Modernization of Patient Care Management

The current United States healthcare system is in transition from an era driven by paper records, human paper-handling and telephone calls, to an of era of electronic health records, people connected through mobile devices and the Internet, with moment-to-moment collaboration, communication and coordination.

In this article, I discuss a potential patient care system that exploits current computing and communications technology to transform healthcare delivery to a more integrated, responsive and efficient system.  I begin with related observations on the current state of the healthcare system, followed by a list of principles for an improved system, and finally I discuss modernization based on current information technology.  I conclude with references to current standards work that enables this transformation.

The Current System

Below, I focus on four fundamental problems with the current healthcare system: (1) care management is fragmented and inefficient, and (2) there is a failure of competition, (3) adoption of new medical technology is too slow, and (4) automation is preserving legacy systems.

1.      Fragmentation.  Healthcare providers tend to operate in silos, delivering their special capabilities.  An individual’s healthcare records are scattered among different providers.  The patient becomes the inefficient courier of records and medical information.  There is minimal coordination of care among specialists.  Tests are often duplicated, and risks of interactions may be overlooked.  Providers do not have incentives to share records with other providers.

2.      Competition.  Providers do not compete for patients based on service quality and price. Under capitation-based, managed care, patients choose providers from the payer’s network.  Providers are paid a fee for each covered patient, so they have incentives to minimize services and avoid patients with high service needs.  Under fee-for-service, providers are paid for performing services; more services generate higher income.  They receive the negotiated rates regardless of the quality of care.  Patients only see their deductibles, co-pays and denials of coverage, and they are not informed purchasers of healthcare services.  Unlike other markets, cost and quality have minimal impact on a patient’s treatment decisions or choice of provider.

3.      Technology transfer.  Transfer of new medical technology, including new services and procedures, from research to practice is hampered by many factors including FDA approval, denial of insurance coverage, provider business risk, resistance to change, and malpractice lawsuits.  The market does not reward rapid adoption of advanced medical technology. 

4.      Legacy systems.  Information technology has had a significant impact on medical testing and diagnosis, but, for the most part, it has not changed the way care is managed.  Automation of legacy systems solidifies conventional methods and may make the overall healthcare system more difficult to change.  While paper has been converted to electronic data and data is entered and viewed using electronic devices.  Patient records are more vulnerable to electronic intrusion, and the management of patient care remains unnecessarily fragmented, unresponsive, inconsistent and inefficient.

These problems require transformation of the healthcare system.  In this article I focus on one aspect—transformation of the way patient care is managed.

Key principles

Of course there are many principles for good healthcare.  The following principles are particularly relevant to patient care management. 

Market-Driven Improvements

For effective competition, provider pricing and quality improvements should be driven by market demand as expressed by patients.  Treatment decisions by patients should reflect consideration of cost as well as performance of providers.  Providers should be free to charge what they believe their services are worth, and consumers should be able to select a more expensive service that exceeds their coverage if they believe the value of the service to them merits the additional cost.  Demand from patients who are willing to accept the increased cost and potential risks of new technology should drive adoption of new technology as a competitive necessity.

Informed Consumers

Patients (consumers) should make informed decisions in their selection of care providers and treatment options.  Physicians are responsible for educating a patient about their treatment needs and options.  Costs and outcomes of procedures and medical conditions, including availability of advanced technology, should be published using standard categories and designations so they can be compared across providers.  A consumer should be able to consider providers and treatment alternatives along with the net out-of-pocket cost reflecting their insurance coverage.

Physician Leadership

Coordination of care requires medical expertise.  A primary care physician and his/her team should have responsibility for the overall health of a patient and coordination of care.  Primary care physicians must know when a patient should be referred to a specialist, must have an incentive to refer rather than treat, and must track and coordinate care.

Collaboration

The patient, the primary care physician and specialists, along with their respective teams, must collaborate to provide appropriate planning and treatment for the whole person.  Collaborative planning and follow-up should be life-long (at a level of intrusion determined by the patient) addressing not only acute and chronic care, but also health monitoring and preventive care.

Development of Best Practices

Generally, physicians develop their own best practices.  Professional groups must collaborate to define, share and continuously improve industry best practices.  This includes adoption of advanced technology and improvements to performance measures.  Acceptance of best practices should be supported by empirical data on performance and outcomes from controlled trials.  Performance measures and associated reimbursements must provide appropriate incentives for utilization and improvement of best practices.

Risk Management

Outcomes must be analyzed and rules must be formulated to define and manage risks.  Risk should be assessed based on patient circumstances and alternative technologies, while considering regulations, medication interactions, contraindications and conditions requiring immediate attention.  Risk data should be available for professionals and patients considering treatment options.

