Oplægget blev holdt ved InfinIT-arrangementet "Sammenhængende patientforløb, sundheds-processer og it" afholdt den 20. april 2012. Læs mere om arrangementet på http://www.infinit.dk/dk/hvad_kan_vi_goere_for_dig/viden/reportager/en_forandret_sundhedssektor_med_it.htm

1. Fleksible
sundhedsprocesser
Trustworthy Pervasive Healthcare Services
(Trustcare.dk)
Støttet af det strategiske forskningsråd (2008-2012) # 2106-07-0019
Thomas Hildebrandt
lektor, IT Universitetet i Købehavn
leder af Process and System Models Group
Programming, Logic and Semantics Group
Processer og IT
Temadag om sammenhængende patientforløb, sundheds-processer og it
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Problemer
og
mål
• Behov for øget kvalitet: Lige god, og individuel
• Mange typer it-systemer, guidelines og brugere
• Papir, verbal eller desktop-brugergrænseflader
• Dyrt at vedligeholde og tilpasse guidelines
Mål: Fleksibel, opdateret og mobil/pervasive it-
støtte til arbejdsprocesser i sundhedssektoren
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3. Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
Baggrund However, the focus is not on data but on process-related information (e.g., the
ordering of activities). Process mining is also related to monitoring and business
intelligence [41].
8 Conclusion
Process-aware information systems (PAISs) follow a characteristic life-cycle. Fig-
ure 13 shows the four phases of such a life-cycle [7]. In the design phase, the
processes are (re)designed. In the configuration phase, designs are implemented
by configuring a PAIS (e.g., a WFMS). After configuration, the enactment phase
starts where the operational business processes are executed using the system con-
figured. In the diagnosis phase, the operational processes are analyzed to identify
Activity Based Computing (Bardram)
problems1. and to user interface – (A) Context Bar (B) List of Activities, (C) Two resumed activities with their associated resources displayed in a
Figure The MPAD find things that can be improved. The focus of traditional work-
carrousel, (D) An X-ray viewing application launched as part of an activity.
flow management (systems) is on the lower half of the life-cycle. As a result there
is little support for changes in data and/or phase. Moreover, support inone or several machines whichis
based subscription to the diagnosis relationships. The server tier may run on the design phase are
As illustrated Figure 2, aexo consists of two tiers with MPAD then linked together in a peer-to-peer manner, ensuring the
limited to providing an editor while analysis and real of activitiessupport are of devices, while
implemented in two additional layers (C) and (UI). distribution design across a number missing.
also providing mechanisms for synchronizing the activities
on multiple display clients. Aexo supports a very ad-hoc for-
M1 M2 M3 M4 mation and life cycle management of available devices. The
total data map may be distributed across several host ma-
Client tier (MPAD)
UI UI UI UI chines, but at any given time only a subset of the machines
and their part of the map may be accessible. In Figure 2 ma-
C C C USB stick C chine 4 (M4) may, for example, be a laptop which comes and
Prescribe Sign
goes. Aexo is able to dynamically listen for and mount data,
Doctor
which may reside on external datasources such as laptops
and USB drives, and incorporate them into an existing map.
Server tier
P2P
RFID reader
This feature of aexo is used to implement the private and
S S transient activities in MPAD, where users may carry around
activities on a USB stick. The same mechanism is used for
M5
private and persistent data. Here we only store a key on the
USB stick which is then used to unlock a specific part of the
Give Figure 2. The MPAD architecture showing the (S)erver and (C)lient as existing map.
well as the extension points with e.g RFID reader interface. This setup
Nurse
medicine has five machines. An activity is basically comprised of some metadata, a col-
lection of resources like documents and files, and a set of
The aexo server tier is an activity-oriented infrastructure com- participants. This activity model maps directly into the map.
ponent providing a lightweight storage and event system de- The overall activity storage is then organized according to
signed for distributed and interactive environments including a scheme where each activity is stored in a separate subtree
Figure 13: PAIS life-cycle.
dMDEs. The server tier maintains a hierarchical map datas- under the user who owns the activity. The activity is then
tructure that holds all persistent data in the system. The map linked to the rest of the participants.
Process-modeller, logik 3og proces-orienteret IT is not strictly hierarchical however; one node can link to an-
In this article, we showed that PAISs support 2. The aexo client-tier is of threeMPAD as shown in
The MPAD application consists
other thereby providing a way to model data that cannot be
Figure operational business processes
expressed hierarchically. This scheme is similar to that of a part of
layers
and ensures
connectivity to the aexo server tier. The communication be-
unix-based filesystem. On top of the map is an event system
by combining advances in information technologythe aexo client and server tier canfrom using sev-
with recent insights happen man-
tween
which enables clients to listen for changes in any node (and
agement science. We started by reviewing the history but the aexo C# client library layer wraps
eral protocols, of such systems and then
its sub-tree) in the map. Aexo also contains an extension

