THE VISIBLE ELDERLY Understanding and improving the disease management of fall accidents in the elderly

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1 THE VISIBLE ELDERLY Understanding and improving the disease management of fall accidents in the elderly Technical Report TR Department of Medical Informatics Academic Medical Center - University of Amsterdam Richard Westerhof Department of Medical Informatics Academic Medical Center University of Amsterdam Amsterdam, The Netherlands

2 THE VISIBLE ELDERLY Understanding and improving the disease management of fall accidents in the elderly Richard Westerhof

3 THE VISIBLE ELDERLY Understanding and improving the disease management of fall accidents in the elderly - Author / student Richard Westerhof, MD MSc-Student medical informatics, University of Amsterdam (UvA) - Tutor Ameen Abu-Hanna, PhD Department of Medical Informatics Academic Medical Centre (AMC) University of Amsterdam (UvA) - Mentors Sophia de Rooij, PhD, MD Department of Internal Medicine, section of Geriatric Medicine Academic Medical Center (AMC) Marjan Huisman Manager Ketenzorg Amsterdam Home Care (AT) Richard Westerhof 2008

4 Index Abstract... ii Preface & Acknowledgements... iii CHAPTER 1 Introduction Context Fall prevention The PROFIT project Goal Research questions Study characteristics Further chapters... 2 CHAPTER 2 Theoretical Framework DM & IT Frailty and falls General approach CHAPTER 3 Methods Methods pertaining to the current situation Methods pertaining to the analysis Propose an improvement CHAPTER 4 Findings Findings pertaining to the current situation Findings pertaining to the analysis Propose an improvement CHAPTER 5 Discussion & Conclusion Main findings Main strengths and limitations Answers to research questions Further research Conclusion Literature Appendices A. Abbreviations B. Overview of IT opportunities in literature C. The current situation process models and tables D. Scenarios E. DEMO model i

5 Abstract - Background Preventing falls is an important strategy to manage frailty. Many vulnerable patients, however, do not get the needed care pertaining to falls. Various healthcare providers in the South East of Amsterdam decided to act on their shared purpose of improving fall prevention along the lines of disease management (DM) and the use of Information and Communication Technology (ICT). - Objective To better understand the disease management of the frail elderly and to propose improvements with the use of ICT. - Design and Methods We conducted a qualitative explorative case study to describe and analyze fall prevention processes. For describing processes requirements engineering methods -including semistructured interviews and focus groups - and modeling techniques were applied. Literature search and iterative modeling efforts were used to decide on the process description notations and techniques. Literature search, interleaved with preliminary analysis, was also conducted to determine the analytic tools for analyzing the resulting processes. Analysis was conducted with specific attention to disease management concepts which were distilled from the literature. Finally, based on analysis, improvements were proposed. - Setting Key healthcare organizations in primary and secondary care in the area of coverage of the Amsterdam Medical Center (AMC) which are involved in the fall prevention process. - Participants The healthcare providers include the homecare organization Amsterdam Thuiszorg, the primary care practitioners (PCPs) within the Stichting Gezondheidscentra Amsterdam Zuid- Oost and the departments of Emergency, Geriatrics, and the fall prevention outpatient clinic of the AMC. - Main findings and recommendations Main findings include the lack of an owner of the whole DM process; the PCP s role is significant but not formalized; partners have limited visibility of processes performed elsewhere; little is known about patient s care consumption and health outcomes; and it is difficult to commit the patients to participate in their care process. We propose to develop a decision support system (DSS) at the PCPs to establish a case finding safety net, and to enhance adherence to established quality indicators; the use of data mining to find segments and patterns in care consumption and to develop prognostic models based on outcome measurements among others to refine and validate risk assessment tools; and the use of web-engineering and decision support to educate, involve and empower the patient. - Conclusion Disease management-based analysis exposed lacunas in the current fall prevention process and uncovered opportunities for exploiting the DM concept and supporting it with ICT. We believe that our findings are exemplary to other regional settings in the Netherlands. ii

