In the paper beneath, we present the need for shareable clinical pathways in healthcare. If you want to get involved, contact us and also join our mailing list!
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Gabe strives to create innovative solutions to solve real-world problems effectively. Currently he’s focused on improving Radiation Oncology and healthcare workflow and interoperability, with previous experience in the defense industry, quantum computing, and healthcare. He holds a B.S. in Engineering Physics from Colorado School of Mines and an M.S. in Medical Physics from Oregon Health & Science University. He is also certified by the American Board of Radiology in Therapeutic Medical Physics. He resides in Bend, OR where he enjoys the beautiful outdoors hiking, climbing, and camping with his wife and kids.
Before starting our tutorials on creating shareable clinical pathways, hopefully you have already read our post on A Vision for the Future of Workflow in Healthcare. If not, you should check it out to set the context of the standards we will use in these tutorials such as Business Process Model and Notation, Decision Model and Notation, Case Management Model and Notation, and Fast Healthcare Interoperability Resources to create shareable clinical pathways. The models in these tutorials may be deployed and executed in our RO Dynamics platform, or in other commercial or opensource BPM tools. For more information visit our product page at https://quanteksystems.com.
In this series we will work with examples in the context of Radiation Oncology, which uses radiation to treat cancer. The goal is to help those involved in healthcare to understand how to read and create basic workflows using BPMN. Knowledge of radiation oncology is not required, but will make the workflows more interesting. We will start with simple workflows, and over time get more elaborate to handle the nuances of real-world workflows.
Often the best way to learn something new is by doing it. Perhaps the easiest way to get started is using the free web-based modeler at http://bpmn.io. To create a new BPMN model you may use this link: https://demo.bpmn.io/new. Alternately, you may download a free modeler such as the Camunda Modeler.
Let’s now dive in to creating shareable clinical pathways. As more tutorials are added, they will be accessible beneath for easy navigation.
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Gabe strives to create innovative solutions to solve real-world problems effectively. Currently he’s focused on improving Radiation Oncology and healthcare workflow and interoperability, with previous experience in the defense industry, quantum computing, and healthcare. He holds a B.S. in Engineering Physics from Colorado School of Mines and an M.S. in Medical Physics from Oregon Health & Science University. He is also certified by the American Board of Radiology in Therapeutic Medical Physics. He resides in Bend, OR where he enjoys the beautiful outdoors hiking, climbing, and camping with his wife and kids.
At Quantek Systems we seek to keep innovating how workflows in Radiation Oncology are implemented to increase efficiency, improve patient outcomes, and reduce costs. We’re excited to preview RO Dynamics 2.0 at AAPM in San Antonio, Tx booth # 847 to present our latest advances in workflow orchestration.
Highlights include:
An advanced visual workflow engine to direct both human and automated tasks
Direct workflows and decisions based on treatment site, technique, and more
Visual plan list indicates the status of key plan steps including approved/rejected, and passed/failed
Brand new Workload Assistant – Visualize planner and machine workloads to aid in balanced assignment
Builtin chat to streamline communication between individuals, teams, and roles
We will first begin with modeling shareable clinical pathways using the Business Process Model and Notation (BPMN) standard. If you want to follow along, please see the introductory post to this series for links to free modeling tools you can immediately use.
In this tutorial we will model a basic radiation therapy consult workflow from the perspective of the radiation oncologist. The final end result of the workflow is shown beneath.
Basic Radiation Therapy Consult Workflow in BPMN
To create the workflow yourself follow the tutorial using a BPMN modeling tool such as at bpmn.io. If you need help, watch the video beneath where we show the entire model creation.
Please note that in BPMN the term “process” is used, rather than workflow. We may use the terms interchangeably throughout this series, but in the BPMN terminology we use processes to implement the workflows.
One of the great aspects of BPMN is it makes workflows transparent, and easily understandable by even those without training in BPMN. If you have no experience in BPMN, you can probably understand the workflow in the diagram. Even better, is the workflow isn’t hard-coded and embedded in software code that is not available to the user, and would be difficult to understand even if it were available.
In this process we have a single lane denoting the radiation oncologist as the participant. We could have other participants with their own lanes, such as the patient, and other clinical staff such as nurses. For now we will stick with one participant.
Step 1: Create a lane and name it “Radiation Oncologist”.
This process starts with a New Patient Consult Started event. In BPMN events are depicted by a circle. In this case we have a start event, denoting the start of the process. In a process being executed by software, the start event could be triggered manually through a user interface, or automatically when a patient checks in for their consult. Once started, the workflow executes.
