This document discusses business process modeling in healthcare using the Business Process Modeling Notation (BPMN) standard. The main challenges of business process modeling in healthcare include defining complex healthcare processes, accounting for the multi-disciplinary nature of healthcare work, handling the flexibility and variability of healthcare activities, enabling interoperability between information systems, and accommodating continuous changes in scientific knowledge. The authors describe applying BPMN to model healthcare processes and discuss how process modeling can help optimize processes, increase transparency, and improve quality assurance in healthcare institutions.

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Business process modeling in healthcare
Article in Studies in health technology and informatics · August 2012
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2. Perspectives on Digital Pathology
Results of the COST Action IC0604 EURO-TELEPATH
Edited by
Marcial García-Rojo
Pathology Department, Hospital General Universitario de Ciudad Real, Spain
Bernd Blobel
eHealth Competence Center, University Hospital Regensburg, Germany
and
Arvydas Laurinavicius
Vilnius University Faculty of Medicine and National Center of Pathology,
Vilnius, Lithuania
Amsterdam • Berlin • Tokyo • Washington, DC

3. © 2012 The authors and IOS Press.
All rights reserved. No part of this book may be reproduced, stored in a retrieval system,
or transmitted, in any form or by any means, without prior written permission from the publisher.
ISBN 978-1-61499-085-7 (print)
ISBN 978-1-61499-086-4 (online)
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4. Contents
Preface v
Marcial García-Rojo, Bernd Blobel and Arvydas Laurinavicius
COST Action IC0604: Management Committee Members and Participants vii
Part I. Introduction
The COST Action IC0604 “Telepathology Network in Europe”
(EURO-TELEPATH) 3
Marcial García-Rojo, Luís Gonçalves and Bernd Blobel
Part II. State of the Art in Digital Pathology
State of the Art and Trends for Digital Pathology 15
Marcial García Rojo
State of the Art in Telemedicine – Concepts, Management, Monitoring and
Evaluation of the Telemedicine Programme in Alentejo (Portugal) 29
Tiago Cravo Oliveira, Maria José Branquinho and Luís Gonçalves
Paradigm Changes in Health Lead to Paradigm Changes in Pathology 38
Jacqueline A. Hall and Bernd Blobel
Telepathology Interoperability – A System Architectural Approach 51
Bernd Blobel
Consequences of “Going Digital” for Pathology Professionals – Entering
the Cloud 62
Arvydas Laurinavicius and Paul Raslavicus
Digital Pathology for Education 68
André Huisman
Part III. Pathology Business Modeling
Business Process Modeling in Healthcare 75
Francisco Ruiz, Felix Garcia, Luis Calahorra, César Llorente,
Luis Gonçalves, Christel Daniel and Bernd Blobel
State of the Art in Pathology Business Process Analysis, Modeling, Design
and Optimization 88
Thomas Schrader, Bernd Blobel, Marcial García-Rojo, Christel Daniel
and Janina Słodkowska
xv