6 Preface & Acknowledgements Preface This thesis prepares the ground for the PROFIT project (Prevention of Falls using IT), which intends to implement and evaluate a most promising subset of ICT solutions in practice, and is a partial fulfillment of the requirements for the medical informatics Masters program. Acknowledgements My special thanks go to my supervisor Ameen Abu-Hanna, my mentors Marjan Huisman and Sophia de Rooij, and Raynold Bruessing. I enjoyed their shared knowledge and coaching. Further, I would like to thank the many people who, during the several months this study lasted, provided useful and helpful collaboration. This includes the people who participated in interviews, focus groups, the conference and who provided feedback on the thesis. Not in the least I thank the support of the institutions, Amsterdam Thuiszorg, the emergency department, the Geriatrics department and innovation and process management of the AMC, Stichting GAZO and ZonMw and ICT-Regie who made this work possible. I hope future collaboration between these institutions will be fruitful. iii

7 Chapter 1 Introduction 1.1 Context The number of elderly patients is growing, and in the next decades the ratio of elderly patients in the population will increase further, exerting more and more pressure on the healthcare system. Ageing is both associated with an increased prevalence of co-morbidities and functional disabilities and with an increasing need for hospitalization. Because hospitalization is both inconvenient and costly, one attempts to shift as much of the needed care and cure to the home environment. This is the essence of the homecare concept, which is a kind of healthcare that is provided at the client s home by healthcare professionals. 1.2 Fall prevention Falls belong to the geriatric giants because they form one of the most common and most serious threats to older persons resulting in morbidity and functional decline, dependency on others, anxiety and death. Preventing falls is an important strategy to manage frailty of the elderly. However, vulnerable patients do not get the care pertaining to falls that they are entitled to. The problem is that there is no good understanding of the shared care processes pertaining to the elderly. Due to the complex multidisciplinary character of the fall prevention process it is perceived that disease-management (DM) and innovative ICT are key to the solution. Current initiatives to improve fall prevention do not capitalize on employing innovative ICT opportunities available today. An earlier study found that communication is a bottleneck [1]. 1.3 The PROFIT project 1.4 Goal This study prepares the ground for the intended PROFIT (Prevention of Falls using IT) research project proposal submitted to the ZonMw program `ICT and Disease Management. This study has a preparatory role in concretizing the research questions for PROFIT. The healthcare providers that participate in PROFIT are the homecare organization Amsterdam Thuiszorg (AT); the primary care physicians (PCPs) within the Stichting Gezondheidscentra Amsterdam Zuid-Oost (GAZO); and the departments of emergency, geriatrics, and the fall outpatient clinic from the Academic Medical Center (AMC) in Amsterdam. These healthcare providers share the purpose of improving fall prevention. The goal of this study is to understand the disease management of the frail elderly and propose improvements, especially at the intersection between the AT and AMC organization s area of care delivery. To attain this goal, the current fall prevention efforts of the elderly should be described, then analyzed, and improvements with ICT support should be recommended. 1.5 Research questions To attain this goal we devise the following research questions: 1. What is the current state of DM of the frail elderly? a. How do we describe the disease management concept? Context 1

8 Introduction b. What is the current situation of fall prevention? 2. What are the bottlenecks and opportunities of this disease management? a. How should the DM of frail elderly be? b. Which bottlenecks and opportunities can be identified? 3. Which ICT solutions should be employed? 1.6 Study characteristics We used a qualitative explorative case study design to model and analyze the current fall prevention processes. For modeling processes, requirements engineering methods - including semi-structured interviews and focus groups- were applied. Literature search and iterative modeling efforts are used to decide on the process description notations and techniques. The described processes were then analyzed with specific attention to disease management concepts which were distilled from the literature. 1.7 Further chapters The figure below shows an Eriksson Penker Business Extension (EPBE) process diagram. The bright yellow parts relate to chapters and sections in this thesis. Chapter 2 provides the reader with the theoretical framework. The theoretical pillars of this study are: (2.1) DM and the role of IT, (2.2) falls & frailty: how they relate, and (2.3) general approach. In Chapter 3 methods are presented and in Chapter 4 the findings are presented. These two chapters follow the activities in the figure below. In sections 3.1 and 4.1 the methods and findings of the current situation are presented; 3.2 and 4.2 cover the analysis; in 3.3 and 4.3 the solution is proposed. Finally, Chapter 5 discusses and concludes this study. Figure 1 Overview of this thesis Study characteristics 2