Step 2: In the lane create a start event and label it “New Patient Consult Started”.
Once the process starts the first step is a consult between the radiation oncologist and the patient. This is modeled as a user task in BPMN. Tasks of various kinds all have a rounded rectangle. The person icon indicates this is a user task, to be performed by a person. The process waits until this task is complete before proceeding. In software this could be completed manually from a task list, or it could be completed automatically when the patient checks out from the consult. These are implementation details beyond the current scope.
Step 3: Create a new user task, and label it “Consult with Patient”. Make sure the start event is connected to this task.
Once the consult task is complete, the radiation oncologist must determine if radiation therapy is indicated. In the present example we will assume that if radiation therapy is indicated the patient also decides to undergo radiation therapy. In a more realistic model we would also handle the decision from the patient. The decision if radiation therapy is indicated would be selected by the radiation oncologist in a user interface as a simple Yes/No choice.
Step 4: Create a new user task and label it “Determine if Radiation Therapy Indicated”. Make sure the consult task is connected to this new task.
Once the decision is made regarding if radiation therapy is indicated, there are two different flows. BPMN uses gateways with a diamond shape to direct flows within a process. Decisions are not made in gateways, but must happen before the gateway. In this example an exclusive gateway, also know as XOR is used, which only allows one path to be executed out of the gateway.
Step 5: Create a new XOR gateway, and connect the previous task to it. Set the label for the gateway to “Radiation Therapy Indicated?”.
In the current example if radiation therapy is not indicated, we end the consult and for the sake of this example, assume there is nothing further to do in this workflow. If radiation therapy is indicated, a Start Radiation Therapy event will be generated, using a BPMN signal event depicted by two circles with a solid triangle in the middle. Signal events broadcast to other processes to react to. In this case a separate process could be triggered from this signal to start a new radiation course workflow automatically. Finally, once the signal is generated, the process ends with an end event.
Step 6: Create an end event beneath the gateway and label it “Patient Consult Ended”. Connect the gateway to the event, and mark the flow as the default. Finally, label the flow “No”.
Step 7: Create a signal event to the right of the gateway and label it “Start Radiation Therapy Course”. Finally, create an end event and label it “Patient Consult Ended”.
Your workflow should now look like our diagram, and you have created a basic clinical workflow. To make it executable, one would normally add a few more details, such as the candidate group for the task (radiation oncologist), as well as create the implementation details for the start new radiation course signal.
In this tutorial you have been introduced to the following BPMN symbols: lanes, start/signal/end events, user tasks, and XOR gateways. To learn more, follow our blog and we also encourage you to sign up for our mailing list.
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We will never send you spam and you can unsubscribe anytime.
Gabe strives to create innovative solutions to solve real-world problems effectively. Currently he’s focused on improving Radiation Oncology and healthcare workflow and interoperability, with previous experience in the defense industry, quantum computing, and healthcare. He holds a B.S. in Engineering Physics from Colorado School of Mines and an M.S. in Medical Physics from Oregon Health & Science University. He is also certified by the American Board of Radiology in Therapeutic Medical Physics. He resides in Bend, OR where he enjoys the beautiful outdoors hiking, climbing, and camping with his wife and kids.
Radiation Therapy Treatment Planning Workflow in BPMN
Prior to focusing full-time on developing our digital whiteboard and workflow orchestration platform RO Dynamics, I worked as a clinical physicist in radiation oncology. I enjoyed working in radiation therapy as it allowed me to directly apply my background in physics and engineering. I was able to be part of a team helping to improve and save the lives of those who have been diagnosed with cancer in the region that I live. Cancer directly affects the lives of many of those around us, and indirectly affects many more. While there has been marked improvement in treatment, there is further to go.
Radiation therapy as a field has made significant progress since its first inception around 100 years ago. We’re still learning more every day about cancer, radiobiology, and better methods to treat cancer with radiation. The technological improvements in both the machines and software of the last 20 years has been amazing. However, one of the areas that does not receive as much attention is clinical workflow.
