This document discusses using business process modeling standards like BPMN, CMMN, and DMN to model clinical pathways and share healthcare knowledge. It provides an example of using these standards to model guidelines for hypothyroidism in pregnancy, including a decision to adjust synthroid dose. The standards help make clinical pathways machine-readable and executable to improve outcomes. ACOG is working to translate narrative guidelines into computable artifacts like this to embed guidance in digital tools using these open standards.

1. Business Process Management
and its Evolution
An ACOG example
Denis Gagné
CEO & CTO, Trisotech
Steve Hasley
CMIO, ACOG
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2. OMG Standard Body
• One of the most successful forums for creating open
integration standards in the computer industry
• Middleware platforms (DDS™, CORBA® and related specs)
• Modeling platforms (UML®, BPMN™, SysML® and related
work)
• System Assurance (SACM, DAF for SSCD ...)
• Vertical domain specifications (Finance, Healthcare, C4I, ...)
• Member-controlled industrial consortium
• Both vendors and users
• Not-for-profit
• Adopted specifications are freely available to all
• Visit http://www.omg.org
• Path to adoption by ISO and other standards bodies

3. The evolution of business applications
“Giving back control to business”
Data
Process
Rule
Business
Application
Process
Rule
Business
Application
Data
Process
Rule
Business
Application
Data
Process
Business
Application
Data
Rule
Legacy Modern
From systems of records to systems of engagements

4. What are
BPMN,
CMMN and
DMN
• Open Standards published by the Object
Management Group (OMG)
• Unambiguous graphical notations for
modeling processes, cases and decisions
• Platform agnostic
• Modeling techniques that can easily be
learned by both clinicians and
informaticians
Business Process
Model & Notation
Case Management
Model & Notation
Decision
Model & Notation

5. BPM+
• BPMN
• Flow diagrams
• Good for processes
• DMN
• Can make complex decisions
• Can input numbers, T/F, valuesets, dates
and durations
• Can have multiple outputs
• CMMN

6. Trisotech is a global leader in digital enterprise solutions, offering innovative and easy-to-use software tools
that allow customers to discover, model, analyze and find insights into their digital enterprise.
BASIC ELEMENTS
Pool
Event
Activity
Gateway
FLOW
20161007
BPMN Quick Guide
A simple, basic, yet
complete, BPMN reference
accessible to everyone.
www.BPMNQuickGuide.com
Start
Event
Service
Task
Decision
Task
Data
Object
End
Event
End
Event
Intermediate
Message
Event
BPMN is a universal graphical notation for documenting business processes and driving process
improvement initiatives. It enables a disciplined process approach that allows organizations to
become more efficient.
www.Trisotech.com
Download Free
BPMN, CMMN and DMN
templates at
www.Trisotech.com/Visio
Sequence
Flow
Message
Flow
Data
Association
Subprocess
Case
TaskTriggers a new
process instance
External Participant
to the process
What is done next
Task to be
completed
Routing
Information
required as input
End state
of the process
External
communication
Business Process
Model & Notation

7. Stage
BASIC ELEMENTS
CONNECTOR
Trisotech is a global leader in digital enterprise solutions, offering innovative and easy-to-use software tools
that allow customers to discover, model, analyze and find insights into their digital enterprise.
20161007
www.Trisotech.com
Download Free
BPMN, CMMN and DMN
templates at
www.Trisotech.com/Visio
Timer
Event
Non
Blocking
User Task
Process
Task
Discretionary
Task
Decision
Task
Milestone
Case File
Item
User
Event
[Update]
Case Plan Model
Blocking
User Task
CMMN offers a common notation for graphically expressing work patterns that require
management of a case. It enables a paradigm shift from prescriptive processes to supporting
knowledge-intensive work facing uncertain contexts.
Task done at the
user's discretion
Manually
activated stage
Occurrence of
a change in the
file information
A required task
Action
Condition
Event
The context in which to react to
events. Event- Condition- Action
Termination
criteria
EVENT
CONDITION
ACTION
Discretionary
Association
OnPart
Connector
Task
Criterion
Event Listener Case File Item
Case Management
Model & Notation

8. Decision
Input Data
Decision 1
Decision 2 Input Data 3
Input Data 1 Input Data 2
Knowledge
Source
www.Trisotech.com
BASIC ELEMENTS
REQUIREMENTBusiness
Knowledge
Model
20161007
Download Free
BPMN, CMMN and DMN
templates at
www.Trisotech.com/Visio
Trisotech is a global leader in digital enterprise solutions, offering innovative and easy-to-use software tools
that allow customers to discover, model, analyze and find insights into their digital enterprise.
DMN provides a modeling notation to capture business decision requirements and decision logic.
It increases an organization’s agility and adaptability by capturing the business decisions
independently from where they are used.
Decision logic using a Decision Table
Decision Requirement Diagram (DRD)
Each row
is a rule
Conditions
Result
Defined
decision logic
Re- usable
decision logic
Input required
for the decision
Authority source
of this data
Information Knowledge Authority
Decision
Model & Notation

9. Variable
Every work effort instance
looks slightly different
Unpredictable The exact course of action is
unknown and highly
situation specific
Emergent
The exact course of action
only emerges during process
execution when more
information becomes
available
When to use BPMN, CMMN or DMN

10. OMG BPM Health
Work Group
Goals:
• Exploring a Model Driven approach to capturing Clinical
Pathway
• Use OMG open standards BPMN, CMMN, and DMN to
define the workflow of care and decision-making at the
level of granularity that offers a complete, flexible
solution, including semantic clarity, robust decision logic,
human readable AND machine executable.
Deliverables:
• Field Guide to Shareable Clinical Pathways
• Pilot use case: Antenatal Care Models
www.OMG.org