9 Chapter 2 Theoretical Framework This study builds upon three pillars: disease management (DM), information technology (IT) and fall prevention (FP). The figure below gives an outline of the domains of the pillars and their overlap, with reference to relevant paragraphs. Section 4.2 (findings: analysis) combines the three pillars. Next to the three pillars, section 2.3 (generic approach) adds a theoretical rationale to the approach of this study. Figure 2.1 Overlap of the three theoretical pillars 2.1 DM & IT In the design of healthcare processes of chronically ill patients, the concept of DM is influential, including those pertaining to falls. Hence in order to analyze and improve such processes, description of the DM concept is required (in paragraph 2.1). Another important aim of this study is to find opportunities for IT. Therefore an overview of IT concepts are described in paragraph We combine DM and IT by describing the role of IT in DM in section Disease Management Definition and characteristics DM is a modern concept of healthcare service delivery. It aims to reduce costs and improve clinical outcome and quality of life of patients with mostly chronic conditions. The most commonly used definition of DM is that of the Disease Management Association of America (DMAA): A system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant [2]. The DMAA-model of DM defines the requirements for a full-service DM program [3]. It defines a set of six components and a healthcare program should fulfill all six components to attain DM & IT 3

10 Theoretical Framework the status of DM. Spreeuwenberg sharpened these components into 10 characteristics to which an ideal DM program satisfies [4]: Ten disease management characteristics (headings are added by the author) Patient care provision 1 A distinct disease or population 2 Application of evidence based medicine 3 Connection of relevant care processes 4 Patient education and self-management (Re-)organization 5 Task rearrangement from physicians to nurses 6 Management instruments like benchmarking and feedback 7 Large scale and division of patients in treatment flows based on sub-characteristics of patient groups Conditions (for success) 8 IT and technology use 9 A robust organization structure with central control 10 A finance structure supporting cohesion The DM organization The abovementioned characteristics have their effect on the DM organization. But what does this organization look like? We translated the characteristics of Spreeuwenberg into the characteristics of an organization in a way that they interlock as much as possible.: We suggest the following representative mission statement of a DM organization: Mission - To provide the most effective evidence based care in an efficient way, - concerning the cure and care along the clinical pathway, in a patient-centered way, for a patient in a well defined population (a system s view of healthcare, clinical pathway orientation, and patient-centeredness, distinct population), - by extended collaboration with and between patients, institutions and professions (the clinical pathway orientation, patient s self-management and task rearrangement, connecting relevant care processes), - striving for continuous self-improvement (feedback and benchmarking). - Organization structure: the Learning Organization This mission fits a learning organization. Walburg shares this viewpoint on DM in his book performance management in health care [5]. Daft describes: The learning organization involves breaking down boundaries both within and between organizations to create companies that are focused on knowledge sharing and continuous learning [6]. Daft continues: In the learning organization structures become horizontal and involve empowered teams working directly with customers. Knowledge and control of tasks are located with employees rather than supervisors. Information is broadly shared rather than being concentrated with top managers. At first glance this decentralized view of the organization does not appear to comply with the central management and robust organization characteristic described by Spreeuwenberg and by the conditions as stated by the DMAA. However, it appears that these centralizing aspects are necessary to secure quality (e.g. application of best-practices and evidence base guidelines), overview the process and orchestrate process optimization, and to provide a comprehensive performance-oriented DM & IT 4