Medical Records

Patients and personnel of their authorized medical teams, as appropriate to their individual roles, must have timely access to the patient’s current medical records from all sources.  Even though individual providers go out of business, lifetime patient records must be available to support diagnosis and treatment as well as research. Reliable security methods must ensure privacy of patient medical records and enable the patient to restrict access by professionals based on need to know.  Providers must accept that patient records belong to the patient, and records must be available to support diagnosis and treatment by other providers.

You Get What You Pay For

Quality care requires extra effort to educate patients, collaborate with treatment teams, develop best practices and share medical records.  These efforts must be paid for or they won’t happen.

Application of Information Technology

Information technology is changing the way the world works.  The cost of computers, communications and data storage have become negligible.  Individuals can be always connected through mobile devices.   Computers can help improve timeliness, consistency, validation, guidance and retrieval of information, and they can alert professionals to emergent conditions and the availability of relevant information.  Computers can also relieve professionals of tedious, repetitive tasks, ensuring that they are performed in a timely and accurate manner. 

My previous article describes a vision of “The Knowledge Worker Cockpit.”  Healthcare professionals are knowledge workers.  That technology is a basis for the following characteristics of a future care management system.

Engagement of Services

Consistent data on provider rates and outcome statistics as well as availability of new technology should be publicly accessible, particularly in support of patient selection of a provider.  Web services should support comparison of out-of-pocket costs of different providers based on the coverage schedule of a patient’s payer.  As a result, providers will compete for patient business.  The patient should be able to proceed to schedule a doctor’s appointment and obtain preliminary tests based on symptoms, medical records and potentially a teleconference with a medical professional (see telehealth, below). 

Collaboration

Collaboration is an important and often overlooked element of good patient care management.  A primary care physician should collaborate with specialists, and each physician should collaborate with his or her team.  Some collaborations may engage international experts in teleconferences.  Information technology can support collaboration through communication of messages as well as scheduling and support of meetings and teleconferencing.  This may be obvious in a hospital setting, but it should continue in community care and through transitions between community and hospital care.

Telehealth

Telehealth supports some aspects of healthcare remotely, using electronic devices and communications.  This includes devices for monitoring vital signs and other symptoms as well as support for collaboration between patient and professionals.  Patients, particularly in remote areas, may resolve some health problems without the necessity of travelling to an office, clinic or hospital.  For others with chronic conditions, it provides monitoring of symptoms that might otherwise require hospitalization.  The data collected by electronic sensors or patient inputs can be sent directly to a care management system for monitoring and initiation of alerts to professionals if important changes occur in the condition of the patient.

Treatment Planning and Coordination

The care management system will be highly interactive and support collaboration on treatment planning and decision-making.  Pre-defined planning elements will include guidance and constraints, links to defined services (e.g., lab tests) and frequently occurring patterns of activities applicable to particular situations or medical conditions, including best practices.  Individuals doing treatment planning may capture frequently used tasks and patterns of activities in their personal libraries to expedite their planning efforts.  Treatment plans can be developed and changed as the patient’s circumstances evolve.

Timely Response

Automated plan management will provide personal schedules along with follow-up actions on events such as alerts on over-due activities, reports of relevant information, and completion of pre-requisite activities. Critical changes in the condition of a patient can trigger alerts or corrective action to ensure that appropriate action is taken in a timely fashion.  Appropriate professionals or their alternates can be notified immediately regarding key events via mobile devices.

Electronic Health Record

There has been much attention to the development of electronic health records (EHR).  The primary care physician, the specialists and their teams must all have access to a consistent, shared EHR (not necessarily stored in one location).  A patient HER should provide access to all current medical information and should be retained, under patient control, for a lifetime medical history. The system will apply standards for the form of various types of records or transformation of records from different sources to a consistent form.  It also will support timely communication of updates.  Records must be accessible to authorized personnel only to the extent authorized by the patient.  Authorization and withdrawal of authorization must extend to all sites where a patient’s records may be accessed or replicated.

Audit Trail

The care management system will generate an electronic audit trail of activities performed, events that occurred, decisions made, and the associated circumstances as defined by the EHR.  The system should provide the ability to reconstruct a case snapshot that reflects the state of the case at a particular point in time as the context for events, activities and decisions.  An audit trail will also track individual accesses to medical records for privacy assurance.  Records on services to individual patients will provide the basis for reimbursement for services, including services delivered through remote monitoring, teleconferences or other means that do not require a physical meeting of the physician and patient.   