4. agement: (1) the setting of objectives jointly with the client, (2) a planning phase where
Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
the case manager selects possible services, but also needs the buy-in of the client that
these services can be applied and constitute a solution to the complex problems faced 5
Sagsbehandling
by the client, (3) the controlling (and revision) of service execution towards achieving
i.e., the result must logically follow from the assessment outcome and the defined ob-
the objectives.jectives, which set the constraintsphases. is possible and meaningful for a specific
Figure 1 summarizes the for what
client.
Case management is thus considered as a coordinated response to a differentiated
Intake landscape of offerings that can constitute a solution to a client’s complex problem.
Assessment Planning Linking & Evaluation
It has the goal of empowering clients and also often initiates change in the resource
Monitoring
system when necessary. Thus, in response to [15], one may argue whether a term such
as adaptive case management is meaningful as case management is by definition a
highly adaptive process.
Following [3], we use a four-quadrants model to characterize human work along
two dimensions: the complexity of knowledge (KC) required to successfully accom-
plish a work task and the complexity of the personal and business relationships (RC)
required. Four quadrants can be distinguished, which allow us to differentiate and posi-
16
tion modern IT solutions supporting human work, cf. Figure 2.
oriented work, social collaboration,The 5 case management phases.
Fig. 1. intelligent problem-solving. We derive a set of ca-
pabilities required by case workers and show how these capabilities are supported at
the low, average, and advanced levels of using IT-based case management systems. We
present a maturity model for IT-based case management consisting of five levels where
we relate the characteristic capability of each level with the main benefit and risk of
Historically, case management has emerged as a management discipline within so-
technology adoption.
Ongoing work focuses on the review of the model with stakeholders, on improving
cial work to ensure the continuity of care in the United States in the 1970/1980 years
its refinements, and applying the model. Furthermore, we investigate the problem of
case similarity, which requires to develop similarity notions that apply to the assess-
where social work and health care were extended into a coordinated end-to-end process
ments, objectives, and history used to describe a case.
involving different institutions and professions. Elements of case management can be
References
found much earlier in social work, but the management discipline was coined in this
decade. A core metaphorWeske,caseunbauer, D.: Case handling:is(2005) tailor businesscare-giving process to the
1. van der Aalst, W.M., of M., Gr¨ management a new paradigm for the
process support. Data & Knowledge Engineering 53(2), 129–162
to
needs of the 2. Bruin, T.D., Rosemann, M.:the creationprocessamanagement maturity model. In:
individual, i.e., Towards a business of personalized instance of this process. The
Proc. 13th European Conference on Information Systems (ECIS) (2005)
tailoring itselfDavenport,2.T.H.: Thinking for a Living: How to Get Better(credits also tocasefrom
3. is a qualified process conducted by the Results manager who needs a vari-
Fig. Workers.quadrants of human work [3]
Four Mcgraw-Hill (2005)
Performance and
Pascal Sieber, Sieber & Partners).
Knowledge
ety of competences to succeed. Furthermore, transparency of the tailoring is required,
4
4. Fisher, D.M.: The business process maturity model - a practical approach for identifying
opportunities for optimization. BPTrends September (2004)

5. ness goals play a much more prominent role than predefined workflows: “In case han-
Processer ogknowledge 2012
dling, the IT, 20. april, worker in charge of a particular case actively decides on how the
Thomas Hildebrandt, hilde@itu.dk
goal of that case is reached, and the role of a case handling system is assisting rather
Sagsbehandling
than guiding her in doing so.”
The original setting of case management as it was defined in the context of social
work emphasizes additional aspects. For example, the definition of case management
by the case management network of Switzerland5 states that case management is
. . . a specific approach for the coordinated handling of complex situations in
social work, health care and insurance. A bundle of services is provided to a
client based on his/her individual needs in a systematic and cooperative pro-
cess in order to effectively achieve jointly defined objectives in high quality.
Case management coordinates inter-professional and inter-institutional ser-
vices and respects the autonomy of the clients while preserving resources in
the client’s and the supporting systems.
5
Netzwerk Case Management Schweiz, http://www.netzwerk-cm.ch
Capabilities and Levels of Maturity in IT-based Case
Management
Jana Koehler1 , J¨ rg Hofstetter1 , and Roland Woodtly2
o
1
Lucerne University of Applied Sciences and Arts, School of Engineering and Technology
2
Lucerne University of Applied Sciences and Arts, School of Social Work
email: firstname.lastname@hslu.ch
5