One of the challenges that I faced in the clinic, as do many others, is how to coordinate patient care as a team from consult to the end of treatment. Generally, this is not particularly challenging when the clinic has a single linear accelerator and doesn’t have a high volume of patients as one can keep quite a bit of information in their head or use personal methods to track what needs to be done. However, there are a variety of circumstances that can significantly compound the challenges in knowing what needs to be done, when it needs to be done, and knowing key information to get it done right. Some of the contributing circumstances include:
High patient volumes
Emergent treatments and changes to treatment plans
Patient specific information such as a pacemaker or previous radiation
Remote coverage across clinics within a healthcare system
Special Procedures (SRS, SBRT, IORT, LDR, HDR)
Projects to install, accept, commission, upgrade, and maintain equipment, machines, and software
Lack of easy to understand policies and procedures or adherence to them
Staff in and out of the department due to meetings, specialty procedures, vacation, or illness
Too many communication methods – whiteboards, excel sheets, sticky notes, email, text messages, health information systems
These circumstances can make it challenging for staff to be notified or discover important patient and treatment plan information such as:
Prescription changes
Scheduling changes
Plan Changes
Plans failing quality assurance
Cardiac implanted electronic devices
Previous radiation
Technical mistakes
Cancelled or partially delivered treatments
Necessary Insurance pre-authorizations
The unintended consequences of these challenges vary, but may include:
Delays or missed task completion
Down stream staff having to rush to complete tasks
Increased probability of making mistakes ranging from insignificant to decreased tumor control, or adverse clinical outcomes
Lack of useful data to analyze processes for improvement
Billing mistakes
In order to minimize these consequences and streamline department workflow and communication, clinicians need standardized, transparent workflows that can be customized for their departments needs and automated as much as possible by software. Even though policies and procedures to document workflow typically exist, they are often buried in a document somewhere, out of date, inconvenient to locate and reference, and often in a textual form that makes the overall high-level workflow hard to understand. The result is evolving workflows that are inconsistently executed and poorly understood. Even worse, these are mostly manually executed, and not automatable by software. Where automation does exist, it is done in proprietary workflow methods with limited functionality in oncology or health information systems. The latest configuration and historic changes of such mechanisms is typically not documented clearly in procedures and often out of date. Furthermore, being proprietary, these automation mechanisms are not transferable if a department switches software vendor, having to start from scratch to rebuild workflows.
Is there a better way to document and implement workflows without reinventing the wheel? I believe there is through existing standards used widely outside of healthcare. Look no further than the business world where standards have been widely adopted and implemented. Perhaps the most widely adopted standards in the business process world that can be applied to healthcare are Business Process Model and Notation (BPMN), and Decision Model & Notation (DMN). These standards provide standardized models and graphical symbols to define business processes that are readily understandable by all stakeholders, whether the end user, manager, or technical developer. Rather than processes being buried in textual descriptions, processes are transparently understood by visual diagrams. Even better, these models are potentially executable and automated by software in a vendor-neutral manner. These standards can be applied to many areas within healthcare.
In order to solve workflow challenges in Radiation Oncology, and broader healthcare, I believe we need to adopt existing relevant standards that enable customizable, shareable, vendor-neutral workflows and clinical pathways which is why our digital whiteboard platform, RO Dynamics, incorporates both BPMN and DMN. I am not alone in this view. In fact, the organization BPM+ Health (https://www.bpm-plus.org/) was created to make this a reality, and is composed by a community of clinicians, hospitals, universities, government agencies, and vendors working together with a common vision for the future of workflow in healthcare. Let’s work together to build a better future for clinicians, and ultimately patients.
To follow our journey at Quantek Systems to provide vendor neutral shareable workflows and clinical pathways with our software platform RO Dynamics, follow our blog. If you are interested in getting involved, please reach out to us!
Stay in the know about our new products and updates:
We will never send you spam and you can unsubscribe anytime.
Gabe strives to create innovative solutions to solve real-world problems effectively. Currently he’s focused on improving Radiation Oncology and healthcare workflow and interoperability, with previous experience in the defense industry, quantum computing, and healthcare. He holds a B.S. in Engineering Physics from Colorado School of Mines and an M.S. in Medical Physics from Oregon Health & Science University. He is also certified by the American Board of Radiology in Therapeutic Medical Physics. He resides in Bend, OR where he enjoys the beautiful outdoors hiking, climbing, and camping with his wife and kids.
Come check out the latest features in RO Dynamics at ASTRO 2018 to see how it enables Radiation Oncology departments implement, analyze, and streamline their processes. We’ll be at booth #3951!
At Quantek Systems we seek to keep innovating how workflows in Radiation Oncology are implemented to increase efficiency, improve patient outcomes, and reduce costs. We’re excited to preview RO Dynamics 2.0 at AAPM in San Antonio, Tx booth # 847 to present our latest advances in workflow orchestration.
Highlights include:
