Computerization of workflows, guidelines and care pathways: a review of implementation challenges for process-oriented health information systems

There is a need to integrate the various theoretical frameworks and formalisms for modeling clinical guidelines, workflows, and pathways, in order to move beyond providing support for individual clinical decisions and toward the provision of process-oriented, patient-centered, health information systems (HIS). In this review, we analyze the challenges in developing process-oriented HIS that formally model guidelines, workflows, and care pathways. A qualitative meta-synthesis was performed on studies published in English between 1995 and 2010 that addressed the modeling process and reported the exposition of a new methodology, model, system implementation, or system architecture. Thematic analysis, principal component analysis (PCA) and data visualisation techniques were used to identify and cluster the underlying implementation ‘challenge’ themes. One hundred and eight relevant studies were selected for review. Twenty-five underlying ‘challenge’ themes were identified. These were clustered into 10 distinct groups, from which a conceptual model of the implementation process was developed. We found that the development of systems supporting individual clinical decisions is evolving toward the implementation of adaptable care pathways on the semantic web, incorporating formal, clinical, and organizational ontologies, and the use of workflow management systems. These architectures now need to be implemented and evaluated on a wider scale within clinical settings

Improvisation in tightly controlled work environments: The case of medical practice

We present a qualitative analysis of organizational improvisation and provide a preliminary insight into the following question: how is improvisation present in tightly controlled work environments? We conducted in situ observations of, and interviews with, several emergency medical teams and complemented this information with statistical and media data. Using grounded theory, we developed four propositions that were arranged into a model that allowed the identification of two use levels of established routines: (1) the visible side that accommodates contextual requirements, and (2) the improvisational side that provides a response to activity characteristics. This dual process is related to the existence of pressures that operate at the institutional level with practical needs emerging from the operational domain. In contrast with most of the literature, this study reveals that the presence of a broad procedural organizational memory does not restrict improvisation but enables a bureaucratic system to produce flexible improvised performance.Nova Foru

MODELFY: A Model-driven Solution for Decision Making based on Fuzzy Information

There exist areas, such as the disease prevention or inclement weather protocols, in which the analysis of the information based on strict protocols require a high level of rigor and security. In this situation, it would be desirable to apply formal methodologies that provide these features. In this scope, recently, it has been proposed a formalism, fuzzy automaton, that captures two relevant aspects for fuzzy information analysis: imprecision and uncertainty. However, the models should be designed by domain experts, who have the required knowledge for the design of the processes, but do not have the necessary technical knowledge. To address this limitation, this paper proposes MODELFY, a novel model-driven solution for designing a decision-making process based on fuzzy automata that allows users to abstract from technical complexities. With this goal in mind, we have developed a framework for fuzzy automaton model design based on a Domain- Specific Modeling Language (DSML) and a graphical editor. To improve the interoperability and functionality of this framework, it also includes a model-to-text transformation that translates the models designed by using the graphical editor into a format that can be used by a tool for data analysis. The practical value of this proposal is also evaluated through a non-trivial medical protocol for detecting potential heart problems. The results confirm that MODELFY is useful for defining such a protocol in a user-friendly and rigorous manner, bringing fuzzy automata closer to domain expert

Process Model Metrics for Quality Assessment of Computer-Interpretable Guidelines in PROform

Background: Clinical Practice Guidelines (CPGs) include recommendations to optimize patient care and thus have the potential to improve the quality and outcomes of healthcare. To achieve this, CPG recommendations are usually formalized in terms of Computer-Interpretable Guideline (CIG) languages. However, a clear understanding of CIG models may prove complicated, due to the inherent complexity of CPGs and the specificities of CIG languages. Drawing a parallel with the Business Process Management (BPM) and the Software Engineering fields, understandability and modifiability of CIG models can be regarded as primary quality attributes, in order to facilitate their validation, as well as their adaptation to accommodate evolving clinical evidence, by modelers (typically teams made up of clinical and IT experts). This constitutes a novel approach in this area of CIG development, where understandability and modifiability aspects have not been considered to date. Objective: In this paper, we define a comprehensive set of process model metrics for CIGs described in the PROforma CIG language, with the main objective of providing tools for quality assessment of CIG models in this language. Methods: To this end, we first reinterpret a set of metrics from the BPM field in terms of PROforma and then we define new metrics to capture the singularities of PROforma models. Additionally, we report on a set of experiments to assess the relationship between the structural and logical properties of CIG models, as measured by the proposed metrics, and their understandability and modifiability from the point of view of modelers, both clinicians and IT staff. For the analysis of the experiment results, we perform statistical analysis based on a generalized linear mixed model with binary logistic regression. Results: Our contribution includes the definition of a comprehensive set of metrics that allow measuring model quality aspects of PROforma CIG models, the implementation of tools and algorithms to assess the metrics for PROforma models, and the empirical validation of the proposed metrics as quality indicators. Conclusions: In light of the results, we conclude that the proposed metrics can be of great value, as they capture the PROforma-specific features in addition to those inspired by the general-purpose BPM metrics in the literature. In particular, the newly defined metrics for PROforma prevail as statistically significant when the whole CIG model is considered, which means that they better characterize its complexity. Consequently, the proposed metrics can be used as quality indicators of the understandability, and thereby maintainability, of PROforma CIGs