5. Business Process Modeling in Healthcare
Francisco RUIZ a,1
, Felix GARCIA a,
, Luis CALAHORRA a
and César LLORENTE a
a
Institute of Information Technologies and Systems, University of Castilla-La Mancha,
Spain
b
Quality Department, Hospital General Universitario de Ciudad Real, Spain
Abstract. The importance of the process point of view is not restricted to a
specific enterprise sector. In the field of health, as a result of the nature of the
service offered, health institutions’ processes are also the basis for decision
making which is focused on achieving their objective of providing quality medical
assistance. In this chapter the application of business process modelling – using the
Business Process Modelling Notation (BPMN) standard is described. Main
challenges of business process modelling in healthcare are the definition of
healthcare processes, the multi-disciplinary nature of healthcare, the flexibility and
variability of the activities involved in health care processes, the need of
interoperability between multiple information systems, and the continuous
updating of scientific knowledge in healthcare.
Keywords. Business Process Modelling, BPMN, healthcare
Introduction
Any system development process covering the system’s lifecycle from analysis through
design, specification, implementation, testing, certification and maintenance must be
started from the business needs to be met by running an appropriate business process.
For describing that business process in a way understandable by both humans and
machines, business process modeling is widely used in any kind of enterprises. This
also holds for the medical domain. The objectives driving this procedure range from
the economic aspects of process optimization through the increase of transparency and
exchangeability of data and knowledge up to the assurance and certification of quality.
The development and standardization of meta-languages to formally describe and
model business processes as well as solutions for the execution of model files enables
the reuse of those models for different purposes with theoretical and practical
implications.
Various modeling languages have been developed to cover different aspects of
business processes and organizations. In that context, the Business Process Modeling
and Notation (BPMN) standardized by the Object Management Group (OMG) plays a
pivotal role. Some of the models and notations (e.g. organigram, value added chains)
are used to describe structures and processes on a very high abstract level and cannot
1
Corresponding Author. Francisco Ruiz González. Dep. of Technology and Information Systems.
School of Computing Engineering. University of Castilla-La Mancha. Paseo de la Universidad, 4. E-13071
Ciudad Real (Spain). Email: francisco.ruizG@uclm.es Phone: +34-926-295300 ext 3741 Fax: +34-926-
295354. URL: web: http://alarcos.inf-cr.uclm.es/per/fruiz/

6. be executed. BPMN and the Business Process Execution Language (BPEL) in contrast
enable modeling problems on an abstract level and facilitate execution and re-usage.
BPMN models also support communication between domain experts and computer
scientist. Figure 1 presents the BPMN and BPEL stack in an Web services environment.
Figure 1 Abstraction and execution in business process modeling languages
Chapter 5 of this volume aims at introducing business modeling with BPMN and
presents the state of the art in practical application of modeling in Pathology. Chapter
5.1 covers state of the art in modeling and analysis, Chapter 5.2 exemplifies advanced
models, and Chapter 5.3 discusses future trends in business modeling.
This introductory chapter is organized as follows: First, importance and role of
business processes for organizations are discussed in general, also tackling the
characteristics and usefulness of process models. The second section describes the
BPMN language for the representation of business processes. Finally, some
experiences about applying the business process perspective and/or BPMN in Health
sector are presented.
1. Organization, Processes and Models
IT supported Business Process Management (BPM) plays a key role at organizations’
strategic and tactical levels. BPM focuses on discovering, designing, deploying,
executing, interacting with, operating, optimizing and analyzing end to end processes.
This is performed at the level of business (organizational) design, not at the level of
technical implementation. In fact, BPM technology is framework, integrating diverse
and previously existent IT technologies from a new perspective, thereby providing
support of different phases of a business process’ (BP) lifecycle. Figure 2 presents a
summary of the BP life cycle based on a proposal of Weske [1], which includes four
main phases:

7. • Design, including the production of the BP models and an analysis to optimize
the models;
• Configuration, establishing details of implementation – automatically or
manually;
• Execution, enacting in real environments; and
• Evaluation, comparing the real as-is version of BP versus the designed to-be
version of models in order to identify improvement opportunities.
BP identification and
modeling
Analysis (validation,
simulation, verification)
Design
Using
Process mining,
Business Activity Monitoring,
…
Evaluation
IT selection &
implementation
Test and deployment
Configuration
Operation, Monitoring,
Maintenance …
Execution
Improvement
opportunities
=> new iteration
BP life cycle BP identification and
modeling
Analysis (validation,
simulation, verification)
Design
BP identification and
modeling
Analysis (validation,
simulation, verification)
Design
Using
Process mining,
Business Activity Monitoring,
…
Evaluation
Using
Process mining,
Business Activity Monitoring,
…
Evaluation
IT selection &
implementation
Test and deployment
Configuration
IT selection &
implementation
Test and deployment
Configuration
Operation, Monitoring,
Maintenance …
Execution
Operation, Monitoring,
Maintenance …
Execution
Improvement
opportunities
=> new iteration
BP life cycle
Figure 2. Business process life cycle.
In many world-real situations it is not possible or convenient to face the four
phases in one step. Therefore, in a first step an organization usually only wants to know
the internal way of work making its BPs explicit. Thanks to BP models, the activities of
any organization can be described in a way understandable by all the users and
stakeholders. Furthermore, process models are a key and necessary input for process
improvement initiatives. That’s why design and modeling of the BPs represents one of
the most important phases within the life cycle of organizational processes.
The main concept in BPM is the BP itself. BPs are a set of activities that deliver value
to the customers, in healthcare, e.g., to patients and staff members. In this context the
word ‘business’ means ‘organizational’ independently of the nature, mission and
lifetime of the organization. In practice it is not possible, and frequently also not
desirable, to fully automate BPs. In real world cases, processes are therefore composed
of both automated and manual activities. Although BP modeling not necessarily aims at
automation, a correct and appropriated representation of all BP activities is very useful.
So, BPs models can be used as learning material or as facilities to reasoning about
changing the way of work.
BPs are rather stable and represent the end to end flow of materials, information
and business commitments. BP models describe the activities in the context of a
business and how they relate to, and interact with, the necessary resources to achieve an
organization’s goal. A BP model facilitates to answer questions such as: What is the
outcome of the BP?; What activities are performed within the process?; What is the

8. order of activities?; Who performs the activities?; Which documents are exchanged
within the process?; What are the necessary interactions to complete the process?; or
How foolproof is the process, and how can it be improved in the future?. Answering
these and some other questions provides a good insight into the process workflow. It
also enables to identify structural, organizational, and technological weaknesses or
even bottlenecks, but also potential improvements to the process.
To met the aforementioned interests, a BP model integrates elements from several
points of view (see figure 2):
a) Information view, focused on WHAT information is important (i.e., patient
history, supplier data, medicine characteristics, …).
b) Functional view, focused on HOW the organization works, i.e., which
functions will be performed (e.g., interventions of ambulatory surgery,
recording of patients’ data, ...).
c) Organizational view, defining the organization’s subdivisions or roles and
their responsibilities in order to establish WHO carries out each effort (e.g.
Administration, Nursing, Anesthesiology).
d) Product/service view, focused on the WHY or motivation. Representation of
this viewpoint indicates which products or services are important for the
organization and why (i.e., patient's health, new experimental medicine, ...).
e) Process view, interrelating the elements of the four other views in order to
define WHO carries out something, HOW it is carried out, WHAT
information is needed or managed to carry out it, and WHY the effort must be
made.
Figure 3. Elements in a BP model.
Some specific advantages of the availability of BP models are [2]: a) To ease the
understanding of the key mechanisms of an existing business (please remember here
‘business’ is similar to ‘organizational’); b) To serve as the basis for the creation of
appropriate information systems that support the business; c) To improve the current
business structure and operation; d) To show the structure of an innovated business; e)
Functional
View
Product / Service View
Process
View
Organizational View
Information
View
Functional
View
Product / Service View
Process
View
Organizational View
Information
View

9. To identify outsourcing opportunities; and f) To facilitate the alignment of IT
framework and systems with business goals and needs.
2. BPMN Language
As mentioned in the introductory section already, BPMN is the industrial standard for
modeling BPs. The goal of this standard is to provide business people – non experts in
information technology – with a legible and understandable notation. BPMN aims at
serving as a communication bridge between business users, who are devoted to the
process design, and technical people, who are responsible of the process
implementation, both using their own terminology and ontology (see also Chapter 4.3).
The BPMN diagrams are composed of five main categories of elements:
• Flow Objects
• Data Objects
• Connecting Objects
• Swim Lanes
• Artifacts
2.1. BPMN Elements
The main elements for each BPMN element category are summarized in the following
tables (from 1 to 5) [3]:
Table 1. BPMN: Flow Objects.
Element Description Icon
Event
An event is something that “happens” during the
course of a process or choreography (section 1.2).
Events usually have a cause (trigger) and/or an
impact. There are three main types of events: Start,
Intermediate and Final. The Start and some
Intermediate Events have “triggers” that define the
cause for the Event.
Each one of these can be decomposed in different
types: Message, Timer, Error, Escalation, Cancel,
Compensation, Conditional, Link, Signal,
Terminate, Multiple, Parallel Multiple.
Intermediate events can be attached to activities
(boundary event).