Analysis                                                                                                       

Computer-based analysis of treatment histories will provide insights on treatments, health trends, causes of medical conditions, and best practices.  The care management system will provide data on actual practices and outcomes to support identification and improvement of best practices and analysis of risks.  Applications will support analysis of outcomes, costs and timeliness of procedures as well as identification of factors related to variances in treatment, outcomes and total costs of treatment for specific medical conditions. 

Guidance

Interactive guidance can provide support for use of best practices and can both encourage and support consideration of new technology.  Guidance can be provided in terms of task requirements, planning and decision-making alternatives, risk and cost factors and contingency plans for emergent conditions.   Guidance may be triggered by the initiation of certain activities, or it may be determined by automated reasoning triggered by events and based on the patient’s EHR.  A more sophisticated system may “learn” case circumstances when certain activities or patterns are often initiated and suggest them to physicians. The system may also inform the physician of current trends or epidemics that may be relevant to the patient’s condition.

Constraints

Constraints can be specified for the planning or initiation of tasks, task completion criteria, authorizations as well as actions that may be affected by regulations, interactions or contraindications.  Constraints can help prevent mistakes or oversights and enforce policies and procedures.

Conclusion

The automation of patient care management is typically envisioned within a hospital setting where solutions can be implemented and governed by a single administration.  However, patients don’t spend their lives in a hospital; for most people a hospital stay is a brief episode in their lives.  Advances in information technology will support automation that integrates hospital care, community care, remote care, continued health monitoring and preventive measures.

The facilities discussed above are based on technology described in my previous blog post on “The Knowledge Worker Cockpit.”  The goal is to provide access to “power tools” for knowledge workers, such as doctors, nurses, medical technicians and others, including patients, who must participate in health care and make decisions about services based on their personal insights, experience and expertise in order to do the job right.

Development of standards is a key challenge.  The healthcare system consists of many independent providers and payers with scattered patient records and diverse computer systems.  The activities of multiple providers must be integrated and coordinated through shared supporting technology, and the records (or interfaces to them) must be consistent for sharing and electronic processing through compliance with an Electronic Healthcare Record (EHR) standard.

The Object Management Group (OMG) is developing a specification for case management modeling (Case Management Model and Notation) that supports the modeling of specific types of cases (including patient care management).  A case-type model will provide case record specifications and planning elements that make it easy and flexible  to plan and manage individual patient care in collaboration with others, to streamline care management and to improve the quality and timeliness of outcomes.  

The OMG Healthcare task force is working on additional standards in cooperation with the HL7 standards organization.  Public recognition of the value of these standards, along with demand for their implementation, is a key factor in transforming the US healthcare system.

A Knowledge Worker Cockpit

In my last two blogs, I noted the shift of the work force from production workers to knowledge workers.  Most routine work has been automated.  The work that now dominates is to resolve problems and exceptions, and to implement changes that address new opportunities or requirements.  In the future, improving the efficiency and effectiveness of knowledge workers will be key to achieving competitive advantage both through improving the delivery of greater value at competitive prices, and through the ability to quickly adapt to changing business needs.  Current technology—e.g., the Internet, mobile communications, hand-held computers—have enabled more powerful support for knowledge workers.  I believe a knowledge worker can become much more effective with controls at his/her fingertips to access information and supporting services along with interactive supports for planning, decision-making, communication, collaboration and coordination—a knowledge-worker cockpit.

The following are a few examples of knowledge work that are representative of much of the work of running and managing an enterprise.

·         Customer support

·         Process improvement

·         Professional services

·         Product development

·         Product introduction

·         Business transformation

·         Application development

·         Facility construction

·         Process improvement

·         Marketing campaign

·         Claim resolution

·         Audit

The diversity of these forms of knowledge work illustrates the potentially broad scope of application of technology to support knowledge work.

Knowledge work is not predictable.  Each situation may require a variation in the necessary tasks and decisions, but it is also necessary to plan the work for timely, coordinated action.  I believe knowledge work is most often work that requires collaboration, and that participants are often involved in multiple collaborations at the same time, with different teams.

In the Object Management Group (OMG) we are currently working on a specification proposal for modeling a case management environment that we (the submitters) call Case Management Model and Notation (CMMN).  This specification defines a language for modeling a type of case to support planning, decision-making, collaboration and coordination on individual cases. 

The following are definitions of terms used for a number of key concepts in CMMN.  These terms are incorporated in the discussion of knowledge worker cockpit functions later in this blog.

Case. A situation to be managed or resolved that may involve multiple participants and occur over an extended period of time.  In different contexts, this may be called an “initiative,” a “pursuit,” a “project,” a “campaign,” etc.