11. Motivation
• Healthcare Information Technology
(HIT) has a great potential to improve
efficiency and quality of clinical health
care
• Our goal is to make an explicit,
understandable connection between
HIT and the methodical improvement
of clinical health care
• To make Clinical Pathways shareable it
is recommended to use
internationally accepted standards
where possible
• Process Management: BPMN
• Case Management : CMMN
• Decision Management : DMN

12. Sharable
Clinical
Pathways
A clinical pathway is a care process (activities and
resources) involving orchestration and coordination of
multidisciplinary care organizations along with the
patient to realize the patient’s Care Plan
Well documented clinical pathways can improve
communication by providing consistent and
coordinated workflow steps and goals to patients and
care team members, to ensure common practices and
results
Sharable Clinical Pathways are meant to be explicit
guidelines with formal, repeatable semantics that are
understandable by care team members and patients as
well as being computer interpretable

13. Field Guide Antenatal Pilot

14. Overview of ACOG Projects
OPA FPAR 2.0
Modeling Shareable
Clinical Pathways
Electronic Clinical
Quality Measures
(eCQMs)
ACOG Prenatal Record -
Dorsata
ACOG Comprehensive
Women’s Medical
Record
Birth Registry
iGroup
Antenatal Care
Pain and Bleeding
Genetics
Menopause

15. Narrative Documents
Benefits Gaps
And we don’t seem to be able
to move the needle on
Outcome metrics

16. Outcomes
Maternal
Mortality 2x up
over last 20
years
01
Many other US
metrics at third
world levels
02
Delivery of
preventive
services less
than 40%
03
Only 40% of
pregnant
women get a
flu shot
04
Only 7% (in
Louisiana) get
17-OHP
05
We are failing in basics!
So how do we get our guidance to the Point of Care?

17. Current State
Most EHR’s are transactional billing
systems, with some provider stuff
tacked on.
Think of a transaction at WalMart
• Date/Time/Location
• Item Number
• Amount
• Your credit card number
Woefully inadequate to
understand where this patient
is on a care pathway

18. Narratives require:
• Interpretation
• Translation
• Fill in the gaps
• Version control
EHR must contain:
• All discrete data elements
• Metrics and Dashboards
• CDS and Pathways
• Duplicates of all other sources of data
• Immunizations
• Labs
• PDMD
• Med Lists

19. Future State
• APIs
• Interoperable Data Models
• FHIR
• Care pathways for digital
platforms
• BPM+
• BPMN
• DMN
• CMMN
• Thoughtful separation of
concerns
• Knowing what belongs
where
• No more square pegs in
round holes

20. Library of
Pathways
EHRApp for Care
Pathway
Dashboards,
Metrics, etc.
PDMP
Immunization
registry

21. What are the
goals of the
ACOG IT
Group?
• External to ACOG
• Create Care Pathways for digital platforms
• EHRs
• Mobile
• Web-based
• Apps
• Other
• Coordinate with other professional societies
• AAFP, ACS, ACEP, ADA, VA, CDC, ACR,
• HSPC, OMG, MITRE
• Internal goals within ACOG

22. Care
Pathways
Provide clear, precise, unambiguous instructions for
software engineers
• Platform independent
• Transparent methodology
• Include necessary:
• Data elements
• Rules
• Decision models
• Performance measures
• eCQMs
• CQL scripts

23. ACOG
Experience
with the
approach
• Transforms our narrative guidelines into computable artifacts
• Enforces rigor in our guideline development process
• Having CDS in the context of workflow reduces burden
• Data derived from the models supports guideline evaluation
www.ACOG.org

24. How do we
translate
narratives to
“Artifacts”?
• Scrape Recommendations from ACOG
narratives
• Called out Recommendations
• Link Recs to Problems
• Had to create a curated PL for OB
• Make the BPM+ model
• SME review
• Working Group for triaging
• OK to go out the door
• Nothing per vagina for
Placenta Previa
• Needs more formal ACOG review
• Check for A fib if patient on
levothyroxine, refer to
cardiology

25. So….
Why do
this?
Improve process of care
• Hopefully move the needle on outcomes
Reduce provider burden
• Documentation
• Pre-auth and billing
• Empower our members’ survival in a Value-
based care system
We need the data
• Close the loop on the Learning Healthcare
system

26. Thyroid Disease in
Pregnancy
Guideline Example

27. Hypothyroid Pregnancy:
Sharable Clinical Pathway Model

28. Hypothyroid Pregnancy:
Adjust Synthroid Dose Decision

29. A single visual
Knowledge Artifact
is created
for clinicians and
for automation
• The model is the specification
• The model is the logic
• The model is the documentation
• The model is the code

30. Demonstrating Automation of Sharable Pathway

31. CDS Hook
• A vendor agnostic remote decision
support specification
• Created by the team behind SMART
CDS Service
• A service that is invoked by the EHR via
a Hook, evaluates its own logic using
FHIR data and returns decision support
via Cards
www.cds-hooks.org

32. FHIR
• The basic building block in FHIR
is a Resource
• All exchangeable content is
defined as a resource
• Resources all share the
following set of characteristics:
• A common way
to define and represent them,
building them from data types that
define common reusable patterns
of elements
• A common set of metadata
• A human readable part
Automate healthcare
data sharing and
improve patient care
www.hl7.org/fhir/

34. BPM+ Health Community
Forming a robust and thriving
community-of-practice of healthcare
institutions, professional societies,
and vendors
Established to foster the sharing and
promulgation of best-practices
around modeling and sharing:
• clinical pathways,
• clinical guidelines, and
• other healthcare knowledge

35. Questions ??
dgagne@Trisotech.com
hasleysk@upmc.edu