology required. As well, separating the care performance model from the business process model makes it difficult to maintain the relationship between the two as both evolve over time.

Fig. 2. Integrated CPM Architecture

III. LAYERED BPM MODEL FOR CPM

In this section, we basically identify the key elements of our approach in terms of the layer BPM model and the associated methodology used to implement it. In section 4, we give a detailed example of how these were applied in our case study. Figure 3 shows the sequence of steps we follow to integrate CPM into a business process model.

Fig. 3. Methodology for CPM Integration

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The first step is Create Initial Care Process Model with horizontal swim lanes based on reviewing the existing business process model. The purpose is to identify the actors, forms and activities involved in the care process.

The second step is Structure the Care Process Model into three layers. At the top layer (organizations layer) the activities of the initial process model are grouped according to organizational divisions and handoffs. The middle layer (processes layer) contains the basic activities and swim lanes from the initial process model. While in the bottom final layer (interfaces layer), the activities from the middle layer are detailed in terms of the human interfaces (forms) and systems interfaces (web services) by which interactions with humans and systems are orchestrated to implement the business process online.

The third step is Integrate Monitoring into Processes Layer. This involves interacting with stakeholders to identify the goals, states, tracking points and metrics. Performance monitoring is integrated and modeled in the processes layer with tracking points for capturing monitoring data and vertical swim lanes for grouping and identifying wait and service states.

The fourth step is Operationalize the care process model by filling in the details in the interfaces layer and deploying in the typical fashion for executable process models. A special event messaging mechanism is used in the interfaces layer to implement the handoffs and feedback needed across organizational boundaries for the transitional processes identified in the organizations layer.

The final step is Reporting (using charts and graphs) to visualize the results of care process monitoring. These are displayed in a care process monitoring dashboard, as well as integrating performance monitoring data into regular data warehouse reporting as needed.

IV. CASE STUDY

In this case study, we used an existing care process model from the literature [8] [5] [6] that implemented the Acute Coronary Syndrome (ACS) care process as defined by the Ontario, Canada Ministry of Health [22]. We had access to the full implementation of this CPM application that integrated RTLS, CEP and BPM technologies as shown in Figure 2.

We analyzed both the separate CPM application implemented using the State Monitoring Engine (SME) as well as the business process model that was used to support and manage the online care process in the IBM BPM environment. We then

experimented with the business process model in the IBM BPM environment to see how well CPM could be provided using the IBM BPM environment. In the first iteration we took a simplified approach based strictly on IBM’s methodology [7]. In the second iteration we used a three layered business process model and followed the steps we have described in section 3. We then compared the three versions of the cardiac care process (Original CPM application, IBM methodology, and our proposed methodology) in terms of the quality achieved and the effort/cost needed for the CPM provided.

A. Create Initial Care Process Model

Figure 4 illustrates an initial process model for the ACS care process that is modeled using IBM Process Designer tool. The ACS care process takes place between five stakeholders (ED) Nurse, Cardiologist, (CW) Nurse, Cardiac Catheterization Lab (CCL) Nurse and Housekeeper with the purpose of giving care to cardiac patient and discharge him/her.

Fig. 4. Initial Care Process Model

B. Structure Model into Layers

Figure 5 shows the organizations layer view of

the ACS care process.

Fig. 5. Organizations Layer

There are two departments: the Emergency

Department and the Cardiac Ward. Two critical transitional processes are identified: the Admission process that transitions patients from Emergency

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Department to Cardiac Ward, and the Discharge process that transitions patients from Cardiac Ward out of the hospital. In our approach, these are clearly identified and grouped, but in both the Original CPM Application and the IBM Methodology, these elements are either missing or hopelessly commingled in the interfaces details of the business process model. C. Integrate Monitoring into Processes Layers

Figure 6 presents the ED sub-process for the ACS care process in terms of major steps with horizontal swim lanes showing roles (ED Nurse, Cardiologist).

It is annotated with vertical swim lanes to identify what steps are service states that directly engage the patient and which steps leave the patient waiting. For example, the patient is waiting while the Cardiologist confirms his availability with the ED nurse and travels to the examination room to assess the patient. The flag icons indicate tracking points where process data will be collected and logged to support care process monitoring. The original CPM application did not model wait and service states at all, but often had external service calls to communicate tracking data to the external state monitoring engine. There was no easy way to distinguish which service calls were part of the care process and which were service calls to support external process monitoring. The IBM methodology did not give guidance on tracking points at all (although the feature is documented in the IBM BPM manual). The concept of vertical lanes was a new feature we added.