Case file.  Records or references to data relevant to a specific case that represent the history and current state of the case.

Task.  A unit of work or a delegation to an independent application, service, process or case.  A task may be performed by one or more participants, or it may be automated.  A complex task may encapsulate multiple, related tasks.

Fragment.  A reusable pattern of related tasks that occur together.  A fragment may be adapted for a particular case plan.

Event.  Specification of a change of state or occurrence in time that triggers an alert or action.

Gateway. A decision activity that may be manual or automated where subsequent actions must be determined based on current circumstances.

Plan.  Tasks, fragments, events, other elements and dependencies between them that represent the current plan for a particular case.  The plan may be revised and extended as the particular case evolves.

Role.  A specification of the involvement of a participant in the case.  Multiple tasks may reference the same role indicating that they are to be performed by the same participant.

Pallet.  A collection of the elements that are available for planning in a particular case. Such elements may be dragged and dropped into a case plan.

Lifecycle.  The phases of a case that reflect progress and determine the nature of work required during different periods in the life of a case.

A case type model will contain specifications for the case file, commonly occurring tasks, process fragments, alerts for delayed actions, decisions with suggested alternatives, events that are triggered by changes in the case file, rules that validate inputs and control when tasks can be enabled, tasks that engage multiple participants in a collaboration, and so on. 

The case type model will facilitate planning and incorporates best practices by defining templates of the above concepts for a particular type of case. This will be a significant step toward providing a knowledge worker cockpit that puts information, connections and controls at the fingertips of the knowledge worker and assists him or her in keeping track of multiple responsibilities and collaborative relationships.

In earlier blogs I have discussed case management automation as a technology to support the work of knowledge workers, but my focus has been on modeling.  In this blog I approach the issue from a different perspective—exploring ways that information technology could improve the efficiency and effectiveness of knowledge workers in both their individual and collaborative efforts. This is broader in scope than the proposed CMMN specification.  In particular, this discussion includes features that would be part of an interactive case management system, not just the modeling of a case type as defined by CMMN.

I have organized features of a knowledge worker cockpit under seven general categories that are discussed in the sections that follow.  These are features to be experienced by knowledge workers when they are doing their knowledge work.

Planning and decision-making support

Knowledge work involves planning and decision-making to organize what will be done, when and by whom.

·         Interactive planning and display options.  Planning of activities for a case requires an interactive facility for structuring a plan with display options that provide different ways of looking at the plan.

·         Filtered pallet.  There may be a number of different types of elements that may be incorporated in a plan.  A filtered pallet will offer the elements that are valid both in that context, such as the current lifecycle state, and for the person doing the planning.

·         Best practice patterns.  Relevant patterns of activities that represent best practices are provided as tasks and fragments in the pallet to make it easy to apply best practices.  Historical data can be analyzed to identify new or evolving patterns.

·         Guidance on alternatives.  When planning is required or a gateway is encountered, a list of alternatives that are based on the particular situation can be offered for consideration.

·         Contingency plans.  Contingency plans can be included in a plan to be put into immediate effect if the associated circumstances occur.

·         Estimates of cost and duration. Computations can be performed on plan fragments or proposed plan alternatives to compute estimated costs and durations.

·         Risk factors.  Risk factors for tasks or fragments can be obtained from reference information and potentially can be adjusted for particular circumstances or for consideration of alternatives.

·         Priority scheduling. Planned activities can be automatically scheduled based on duration estimates and resource availability so that priority activities may preempt lower priority activities.

Support for collaboration with others

Knowledge work typically involves collaboration with others to determine a course of action and coordinate the delivery of results.

·         Meeting scheduling and notices. Meetings can be scheduled based in appropriate participants, their availability and priority of issues.

·         Specialized collaborations.  Information, queries and conversations can engage appropriate personnel based on their role assignments and collaboration topics.

·         Teleconferencing with shared display. Ad hoc teleconferencing with shared displays can be immediately available as appropriate to circumstances and availability of participants.

·         Access to experts.  Experts on relevant topics should be easily identified and engaged in ad hoc collaboration using appropriate modes of communication.

Monitoring

Connectivity of participants through various devices and locations enable them to provide timely updates and be kept aware of evolving circumstances.

·         Tracking and follow-up.  Participants should be connected so that the current state of the case is immediately available and can be monitored to identify delays, disruptive events and variations from the plan.

·         Progress reporting.  Problems, accomplishments and progress should be reported to concerned individuals according to their interests and authorization.

·         Event alerts.  Certain changes in the state of a case should be recognized and trigger actions or awareness for appropriate persons.