10. Element Description Icon
Activity
An Activity represents the work to be performed in
a Process. It can be atomic (task) or compound
(subprocess).
The tasks can be simple or choreography ones
which represent a set of one or more message
exchanges and which involves two participants.
Choreography Task
Gateways
A Gateway is used to control the divergence and convergence of Sequence Flows in a
Process and in a Choreography. In their convergence version they have one ingoing sequence
flow and several outgoing flows whereas in their divergence version they have several
ingoing flows and one outgoing flow.
Exclusive (XOR), which represents an
exclusive decision, i.e. only one outgoing
flow is activated. The decision can be
evaluated depending on data or events.
Parallel (AND), in which all outgoing
flows are activated in parallel.
Inclusive (OR), in which each outgoing
flow is activated depending on the
evaluation of its associated condition. It
implies that as a result one or several
outgoing flows can be activated.
Complex, which can be used to model the
behavior of more complex
synchronizations for which an activation
condition is used.
Table 2. BPMN: Data Objects.
Element Description Icon
Data Objects
Data Objects provide information about what
Activities require to be performed and/or what they
produce. They can represent a singular object or a
collection of objects.
Data Inputs,
Outputs
Represent the necessary data (input) to adequately
perform the activities and processes and the produced
data (output).

11. Element Description Icon
Data Store
Provide activities with a mechanism to retrieve or to
store data will persist beyond the scope of the
process.
Table 3. BPMN: Connecting Objects.
Element Description Icon
Sequence
Flow
Sequence flows are used to show the
order in which the activities are performed
in a process and choreography. They can
be normal, conditional (includes a
condition which is evaluated in runtime to
determine if the control flow is followed
or not) and default (it only can be
associated to a data exclusive gateway and
represents the default outgoing flow which
is activated if none of the others is
activated).
Message Flow
Messages are used to show the
communication flow between two
participants (represented as two separated
pools). They can include messages which
represent the content of the participant’s
communication.
Message Flow
Message
Association
Associations are used to link Artifacts and
Text Annotations with other graphical
BPMN elements. An arrow can be used to
denote the association direction.
Table 4. BPMN: Swim Lanes.
Element Description Icon
Pool
Represents a Participant in a Collaboration
and acts as a graphical container (“swim
lane”) for partitioning a set of Activities
from other Pools, usually in the context of
Business to Business situations. It can
include internal details (process) or act as
a “black box”.
Lane
A Lane is a sub-partition (horizontal or
vertical) within a Pool and it is used to
organize and categorize activities.

12. Table 5. BPMN: Artifacts.
Element Description Icon
Group
Groups represent a grouping of
graphical elements that are within the
same category. They are used for
documentation or analysis purposes.
Text
Annotation
Text Annotations are used by
modelers to provide additional text
information for the reader of a BPMN
Diagram.
2.2. BPMN Diagrams
With BPMN, it is possible to cover three basic models of processes: Private Processes
(both executable and non executable), Public Processes, and Choreographies. To settle
those models, different types of diagrams are used. The three main sub-models covered
are:
1. Processes (Orchestration), which includes:
• Private BPs, which are internal to the organization and can be executable (if it
has been modeled for such purpose) or non executable (see Figure 3).
• Public BPs, which represent the interactions between a private BP and another
Process or Participant. In these models only the required activities to support
the communication between the private process and the other participants are
included (see Figure 4).
Receive the
Order
Fulfill the
Order
Check Credit
Deliver the
Order
Figure 4. Private Process example.
Figure 5. Public Process example [3].