Fig. 6. Integrated CPM in the Processes Layer

D. Operationalize Figure 7 shows the transitional sub-process for

discharging a patient. The black envelope icon shows the triggering of an event message to create a clean_up request. This corresponds to a white envelope icon that receives the request in the same sub-process to initiate cleanup of the room by housekeeping. When clean up is complete, the Update Bed List service interface is triggered to update an external database, and at the same time a “room ready” event message is sent to the

Emergency Department sub-process where they are waiting for a room, in order to transfer a patient. There was no mechanism to handle such handoffs in either the Original CPM application or the IBM Methodology.

Fig. 7. Admission Process Event Messaging

E. Reporting

Our Proposed Methodology supported the same level of reporting, with the same level of details as the Original CPM Application. There were reports that showed wait times and services times for a particular patient, as well as average wait and service times across all patients for a given day, week or month. The individual states could be highlighted in green, yellow or red to indicate whether the times were in the “acceptable” range, “At Risk”, or “Overdue”. However, the IBM methodology was not able to achieve the same level of detail. There were fewer states reported and with less accuracy.

Fig. 8. ED Nurse Task Page Report

In addition, because of the structured integration

of CPM with the care process model, our proposed methodology was able to support additional reports that provided more context. In Figure 8, each individual care provider could get a report of tasks

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they were responsible that were not complete, sorted by red “Overdue”, yellow “At Risk”, or green. The reports were linked with the care process, so that the provider could simply click on the task to work on it.

In figure 9, a manager can oversee the entire care process, as modeled, and see which patients in the hospital are in what state for each task. This makes it clearer where bottlenecks are occurring systemically. They can click on the individual patients to see who is responsible for the task in an alert state.

Fig. 9. Process Status Diagram Report

V. EVALUATION

We use the results of our case study to evaluate our approach. In particular, we compare the results of three approaches (Original CPM application, IBM methodology, and our proposed methodology) in terms of CPM features and implementation complexity.

TABLE 1 COMPARISON OF CPM FEATURES

Table 1 compares the features that were supported

by the three approaches. The Original CPM Application and our proposed methodology were very similar in terms of the fine grained granularity of wait states and services states, detailed performance monitoring and integration of third party reporting. Our approach was much better at handling cross organizational transitions, but some additional human inputs were needed to compensate for the lack of an RTLS. This is significant because this is typically where most bottlenecks happen and are difficult to detect. It is also where most of the

complexity introduced by the integrated approach occurs. The IBM methodology needed the same inputs, and really provided no guidance on how to integrate process monitoring related to wait states and service states into the business process model.

Table 2 summarizes the implementation complexity of the business process model for all three approaches. Even though the Original CPM application had a separate CPM application outside the business process model, its business process model was the most complex and difficult to maintain. This is because it required special low level implementation and mechanisms to communicate data to the CPM application, and it needed to process events from the CPM application in order to handle special state-based notifications relations to transitional sub-processes (like Discharge). There were 98 instances of complex service mechanism compared to only 9 for our Proposed Methodology. Our proposed methodology did have 44 tracking points, groups and timing intervals, but this was a straight forward annotation of the business process model for the care process in terms of flags to indicate data collection for process monitoring that was easy to understand even for non-technical healthcare providers.

TABLE 2 IMPLEMENTATION COMPLEXITY

In the final analysis, our Proposed Methodology was slightly more fine grained (20 wait and service states versus 18 for the Original CPM application) without using any extra technologies and the resulting model was much better structured and understandable by both BPM developers and healthcare providers. It did, however, require 11 simple extra forms in order to compensate for the lack of RTLS technology. The IBM methodology

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was too simple and did not provide enough guidance in order to effectively monitor the care process. It could only monitor 8 wait and service states.

VI. CONCLUSIONS AND FUTURE WORK

The key point in this research is that we built performance monitoring into the BPM model of the care process in a structured fashion while the Original CPM application constructed a separate model for performance monitoring. Maintaining a correspondence between the two separate models introduces unnecessary complexity. Integrating care process monitoring into the BPM model of the care process in a structured fashion, actually results in a simpler and easier to understand BPM model, than the one created in the Original CPM application.

We have not proved, in general that our optimized approach is better than the standalone or integrated approach because we have not tested it yet on enough different types of users, developers and care processes. However, our case study has shown that our proposed methodology has the potential to be a significant improvement over both the general BPM methodology that IBM has defined, and the separate CPM application approach.

In future work, though, we will investigate how to extend our proposed methodology to include other technologies like RTLS and CEP. Rather than an external CPM application, however we will see how we can define the interaction with them directly into the BPM model, with a structured use of service interfaces linked to tracking points and event messages. In this manner, we hope to reduce the need for extra user interface forms while still using a single, layered, business process model.

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