·         Scheduled alerts.  Failure to accomplish actions within a specified time period, or the need to initiate actions on a schedule or at a specified point in time, should be automatically triggered and brought to the attention of appropriate people.

Control

·         Validation of actions. Certain actions (e.g., prescribing a medication) can be validated against facts of the particular case.

·         Authorization.  Restricted actions or decisions can be automatically directed for approval.

·         Checklists.  Lists of potential actions or requirements can be adapted to a particular case to generate follow-up tasks and tracking.

·         Signatures.  Electronic signatures can provide assurance that a document was created or approved by the designated person and that the content has not been changed. An electronic signature can also include specific versions of documents the signer relied upon when endorsing the primary document.

·         Prerequisites.  Planned tasks can be deferred or enabled based on the state of the particular case. Prerequisites may determine activities that must be completed or data that must be available before a planned activity can become active.

·         Planning constraints. Availability of elements for planning can be restricted based on the authority of the planner, the facts of the case or the current lifecycle phase.

·         Application of policies and best practices.  Policies and best practices can be presented to participants when relevant, and can be expressed as rules that restrictor provide guidance for plans, decisions and actions.

Management of participation

·         Resource acquisition, assignments.  Resources and personnel can be acquired and assigned based on availability and priorities.

·         Shift-based teams.  In multi-shift operations, participants must be scheduled as active in their roles during their assigned shifts.

·         Assignment changes.  Alerts and pending actions must be redirected when an active participant is replaced.

·         Sub-teams.  On large projects, multiple teams will work on the same initiative with different plans requiring coordination and shared case information.

·         Participant availability.  Task assignments must reflect participant availability recognizing competing responsibilities and time allocations.

·         Separation of responsibilities.  Persons must not be assigned to roles where there may be a conflict of interest or loss of checks and balances.

Participant personal support

·         Personal viewpoints.  Individuals must be presented with personalized information about their involvement in multiple cases including their personal work list and schedule of tasks.

·         Schedule management. Individuals can modify their schedule to reflect personal preferences and constraints.

·         Priorities.  Participant assignments must have priorities with visibility of effects of delays.

·         Resource requirements.  Participant’s tasks must reflect supporting resource requirements, such as equipment or raw materials, with support for obtaining or scheduling required resources.

·         Progress notes.  Participant progress notes should be included with task records.

·         Record of conversations.  Participants should be able to retrieve threads of messages and meeting notes related to specific topics.

·         Data input requirements. Tasks must provide forms and instructions for entry of appropriate data.

·         Input edits.  Entered data should be validated for syntax, spelling and possible values (e.g., valid state names for a state field) as well as other measures to eliminate inadvertent errors.

·         Computations.  Where appropriate, tasks should include computations to provide supporting information.

·         Personal library.  A participant may capture task specifications fragments and other elements in a personal library to be re-used in the current or other cases.

Information access

·         Case file.  Data on the state of the case must be available and retrieved automatically when appropriate.

·         Reference collection.  A collection of reference information, relevant but not specific to the case, should be available through appropriate searches.  Reference information should be automatically retrieved when particularly relevant.

·         Support for conditional expressions.  Conditions of rules and constraints must be expressed in terms of appropriate case data to implement restrictions or trigger actions.

·         Searches and queries.  Participants must be able to easily find information that is relevant to particular circumstances for current analysis, planning and decision-making.

·         Analyses.  Participants must have access to analysis and modeling tools along with supporting data to properly analyze the current situation, identify historical patterns, and anticipate potential consequences of decisions.

·         Event-driven updates.  The case file should be automatically updated as external events are reported so it reflects the current situation as accurately as possible.

Summary

This list of functions represents a vision of future support for knowledge workers.  Many of these functions are performed in some way today, some with assistance of information technology. Those supported by information technology are seldom integrated to provide a seamless onnection of the knowledge worker to the case and other participants. 

Many of these functions are considered in the proposed CMMN specification for modeling case types.  A case management model will also provide a context for access to supporting functions such as related services, computations and identification of risks.  However, CMMN only addresses modeling of case types, so availability of many of these features will depend on the particular implementation of a case management system.  In addition, the full support of knowledge work will require supporting infrastructure, integration with related systems, and development of additional standards.  For example, development of electronic health record standards is a key requirement for automated patient care management.

In the long term, these functions should be provided in an integrated environment, a cockpit, that surrounds and links knowledge workers with appropriate information, collaboration support and controls as appropriate to the type of case and their particular responsibilities. 

For additional perspectives on case management and the nature of knowledge work, see Mastering the Unpredictable: How Adaptive Case Management Will Revolutionize the Way That Knowledge Workers Get Things Done, by Keith Swenson, et al.

Rethinking Business for a Changing World

The business world has changed dramatically over the last 20 years.  Much of this is a consequence of advances in information technology and the Internet, but it is also a consequence of global transportation that has made the world smaller. 

Some of the ways business has changed:

·         Automation has replaced routine work.  The workforce has shifted from routine work to knowledge work—dealing with exceptions, optimization and transformation.

·         An increasing number of employees work from home or other remote locations, performing in multiple roles and connected by the Internet and cell phones.

·         The marketplace is global with Internet marketing and sales as significant factors.

·         Non-core business operations can be outsourced for improved quality, reduced cost and scalability.

·         Customers expect values that complement the value of a good product such as product warranty, support after the sale, prestige and standards compliance.

·         The market and technology are constantly changing thus decreasing the lifetime of products and competitive advantages.

·         Barriers to entry of new competitors are lowered due to standards and business function outsourcing opportunities.

·         Customers are more sophisticated, expectations are high and competition is more intense.

·         Business risks are increased due to networks of business dependencies and international exposure.

·         The business must rapidly adapt to changes in demand and business disruptions.

All of this has forced executives to think about the business in new ways. What are some of the new fundamentals and what questions do they drive for business leaders?

·         Value creation.  The business exists to produce value for customers and other stakeholders.  Different market segments appreciate different values.  What are the expectations and are these expectations being met or exceeded?  What should change in order to achieve or maintain competitive advantage?  What are the deliverables and values needed by the enterprise from outside sources, including intangible assets?

·         Sharable capabilities.  As resources become more specialized and competition drives cost reductions, executives must seek ways to share capabilities among different lines of business. Existing capabilities must also be leveraged for new lines of business.  What are the core capabilities needed for the business? Are they managed to appropriately serve current and evolving lines of business? Are they delivering the desired results? Are they competitive?  Can they be consolidated or outsourced for economies of scale?

·         Collaborations.  The traditional management hierarchy is still part of the business for management of assets and resources, but there are many cross functional collaborations, both inside the business and with outside participants, that are necessary for successful operation and adaptation of the business. This includes task forces for business initiatives, project teams for development of new solutions, professional communities for sharing ideas, and teams for problem resolution. How can we better manage cross functional collaborations to be sure we are deploying resources effectively? How can we evolve our staffing functions to include collaborations as well as job positions?  How do we manage existing and new collaborations when adapting to changing business needs.

·         Enterprise optimization.  The enterprise is a complex system with many interdependent parts and concerns.  It can no longer be managed as a simple hierarchy but must be optimized across organizational boundaries through shared capabilities and appropriate allocation of resources to achieve value objectives. Optimization must be balanced against agility and the ability to adapt to rising or falling demand. How can we best manage these complex interdependencies and foster systemic decision making?  Who is responsible for enterprise-level optimization?  How do we determine what the optimum might be?

·         Risk abatement.  Executives must address potential single points of failure, vulnerabilities to attack and disruptive changes in technology and market conditions.  Optimization must be balanced with redundancy. Remote workers, globally distributed operations and outsourcing increase exposures.  Disruptions can have compounding effects that require rapid response. Have we expanded risk assessment to include these new vulnerabilities?  How do we define priorities for risk mitigation?  How do we hold business units accountable for risks?

·         Business ecosystem.  Executives must understand the role of the enterprise in a larger ecosystem of customers, business partners, other stakeholders and political entities.  Managing these relationships is essential to sustained success of the business. How well have we expanded our management focus to include ecosystem factors?  How can we assess the impact of business changes on these relationships and their consequential effects?

·         Innovation.  Innovation is a critical aspect of competition in a rapidly changing world.  Executives cannot be the primary source of innovation, but must leverage the talents of employees and other stakeholders.  Innovation should happen at all levels throughout the enterprise, and executives must ensure that when innovation happens it is cultivated. What are the structural and systemic barriers to innovation that slow down adoption of new ideas? How can we build in the kind of flexibility and culture that supports innovation?

·         Regulatory compliance.  Most businesses are now global either in their operations or in the delivery of their products or services.  This means the enterprise must comply with regulations of multiple political entities.  This can affect products, operating practices, employment, privacy controls, intellectual property rights and marketing. Compliance cannot be treated as something isolated from day to day operations or a special department. How widely do we educate our people in standards and legal requirements? How do we achieve timely implementation of regulatory compliance, particularly when it may affect multiple products and business units?

