gms | German Medical Science

Background: Research on clinical pathways showed great benefit for patient outcome and cost effectiveness. However, until now they are rarely supported by computer-based assistance systems. On the same time a continuously growing amount of patient information in electronic health records, clinical studies and treatment guidelines lead to an information overflow in the daily routine of surgeons. Furthermore, economic pressure leads to a higher number of patients per surgeon. Therefore the need is obvious for a standardized model of perioperative treatment pathways that is computer-based. This can be used to provide the surgeon with the right information about guidelines for the right patient in the right phase of treatment.

Materials and methods: To lay the foundation for a standardized perioperative treatment pathways, this approach concentrated on the modeling processes in the perioperative surgical treatment setting. The treatment process of a rectal cancer patient was chosen and modeled with the Business Process Model and Notation (BPMN). As modeling tool a Semantic MediaWiki with a BPMN extension for collaborative modeling was used to annotate visual diagrams with additional process information. To ensure realism of the models work shadowing at the surgical department was performed. Afterwards, the model was discussed and refined in interviews with experienced surgeons.

To adapt BPMN to the surgical domain, new annotation objects were developed for the specific surgical modeling problems leading to a surgical BPMN (sBPMN). Then these annotation objects were applied to the existing process models.

Results: The whole perioperative treatment process was modeled on five levels of granularity (disease, treatment phase, organizational unit, procedure, task). In total N=52 tasks in surgical treatment of rectal cancer patients were modeled in one sBPMN-diagram each. sBPMN including three new annotation objects specifically for modeling surgical processes.

Conclusion: The use of BPMN in modeling surgical processes has already been established in various approaches in clinical process modeling. However, our experiences in modeling with BPMN showed that there are missing annotations to fully represent the reality of a surgical process in a model. This is because BPMN was developed primarily for processes in business and industry. Thus, annotations in BPMN do not consider specific challenges of modeling processes in surgery. Therefore, processes of rectal cancer treatment were modeled with a set of new annotation objects. These have been used to extend BPMN to the proposed sBPMN and the usability has been verified by experienced surgeons and process modelers. This process language represents a refined tool to model processes as a foundation for development of standardized perioperative treatment pathway. In future work sBPMN will be used for modeling other surgical treatment processes such as for pancreatic cancer treatment. Such a standardized model for describing perioperative treatment processes can support establishment of clinical pathways certified surgical centers.

Acknowledgment

This research has been funded by the German Research Foundation DFG within the Transregional Collaborative Research Center 125 “Cognition-Guided Surgery”, projects I01 and A01 and by the Medical School of Heidelberg University with a Physician-Scientist-Fellowship for Martin Wagner.