13. 2. Choreographies, which express the expected behavior in an interaction between
participants (Figure 5). The difference between a Choreography and a
Process/Orchestration is that the last exist in the context of a single Participant (Pool),
whereas a choreography exist between Pools.
Figure 6. Example of Choreography [3].
3. Collaborations, which can include Processes and/or Choreographies and represent
the interaction between two or more business units (Figure 6). Usually, collaborations
contain two or more participants (Pools) who interchange messages.
Figure 7. Example of Collaboration [3].
3. Applying BPM in the Health Sector
Like in all type of organization, also in the health sector it is of vital importance to stay
updatded in relation to its BPs. This is not only a requirement for the continuous
improvement of services, but it also constitutes a fundamental part of quality programs
the organizations are connected with. In a competitive healthcare market, hospitals
have to re-organize their structure and operations [4] to become more responsive
organizations with a patient service as efficient as possible. For that reason not only
labor and capital but also information will be a critical resource: availability,
correctness, and facilities to process information are crucial for an efficient patient

14. service. Nevertheless, properly designed processes are a key aspect for a good use of
information systems. The lack of control in processes used to deliver medical care is
clearly a major problem in the context of preventable medical errors with lethal
damages and high economic costs in many hospitals. On the other hand, care safety
assessment, activity-based analysis, workflow technology and knowledge of care
pathways provide the methodological basis for continuous quality improvement in the
health sector [5]. Additionally, the ISO 9000 standards promote enterprise process
analysis and the use of business process redesigning to describe major processes and a
functional view across enterprises. With all those considerations, it seems clear that BP
models – expressed in an explicit way and understandable for all participants – can be a
very good tool for improving the healthcare service quality.
There are some interesting experiences addressing this issue like the work of
Garcia et al [6], who described how BPMN was used to model the anatomic pathology
processes in a public hospital in Spain. The team was constituted by staff of the
hospital including experts on selected processes and persons responsible for
administrative and quality issues, and external IT experts. Similar experiences have
been published by Parra et al. [7], who applied BP modeling and simulation in
processes like telemedicine and post-transplant hepatitis, however not using BPMN. In
[8], a methodology used to model and describe existing chronic care processes and
pathways in a Norwegian hospital is presented. As a result, it has been concluded that
BPMN is useful for modeling care processes and that it can benefit from adaptations to
healthcare environments to be optimally exploited. A more recent work on using BP
models in hospitals has been presented by Strasser et al. [9]. These authors describes a
new process management system for defining and reconstructing clinical care
processes by using the BPMN language for modeling and also executing processes.
The main goal of the system is to assist hospital operators and clinical process
managers to detect discrepancies between defined and actual clinical processes as well
as to identify main causes for high medical costs.
The Chester County Hospital experience in BPM has been reported with regard to
a workflow system that integrates clinical, operational and financial processes which
provide a significant improvement in patient’s safety, efficiency, and particularly in
bed management and infection control [10]. For instance, the system alerts staff when a
bed is not cleaned in a predetermined amount of time. Hospital BPs modeling has also
been employed in radiology interpretation [11]. In this work, a detailed description of
each task, role and route of the interpretation sub-process was carried out, in addition to
those related to the information flow. Predefined reports associated with each
procedure were created, thus leading to a substantial improvement in efficiency. A last
and very recent example of the application of BP models is a case study of healthcare
human collaboration processes performed at a Dutch academic hospital to evaluate a
novel interaction-centric process modeling method [12]. The process under study is the
care pathway performed by the head and neck oncology team, and the case study
illustrates how the method utilizes BPMN for effective tree-based description of
interactions, their composition and routing relations, and their roles. In summary, BPM
technology in general, and tools for support the BP modeling and simulation in
particular, have achieved a high level of maturity. and their use is growing in all sectors
and specially in healthcare. Previously mentioned references are only a few samples of
a great amount of information available in bibliographies and on the Web.