These are all enterprise-level concerns that require executive awareness and leadership.   Delegation of responsibility bears the risk of diminished priorities and sub-optimization of solutions.  Solutions cannot be fully evaluated from financial data and performance reports.  At the same time, the multiple and interacting dimensions of these factors cannot all be comprehended by the human mind. 

Executives need computer-based models to support the design and analysis of the business and consideration of potential changes.  The enterprise must be designed, evaluated and continually adapted using computer-based models. 

In the latter part of the last century, the US automobile industry underwent a fundamental transformation driven by foreign competition.  Instead of building and testing prototype components and assembled vehicles, computer-based models are now used to design and evaluate vehicles from multiple perspectives: safety, economy, emissions, weight, stress, crash worthiness, failure modes and so on.  The result is vehicles that are higher quality and lower cost, and new products can be delivered more quickly in response to innovation and changes in market demands.  A similar transformation will occur in business management.

This is a thesis of my book, Building the Agile Enterprise with SOA, BPM and MBM, that focuses on the design of the business to exploit information technology and it is the basis for current work on an Object Management Group (OMG)  Value Delivery Modeling Language (VDML) standard that I discussed in an earlier series of blogs. 

Proposals for a Case Management Modeling Standard

Three initial proposals have been submitted in response to the Object Management Group (OMG) Case Management Process Modeling (CMPM) Request for Proposals.  I reported the initiation of this work in a blog entitled “Case Management: The Missing Link in BPM,” in July, 2009.

A recent book, Mastering the Unpredictable, provides a number of perspectives on “adaptive case management.”  The emphasis is on a class of business processes that cannot be predefined as in conventional business processes such as those modeled by BPMN (Business Process Model and Notation).  The OMG CMPM proposals focus on support for modeling the case file structure and process elements of adaptive processes to support the activities of people planning and performing case management or similar knowledge work.

There are two key trends driving the development of case management automation.  First, the Internet has made access to systems available any time, anywhere.  People can access and interact with web pages and email from their cell phones.  This has a significant impact on the level of automation support that is practical.  This development is complemented by a longer-term trend toward a workforce of knowledge workers.  Routine, predictable activities have been automated, leaving the unusual and unpredictable activities to humans to make decisions and take appropriate actions.  The focus of the OMG specification is to support modeling of aspects of each type of case to enable a knowledge worker—case manager or participant—to productively plan, track and perform work interactively with useful guidance, automated alerts and coordination of activities of multiple participants.

I am one of the developers of the proposal entitled “Case Management Model and Notation (CMMN).”  We approached case management as a new process paradigm where the modeler must consider how the case manager and participants will plan and coordinate their work and must anticipate the process elements and case file structure that will be useful for a particular type of case.  The other proposals have approached case management as an extension to the BPMN specification.  In either case, case management may be initiated by a traditional business process, and case management may initiate traditional business processes to perform prescribed services.  However, this integration involves interaction between the processes, not necessarily a single modeling environment designed for modeling both adaptive, unpredictable processes and prescribed, repetitive processes.

However, we recognize that certain groups of activities will emerge as commonly occurring and should be modeled for re-use in an operational environment.  We define these as process fragments.  In general, the case manager will still have discretion to modify these fragments to suit the particular circumstances.  Where these fragments become substantial and stable, they can be specified as BPMN shared sub-processes, to be engaged at appropriate points in a case.

There will be considerable discussion about the potential to extend BPMN.  The following are issues to be considered.

·         Operational paradigm shift.  Case managers and participants actively define what is to be done rather than following a script as defined by a BPMN process.

·         Different modeling paradigm.  Modelers must think in terms of what is useful for case managers and participants while preserving their flexibility and discretion.

·         Event driven.  Various events will occur throughout the lifecycle of a case and must be addressed in the current context of the case.  A BPMN model cannot anticipate many possible events and their different consequences for subsequent activities under different circumstances.

·         Different stage of evolution.  BPMN has matured over many years while case management is new and should be influenced by experience that is incorporated in subsequent versions of the specification independent of BPMN.

·         Participant collaboration.  Participants in a BPMN process are coordinated by following the prescribed process.  Participants in case management must collaborate to define their plan and make decisions.  Automation should facilitate that collaboration.

·         Guidance and controls.  The case file represents the state of the case and will be the basis for guidance and controls affecting plans, decisions and actions, whereas data is a minimal concern in modeling a BPMN process.

·         Knowledge worker empowerment.  Knowledge workers must be able to do what is right, and not be limited by assumptions of the modeler.  BPMN is oriented to specification of a defined process that prevents variation.

·         Continuous improvement.  The repetitive, best practice actions of knowledge workers should be captured and fed back into the case management model to reduce the planning effort and improve outcomes.  BPMN feedback is from comments and observations.