Using conceptual graphs for clinical guidelines representation and knowledge visualization

The intrinsic complexity of the medical domain requires the building of some tools to assist the clinician and improve the patient’s health care. Clinical practice guidelines and protocols (CGPs) are documents with the aim of guiding decisions and criteria in specific areas of healthcare and they have been represented using several languages, but these are difficult to understand without a formal background. This paper uses conceptual graph formalism to represent CGPs. The originality here is the use of a graph-based approach in which reasoning is based on graph-theory operations to support sound logical reasoning in a visual manner. It allows users to have a maximal understanding and control over each step of the knowledge reasoning process in the CGPs exploitation. The application example concentrates on a protocol for the management of adult patients with hyperosmolar hyperglycemic state in the Intensive Care Unit

Process mining for healthcare: Characteristics and challenges

Process mining techniques can be used to analyse business processes using the data logged during their execution. These techniques are leveraged in a wide range of domains, including healthcare, where it focuses mainly on the analysis of diagnostic, treatment, and organisational processes. Despite the huge amount of data generated in hospitals by staff and machinery involved in healthcare processes, there is no evidence of a systematic uptake of process mining beyond targeted case studies in a research context. When developing and using process mining in healthcare, distinguishing characteristics of healthcare processes such as their variability and patient-centred focus require targeted attention. Against this background, the Process-Oriented Data Science in Healthcare Alliance has been established to propagate the research and application of techniques targeting the data-driven improvement of healthcare processes. This paper, an initiative of the alliance, presents the distinguishing characteristics of the healthcare domain that need to be considered to successfully use process mining, as well as open challenges that need to be addressed by the community in the future.This work is partially supported by ANID FONDECYT 1220202, Dirección de Investigación de la Vicerrectoría de Investigación de la Pontificia Universidad Católica de Chile - PUENTE [Grant No. 026/ 2021]; and Agencia Nacional de Investigación y Desarrollo [Grant Nos. ANID-PFCHA/Doctorado Nacional/2019–21190116, ANID-PFCHA/ Doctorado Nacional/2020–21201411]. With regard to the co-author Hilda Klasky, this manuscript has been authored by UT-Battelle, LLC, under contract DE-AC05-00OR22725 with the US Department of Energy (DOE). The US government retains and the publisher, by accepting the article for publication, acknowledges that the US government retains a nonexclusive, paid-up, irrevocable, worldwide license to publish or reproduce the published form of this manuscript, or allow others to do so, for US government purposes. DOE will provide public access to these results of federally sponsored research in accordance with the DOE Public Access Plan (http://energy.gov/downloads/doe-public-accessplan).Peer ReviewedArticle signat per 55 autors/es: Jorge Munoz-Gama (a)* , Niels Martin (b,c)* , Carlos Fernandez-Llatas (d,g)* , Owen A. Johnson (e)* , Marcos Sepúlveda (a)* , Emmanuel Helm (f)* , Victor Galvez-Yanjari (a)* , Eric Rojas (a) , Antonio Martinez-Millana (d) , Davide Aloini (k) , Ilaria Angela Amantea (l,q,r) , Robert Andrews (ab), Michael Arias (z) , Iris Beerepoot (o) , Elisabetta Benevento (k) , Andrea Burattin (ai), Daniel Capurro (j) , Josep Carmona (s) , Marco Comuzzi (w), Benjamin Dalmas (aj,ak), Rene de la Fuente (a) , Chiara Di Francescomarino (h) , Claudio Di Ciccio (i) , Roberto Gatta (ad,ae), Chiara Ghidini (h) , Fernanda Gonzalez-Lopez (a) , Gema Ibanez-Sanchez (d) , Hilda B. Klasky (p) , Angelina Prima Kurniati (al), Xixi Lu (o) , Felix Mannhardt (m), Ronny Mans (af), Mar Marcos (v) , Renata Medeiros de Carvalho (m), Marco Pegoraro (x) , Simon K. Poon (ag), Luise Pufahl (u) , Hajo A. Reijers (m,o) , Simon Remy (y) , Stefanie Rinderle-Ma (ah), Lucia Sacchi (t) , Fernando Seoane (g,am,an), Minseok Song (aa), Alessandro Stefanini (k) , Emilio Sulis (l) , Arthur H. M. ter Hofstede (ab), Pieter J. Toussaint (ac), Vicente Traver (d) , Zoe Valero-Ramon (d) , Inge van de Weerd (o) , Wil M.P. van der Aalst (x) , Rob Vanwersch (m), Mathias Weske (y) , Moe Thandar Wynn (ab), Francesca Zerbato (n) // (a) Pontificia Universidad Catolica de Chile, Chile; (b) Hasselt University, Belgium; (c) Research Foundation Flanders (FWO), Belgium; (d) Universitat Politècnica de València, Spain; (e) University of Leeds, United Kingdom; (f) University of Applied Sciences Upper Austria, Austria; (g) Karolinska Institutet, Sweden; (h) Fondazione Bruno Kessler, Italy; (i) Sapienza University of Rome, Italy; (j) University of Melbourne, Australia; (k) University of Pisa, Italy; (l) University of Turin, Italy; (m) Eindhoven University of Technology, The Netherlands; (n) University of St. Gallen, Switzerland; (o) Utrecht University, The Netherlands; (p) Oak Ridge National Laboratory, United States; (q) University of Bologna, Italy; (r) University of Luxembourg, Luxembourg; (s) Universitat Politècnica de Catalunya, Spain; (t) University of Pavia, Italy; (u) Technische Universitaet Berlin, Germany; (v) Universitat Jaume I, Spain; (w) Ulsan National Institute of Science and Technology (UNIST), Republic of Korea; (x) RWTH Aachen University, Germany; (y) University of Potsdam, Germany; (z) Universidad de Costa Rica, Costa Rica; (aa) Pohang University of Science and Technology, Republic of Korea; (ab) Queensland University of Technology, Australia; (ac) Norwegian University of Science and Technology, Norway; (ad) Universita degli Studi di Brescia, Italy; (ae) Lausanne University Hospital (CHUV), Switzerland; (af) Philips Research, the Netherlands; (ag) The University of Sydney, Australia; (ah) Technical University of Munich, Germany; (ai) Technical University of Denmark, Denmark; (aj) Mines Saint-Etienne, France; (ak) Université Clermont Auvergne, France; (al) Telkom University, Indonesia; (am) Karolinska University Hospital, Sweden; (an) University of Borås, SwedenPostprint (published version