6. We begin by listing a set of capabilities required by case workers, but also offered
Processer the IT, 20. april, 2012 in case management. We group Thomas Hildebrandt,function-
by og IT systems used these capabilities by hilde@itu.dk
ality areas that are relevant for more than one phase of the case-management process:
Sagsbehandling
management of the information and data belonging to a case, tracking and obtaining in-
sights into the case history, recording and managing case-related decisions, support for
collaboration among case workers and organizations, support for administrative tasks
such as benefit or work-time accounting.
Capability Degree of IT usage
low average advanced
Information spreaded/paper-dominated coordinated integrated & consistent
- visualization genogram, ecomap (paper) diagrams advanced & problem-specific
- forms simple templates intelligent
- access individualized role-based inter-organizational
- assessment guided unified standardized
Case History spreaded across documents tracked visualized
- management difficult available advanced insights
- insights descriptive diagnostic predictive
Decisions individually taken systematically recorded best practices
- case groups none possible case similarity
Collaboration disintegrated partially integrated seamlessly integrated
- transfer difficult supported inter-organizational
Administration separated embedded forms partially automated
Table 1. Capabilities grouped by functional area and degree of IT usage.
Table 1 gives an overview over the6 capabilities as they take shape from lower to

7. Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
Sagsbehandling
12
Fig. 4. C3M: The C3M maturity model for IT-based case mangement.
7

8. check$out.$When$the$controlling$pharmacist$has$checked$that$the$produced$drug$and$
patient’s height and weight as well as the latest laboratory results could be registered in the
patient$information$label$matches$the$flowchart$and$the$working$slip,$the$pharmacist$
form.
Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
put$small$green$ticks$on$each$item$in$the$flowchart$and$finally$signs$it.$Subsequently$ information and the patient history, the physician calculated the
Based on the presented
the$ flowchart$ and$ the$ product$ is$ referred$ to$ the$ treatment$ individual where$ of chemotherapy according to the dedicated protocol, ordered it on the
rooms,$ dosage the$
responsible$ nurse$ together$ with$ another$ authorised$ person$ (nurse$ or$ doctor)$ checks$ Then the form was transferred to the pharmacy for preparation
form and signed the form.
Fra
papir
Cl
IT-­‐støGe
of the actual chemotherapeutic drug by a pharmacist assistant. When the preparation was
that$ the$ product$ and$ flowchart$ matches,$ both$ regarding$ content$ and$ patient$
ready the pharmacist validated the preparation and signed the form. Finally, the nurses
information.$ The$ responsible$ nurse$ then$ signs$ the$ flowchart$ and$ the$ medicine$ is$
(two in every case) who administered the chemotherapy used the form for checking
administered$ to$ the$ patient.$ In$ parallel$ to$ this$ the$ nurse$ will$ administer$ adjuvant$
information on chemotherapy dosage and patient data before they finally signed off the
medicine$ like$ anti>emetics,$ cortisol$ and$ other$ drugs$ that$ are$ prescribed$ in$ the$ local$
administration.
practice$ guidelines.$ The$ nurse$ registers$ the$ medication$ in$ the$ Medicine$ Order$ and$
Administration$ (MOA)$ IT$ system$ that$ currently$ is$ being$ implemented$ in$ all$ the$
oncology$departments.$$
$
Ward
Patient
Patient
flowchart + + flowchart
+
+ Pt. A
drug X
Nurse/ Nurse
Doctor doctor
Pharmacy
+ +
flowchart flowchart
+ Pt. A
drug X
pharmacist Pharmacist
Work + Work
sheed sheed
+ Pt. A
drug X
pharmacist
assistent $
Figure'2'Oncologic$workflow$in$relation$to$chemotherapeutic$treatment$of$patient$
2.4 From Paper Based Clinical Practice Guidelines information1in relation of an ‘ordering’ form allowing for documentation of the most relevant and the
Preliminary'conclusion'to'the'case'study' Figure Example
to Declarative Workflow Management. translated by the primary author clinical
to chemotherapy (the form has been
Karen Marie Lyng, Thomas Hildebrandt, Raghava translation has been confirmed by clinicians).
Rao Mukkamala.
Several$characteristics$of$the$work$were$elucidated$in$the$case$study:$$$
2nd International Workshop on Process-oriented information systemsserved as guidance for the ordering activity, it was embedded in the
The ‘ordering’ form in healthcare (ProHealth '08)
work practice as it contained all relevant information and all documentation in relation to
ordering and administering of chemotherapy, it was present at the point of care as it
6
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9. Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
Flowdiagram
(BPMN)
the nurse role. This could be enforced by the formalism, e.g. by introducing a richer
notation for access rights allowing to express that the person executing the second signing
must be different from the first. We leave this for future work.
Figure 3 The chemotherapy workflow in Business Process Modeling Notation (BPMN)
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The tabular form of the process corresponds very closely to the paper based SOGAs

10. Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
Problemer
ved
BPMN
• Besværligt at beskrive at man kan gentage
tidligere handlinger (f.eks. at lægen kan
ordinere mere medicin efter underskrift)
uden at gentage alt hvad der fulgte efter
• Besværligt at beskrive ændring i roller/forløb
• Giver en opskrift på et forløb der opfylder de
gældende krav, ikke kravene der skal opfyldes
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11. Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
Den
deklaraCve
Clgang
• Deklarerer kravene og lader it-systemet
tillade alt hvad der er muligt, og fortælle
hvad der er krævet/foreslået
• Eksempler på krav:
• en ordination skal underskrives før
medicinen kan gives Betingelse
• lægen skal bekræfte (ny underskrift) eller
ændre ordinationen, hvis der udtrykkes
mistillid Respons
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12. Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
Process
Designer
Deklarerer roller, betingelser og respons (opfølgning)
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13. Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
Udfordringer
• Formular-baseret pc brugergrænseflade
• Kan være svært at se vej fra start til slut
• Korrekt?
• Ændringer
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14. Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
DemonstraCon
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15. Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
Login:
Scan
din
QRcode
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16. Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
Overblik
over
forløb
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17. Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
Hvad
er
gjort/muligt/krævet
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18. Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
Oplys
laboratoriedata
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19. Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
Se
detaljer
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20. Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
Sygeplejerske
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21. Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
Fleksibilitet
• Som udgangspunkt kan en handling altid
udføres (igen)
• Processen beskrives ved at angive roller,
betingelser (conditions) og opfølgninger
(responses) til handlinger
• Nem at ændre/vedligeholde - og forstå(!?)
• Grænseflade og kommunikation
kontrolleres af model - kun ændres et sted
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22. 4
Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
Case management defines how a complex situation is handled and how the services,
which respond to the needs of the client, are determined and implemented. Five phases
are commonly distinguished in the client-facing processes of case management:
Iøvrigt,
nu
og
fremover
1. Clearing and Intake: Is a client in a situation in which case management can and
should be applied?
2. Assessment: What detailed situation is the client facing? What services could be
of help, reaching which possible objectives?
3. Planning: What objectives can be jointly agreed with the client? Which services
are possible and can be bundled to achieve the objectives?
4. Linking and Monitoring: How are the services put in place and how is the partner
• Grafisk notation for deklarative processer
network established? How effective are the services?
5. Evaluation: Which results are achieved? Are the objectives met? What change
results when re-assessing the client’s situation?
Phases 1 and 2 constitute the entering of a client into the case-management process.
Phases 3 to 5 are highly iterative. The evaluation often happens in a continuous way
• Recticular spaces (Bardram et al)
leading to changes in the planning and linking of the services when necessary. Three
characteristics stand out when comparing case management to business process man-
agement: (1) the setting of objectives jointly with the client, (2) a planning phase where
the case manager selects possible services, but also needs the buy-in of the client that
these services can be applied and constitute a solution to the complex problems faced
by the client, (3) the controlling (and revision) of service execution towards achieving
• Krav -> flowdiagrammer
the objectives. Figure 1 summarizes the phases.
Intake Assessment Planning Linking & Evaluation
Monitoring
hvad skete -> tilpasning Fig. 1. The 5 case management phases.
• Deklarativ tilgang er grundsten i nuværende
Historically, case management has emerged as a management discipline within so-
cial work to ensure the continuity of care in the United States in the 1970/1980 years
where social work and health care were extended into a coordinated end-to-end process
involving different institutions and professions. Elements of case management can be
found much earlier in social work, but the management discipline was coined in this
arbejde med at udvide BPMN 2.0 standarden
decade. A core metaphor of case management is to tailor the care-giving process to the
needs of the individual, i.e., the creation of a personalized instance of this process. The
tailoring itself is a qualified process conducted by the case manager who needs a vari-
ety of competences to succeed. Furthermore, transparency of the tailoring is required,
til sagsbehandlingsprocesser
• erhvervs-ph.d. startet jan. 2012
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23. Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
RecCcular
Spaces
1.Activity Manager 3.Activity 7.Overview 14.Text 15.Pie menu 16.Action 17.Web page 18.Action 19.Video window 7.Overview
List 2.Participant List 4.Action 5.Status 6.Pie menu button document operation overview operation participant list 20.Action log button
RESUME
SUSPEND
9.Workflow 10.Link 12.Activity 13. 21.Activity overview
8.Participant:
22.Current action
location, status Manager Relevance
current action 11. Participants Color bar 23.Available resources
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24. Processer og IT, 20. april, 2012 Thomas Hildebrandt, hilde@itu.dk
Udvidelse
af
BPMN
2.0
• Der arbejdes pt på at udvide BPMN 2.0
standarden så den bedre kan bruges til at
beskrive sagsbehandling
• Foredrag af Richard Hull fra IBM Research
den 6. juni på ITU
• Videngruppe om digitalisering og proces-
orientering (videndanmark.dk)
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