15. 4. Difficulties and Challenges when Applying BPM in the Health Sector.
The complexity and special characteristics of processes involved in healthcare raise
difficulties and challenges when implementing BP models in this sector. Some of them
are described in different published experiences.
4.1. Health Care Process Orientation
The traditional way to structure an organization is the formation of departments and
vertical functional units, consisting of individuals with a similar area of expertise. In
most cases, this way is dominant. It is necessary however, to perform a transition from
viewing the healthcare organization as a number of departments a patient-centered care
model, which focuses on the performed business processes [7].
4.2. Multidisciplinary Nature of Healthcare Processes
There is a strong involvement of multiple professionals from different departments
working on shared tasks with a common goal. This makes the graphical representation
of processes more complex. When the representation is done through lanes with many
participants, much space is wasted with the representation of the diagrams.
Furthermore, when additional annotations are used to clarify the definition of activities,
the readability could be compromised. In other instances, some activities are shared by
different roles (e.g. programmed surgical patient care). However, BPMN does not
support explicit modeling of shared activities, so the best solution has to be the activity
repetition in different lanes [13].
4.3. Flexibility and Variability of the Activities Involved in Healthcare Processes
The order of the activities can be modified to achieve certain objectives. Moreover, in
some cases, there may be optional activities that include additional functions and roles
in the process. On the other hand, the complexity of patients’ treatment at a hospital
might involve many exceptions that occur in healthcare processes [14].
4.4. Integration, Communication and Interoperability with Existing Information
Systems in Healthcare Organizations
. Results published by various authors in this area are promising in order to get all the
information relevant to the care of patients in the right place and at the right time,
providing continuity of care and ensuring security and privacy [15], (see also Chapter
8.3 in this volume). However, most of these experiences are in initial phases, and the
development of efficient information systems in the health care sector is occurring
slowly.
4.5. Continuous updating of scientific knowledge in healthcare
Various examples of implementation tools providing professionals with decision
support, based on experience (probabilistic model) and scientific evidence via Web,
have been defined. Also the different data that can be generated from process

16. knowledge models can be useful for assuring data quality. They can provide a starting
point for the construction of a documentary system, based on all types of described
documents and related to specific activities and roles [5]. However, such experiences
are still isolated examples in healthcare sector.
4.6. Gap between Hospital and Community Care
Some interesting experiences applying the BP modeling and simulation in processes
such as telemedicine and thecare of chronic diseases may be limited by the
discontinuity in healthcare processes between hospitals and primary care settings [16].
Bridging this gap is still a challenge for health services in order to improve process
efficiency in patients care organization.
5. Conclusion
Business Process Modelling Notation (BPMN) enables modeling process at different
levels of details, as needed, facilitating re-usage. BPMN models also support
communication between domain experts and computer scientist.
The BPMN diagram elements (flow objects, data objects, connecting objects, swim
lanes, and artifacts) and basic models of processes covered by BPMN (Private
Processes, Public Processes, and Choreographies), are easy to understand by end users.
There are few experiences addressing the use of BPMN in healthcare, including
anatomic pathology, telemedicine, chronic patient care, infection control, and patient’s
safety.
The reason why there are few experiences in business process modeling in health care,
may be the complexity and special characteristics of processes involved in this sector,
with a strong multidisciplinary. Since BPMN does not support explicit modeling of
shared activities, the activity repetition in different lanes is needed. This extra work is
compensated by the easy understanding of BPMN diagrams and its reusability.
Information systems interoperability in healthcare organizations, which is developing
quite slowly, can benefit from the use of BPMN to achieve its main goal to provide
continuity of care and ensuring security and privacy.
Acknowledgement
References
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