Process mining for healthcare: Characteristics and challenges

[EN] Process mining techniques can be used to analyse business processes using the data logged during their execution. These techniques are leveraged in a wide range of domains, including healthcare, where it focuses mainly on the analysis of diagnostic, treatment, and organisational processes. Despite the huge amount of data generated in hospitals by staff and machinery involved in healthcare processes, there is no evidence of a systematic uptake of process mining beyond targeted case studies in a research context. When developing and using process mining in healthcare, distinguishing characteristics of healthcare processes such as their variability and patient-centred focus require targeted attention. Against this background, the Process-Oriented Data Science in Healthcare Alliance has been established to propagate the research and application of techniques targeting the data-driven improvement of healthcare processes. This paper, an initiative of the alliance, presents the distinguishing characteristics of the healthcare domain that need to be considered to successfully use process mining, as well as open challenges that need to be addressed by the community in the future.This work is partially supported by ANID FONDECYT 1220202, Direccion de Investigacion de la Vicerrectoria de Investigacion de la Pontificia Universidad Catolica de Chile-PUENTE [Grant No. 026/2021] ; and Agencia Nacional de Investigacion y Desarrollo [Grant Nos. ANID-PFCHA/Doctorado Nacional/2019-21190116, ANID-PFCHA/Doctorado Nacional/2020-21201411] . With regard to the co-author Hilda Klasky, this manuscript has been authored by UT-Battelle, LLC, under contract DE-AC05-00OR22725 with the US Department of Energy (DOE) . The US government retains and the publisher, by accepting the article for publication, acknowledges that the US government retains a nonexclusive, paid-up, irrevocable, worldwide license to publish or reproduce the published form of this manuscript, or allow others to do so, for US government purposes. DOE will provide public access to these results of federally sponsored research in accordance with the DOE Public Access Plan (http://energy.gov/downloads/doe-public-access-plan)Munoz Gama, J.; Martin, N.; Fernández Llatas, C.; Johnson, OA.; Sepúlveda, M.; Helm, E.; Galvez-Yanjari, V.... (2022). Process mining for healthcare: Characteristics and challenges. Journal of Biomedical Informatics. 127:1-15. https://doi.org/10.1016/j.jbi.2022.10399411512