·         More detailed guidance and tracking.  Because of the accessibility of the system, the availability of relevant information and the value of a shared, up-to-date plan, knowledge workers will incorporate case management automation into how they do their work and their record-keeping, resulting in guidance and tracking that are more accurate, timely and complete.  BPMN processes tend to be more abstract and less connected to the specific situation.

·         Product innovation.  Case management is a new, emerging market.  The standard should allow new vendors to enter this market with innovative approaches without the burden of also implementing the BPMN specification.

·         Language simplicity.  Some have complained that BPMN is already too complex.  Integration of case management will increase BPMN complexity,  potentially acting as a disincentive for possible users of both BPMN and case management  technology.

Given these considerations, we will explore the implications of BPMN extension for case management.  An ideal solution would enable one vendor to extend a BPMN product while another vendor implements only a case management product.

Below are some links to previous blogs I have posted about case management.

·         Case Management for Project Management 5-4-10

·         Case Management for Managers 3-2-10

·         Case Management Process Modeling Challenges 9-28-09

·         Knowledge-​Driven Processes for Healthcare 7-30-09

·         Case Management​: The Missing Link in BPM 7-8-09

·         Case Management for SOA 1-31-09

Value Chain Modeling, Part 5: The Organizational Perspective

This is a continuation of a series of posts on value chain modeling that started with “Value Chain Modeling: Part 1, Capability Analysis

A value chain represents the work that is done to deliver a product or service. Responsibility for the work and delivery of value belongs to various parts of the organization.  When considering the performance of the value chain, it is important to identify responsibility and accountability for performance and initiation of improvements.  Improvements as well as new business undertakings may also require organizational changes. 

In this article I will discuss a generic organizational modeling capability and its relationship to the value chain model. 

We define a basic, recursive pattern of organization structure that is a collaboration of participants working together, fulfilling roles for some joint purpose.  “Collaboration” and “Role” are fundamental, abstract concepts.  A collaboration may be a formal organizational unit, an ad hoc group such as a task force or committee, or an informal gathering such as a community of interest.  Traditional nodes in a corporate hierarchy are collaborations specialized as “org units.”  Roles may be filled by actors (e.g. people), other collaborations (e.g., org units) or other roles.  Actors do the actual work.  The diagram, below, illustrates relationships between some hypothetical collaborations and roles.

In the diagram, boxes are collaborations and ellipses are roles.  Each arrow represents a participation relationship.  There is one actor, Fred, depicted with a rounded box.  The XYZ Company is a collaboration with two subordinate collaborations shown: the Claims Processing Department and the Quality Policy Committee.  The Claims Processing Department is shown with one Claims Agent role and a subordinate collaboration—the Claim Resolution Team. 

Fred is an employee of the XYZ Company—he fills an Employee role in the company.  As an employee, Fred fills a Claims Agent role in the Claims Processing Department.  As a Claims agent, he is a Quality Reviewer of the Claim Resolution Team, and as a Quality Reviewer, he is a member of the Quality Policy Committee.  Thus roles are filled by other roles.  In other words, Fred would not be a member of the Quality Policy Committee if he were not an Employee, a Claims Agent, and a Quality Reviewer.

Within a collaboration, participants in roles may exchange ideas and work products to achieve their joint purpose.  In the value chain model, from an organizational perspective, a value chain as a collaboration of capabilities performing activities.  Work products flow between activities.  A capability, in turn, is a collaboration among employees who contribute to that capability, and a capability model may include roles of other supporting capabilities.  A business process can also be viewed as a collaboration among participants.  As collaborations, the value chains and capabilities each have roles in the org units that manage them.

From an organizational perspective, a value exchange, discussed in my previous blog post, is a collaboration among independent business entities.  The business entities fill party roles in the exchange collaboration.  Each of the business entities may be viewed as engaging a high-level activity in the exchange.  Deliverables conveying value(s) are exchanged between activities through transactions between party roles and their internal activities.   In an exchange, deliverables are typically exchanged in both directions, whereas, in a value chain, we focus on the transfer of deliverables as defining dependencies between activities.  The output of one activity enables another activity to proceed.

Although it is beyond the scope of the current modeling language specification effort, the value exchange pattern can be applied to any collaboration where participants work together to create or exchange value.  This is an important perspective for strategic planning because not everything that is important to the success of an enterprise can be understood or evaluated based on financial impact.  This can be used to consider value exchanges in  internal communities of interest that share knowledge, participation in industry standards organizations, informal relationships with suppliers and customers as well as informal relationships between individual employees.