Informatics Experts Taking New Approach to Shareable Clinical Pathways

Feb. 26, 2020
One key use case for BPM+Health is to ease dissemination of clinical policies and recommendations from specialty societies to clinical settings

One of the challenges of the Veterans Administration’s transition from its VISTA platform to Cerner was that over many years the VA had hard-coded more than 1,200 clinical pathways into VISTA. VA informaticians sought the best way to communicate with the Cerner engineers about what they wanted in the build-out. The standard they eventually chose to use for workflow, Business Process Model and Notation (BPMN), is now starting to gain momentum, with a new organization of informatics heavy hitters in an organization called BPM+Health developing ways to create shareable clinical pathways.

Widely used in other industries, BPMN is a “formal graphical and computable language that was developed to diagram processes that are performed by teams of people who must coordinate their activity while using computing to support both information work and physical activities that use and change information,” according to a description in the Field Guide to Shareable Clinical Pathways. A key goal is to foster community building among all types of stakeholders. The use of a well-defined standard to create workflow diagrams promotes a common understanding of their meaning by different participants.

BPM+ Health is a community managed by the Object Management Group, an international, open membership, not-for-profit technology standards consortium.

Stephen Hasley, M.D., former chief medical informatics officer at the American College of Obstetricians and Gynecologists (ACOG) and now CMIO of BPM+Health, was involved in the VA effort. He noted that the problem was tricky because half the veterans get care outside the VA, although the VA pays for their care, so they want to guide and measure it. “This artifact you hand over to Cerner has to be standards-based and consumable by multiple digital platforms,” Hasley said. “We took two years to build models in BMPN and make it do what we needed it to do. The result was the recognition that a standardized notation would be capable of describing clinical pathways, and out of that we also wrote the Field Guide. After that effort, we were pretty sure we could use this.”

People responsible for health system knowledge management and dissemination are taking a strong interest in BPMN’s potential. Jane Shellum is the section head for the Knowledge Management and Delivery Program at Mayo Clinic. “We are accountable for essentially knowing what Mayo Clinic knows,” she said, “including capturing its best practices, our guidelines, our experts’ approaches to practicing medicine, capturing, structuring, annotating and storing it, and finally and most importantly, delivering that knowledge to the point of care in the context of individual patients.”

Why did Shellum choose to get involved in BPM+Health? “We were successful at capturing that expertise in human-readable form. We have an extensive database of core clinical knowledge and a system the clinicians can query, but they have to search for that information,” she explained. “We were motivated to try to get that information into the work flow. To do that, we knew we needed to make that knowledge computable.” Mayo Clinic looked around at what other organizations had done, she said. “Really, for a long time it has been done through computer code; it is a heavy lift, and it is a one-off. Quite frankly, I stumbled on the first meeting of the BPM+Health community. Someone said I should check these guys out. They are applying these standards for representing processes to healthcare.” Now she co-chairs the group’s adoption work group with the Regenstrief Institute’s Theresa Cullen, M.D., M.S.

 The approach Mayo Clinic is taking demonstrates the flexibility of the standards, Shellum said. They are looking at cognitive support for complex clinical decisions that are not easily computable. People tend to think of clinical decision support as alerts and reminders about gaps in practice. “We are using the standards to address those,” she said, “but also using Decision Model and Notation (DMN) to support naturalistic decision making. For every decision that the computer can provide advice on, there are 100 that it can’t. We are using DMN to inform decision-making. DMN formalizes all the inputs needed to make a decision and formalizes how a decision can be made. You can do that with computable language — if this is true and this is true, then this thing should happen. You can also have human-readable content — taking snippets of best practices and guidelines and marrying them up with relevant patient data summarized and presented in a way that the clinician can see all the relevant data and a concise, actionable piece of content that describes how to make the decision.”

Another key use case is transmitting and updating clinical policies and recommendations from specialty societies to clinical settings more readily. Pawan Goyal, M.D., associate executive director for quality at the American College of Emergency Physicians, gave a clear example. ACEP has developed 20 clinical policies of its own and endorsed 500 other cross-functional policies from groups like the American Diabetes Association.

“Our chest pain policy is a 70-page PDF document detailing what to do when a patient comes into an emergency department with chest pain. Today clinicians seeking information have to refer to that PDF on the ACEP website or the hospital’s website before taking action.  “They do not have a digital version of these clinical pathways automatically integrated into clinical workflow or the EHR vendor’s solution,” Goyal said.  

The EHR vendors do try to do that integration, so Epic will hire information architects, download the policy and try to build software logic around those pathways. Cerner will do the same. Allscripts will do the same. Everyone’s engineers interpret them in different ways and build different work flows, which are often in conflict,” he said. “That is where the opportunity is for us. If ACEP can take leadership in building those clinical pathways and digital solutions around those pathways, and then the EHR vendors could include them in their solutions without having to create separate interpretations. It would also save them from having to maintain them, because those policies change all the time when the FDA issues new guidance about drugs, for instance. We issue updates to our policies every few years. These vendors have to rebuild their software and pathways based on the new policies. We are trying to take leadership on the upfront work.”

Hasley said ACOG also is using BPMN to communicate with a developer called Dorsata creating an app that sits on top of the EHR. “We built out over 100 care pathways for antenatal care — all the things than go wrong with pregnancy,” he said. “BPMN is now how ACOG is communicating with that startup to put these care pathways into their app build. The care pathway can contain data elements, decision support rules, actual decisions and calculations, and the work flow. We have this app in the hands of 1,200 doctors today.” He said this approach will also contribute to the creation of a learning health system. “We are accumulating data that is going to let us take the recommendation engine to the next level,” Hasley explained. “Instead of relying on prospective trials with small numbers and single sites, now we can rely on real world evidence to enhance making our recommendations.”

BPM+Health ambassadors are going to be making several presentations at the upcoming HIMSS Conference in Orlando in March. Here are some details:

Veteran Care without Boundaries - Demonstrates the automation and orchestration of the U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines for Chronic Kidney Disease (CKD) using industry standards. Veterans’ journeys will be orchestrated in real time: identifying emerging risks, mitigating CKD impacts and preventing a lifetime of costly dialysis appointments. It includes end-user application workflow integration and plug n’ play clinical decision support (CDS) tools from an ecosystem of partners. BPM+ Health member participants: Perspecta, RedHat, Trisotech and MDIX.

Location: Interoperability Pavilion; Time: Tours start every 45 minutes

Care without Boundaries: Using Standards to Automate Data, Knowledge and Process Exchange across a Federated Landscape - Focuses on the incorporation of the standards for terminology, data exchange, process automation and knowledge endpoints to automate the delivery of best practice guidelines across the patient's journey to make healthcare cheaper, better, faster and more satisfying for all stakeholders. BPM+ Health member participants: University of Utah, industry supporter HSPC and Perspecta Labs.

Location: Interoperability Showcase Education Theater; Time: Tuesday, March 10, from 1:30pm - 2:30pm

A Shareable Clinical Pathway for Anemia Management - shareable clinical pathway is a visual decision model that is both human readable and machine automatable. Such a standardized workflow can improve the efficiency and quality of healthcare processes. Session presents models for the diagnosis and management of anemia and demonstrates the automation capability of BPM+ Health. This session is led by BPM+ Health member Trisotech.

Location: Innovation Live, Theater; Time: Wednesday, March 11 from 11:45am - 12:05pm

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