11 Theoretical Framework incentive structure. The centralizing aspects are an enabler for process integration, securing commitment of partners, enabling a learning organization by providing a performance directed incentive structure, and a means for applying quick changes in a traditionally fragmented environment. - Contingency factors in and between organizations This fragmented environment is a major challenge in DM. A characteristic of the learning organization is a horizontal structure with a learning culture, which is not always present in participants. This expresses one trade-off to which extent efforts should go to change the organizational environment (versus adapting to it). Figure 2.3 shows a view of the DM / learning organization. Figure 2.3 The disease management learning organization Information technology This paragraph describes relevant domains of IT: IT infrastructure, decision support and data mining. These aspects will be used in the next paragraph to describe the role of IT in DM. IT infrastructure IT infrastructure is the foundation of planned IT capability available throughout the business as shared and reliable services and used by multiple applications. Weill and Ross composed a series of questions to guide the IT infrastructure design and application of services [7;8]. Two important questions are: (1) what is the intended process integration and data standardization level? (2) what is the role of IT in the business? Anticipating on the next paragraph and we suggest the answers to be: (1) Process integration is a key aspect of DM and, in the information infrastructure, implies shared terminology and standards for communication. (2) The role of IT in DM is to enable or support the elements and the overall cohesion of the DM concept in a comprehensive way. The answers guide the choice of the following technical infrastructure services: Data management. Examples are data exchange translations and the management of a central, virtual or disease-specific database. DM & IT 5

12 Theoretical Framework Communication & access. Communication encompasses electronic interactions within the organizations and with patients. Integrated electronic channels support mutual partner s access. Enterprise wide infrastructure applications that capture, update and access enterprise data. For example (1) applications supporting business rules execution; (2) workflow systems and (other) logistic services; (3) process & outcome measurement tools. The given examples also encourage integration of processes. Decision support A decision support system is any program that helps making decisions. A clinical decisionsupport system is any computer program designed to help healthcare professionals make clinical decisions [9]. Clinical decision support can be divided three categories: (1) Tools for information management: Information-management tools provide the data and knowledge needed by the clinician, but they generally do not help him to apply that information to a particular decision task. Interpretation is left to the clinician, as is the decision about what information is needed to resolve the clinical problem. (2) Tools for focusing attention: Programs designed to remind the user of diagnoses, problems or tasks that might otherwise have been overlooked. (3) Tools for providing patient-specific recommendations: These provide custom-tailored assessments or advice based on sets of patient specific data. Decision support can be used on the control, tactical and strategic level of organizational decision making (e.g. management support systems). Data mining Data mining techniques are used to generate new knowledge. Search techniques are applied on large sets of data in order to induce general patterns or associations between variables [10;11] The Role of IT in DM Introduction As stated earlier, the role of IT in DM is to enable or support the elements of the DM concept in a coherent way. - The chronic care model A nice illustration of the role of IT in DM on macro and micro levels is described by Wagner in his chronic care model (CCM, figure 2.4). The CCM is a model comparable to and overlapping the DM concept [3;12;13]. DM & IT 6

13 Theoretical Framework Figure 2.4 The Chronic Care Model [13] (used with permission) - Contingency There is no single way of providing effective coordinated care, because a suitable solution depends on the right fit of the structure (characteristics of organizations) and the processes (characteristics of the managed disease and available tools) at hand [14-16]. On the other hand, a too pragmatic DM implementation and IT support might challenge the essence of disease management, and cannot be expected to endure [17]. Next we will discuss integration of care and the support of the individual elements of the DM concept. Integration of care in disease management - Requirements of the disease management - learning organization Data sharing and integration In disease management, information should not only be accessible at the individual record, but also at the patient group level. Combined with non-medical data, data mining techniques may find new knowledge to improve care and the process, including process and outcome measures and research [18]. Flexibility Generated data leads to new knowledge that is to be applied. Continuous improvement, implies that IT in an organization must be adaptable. Integration of processes To increase efficiency and effectiveness of the DM program, obstacles (caused amongst others by organization boundaries, structures and cultures, incentive structures, information silos and professional demarcation of responsibilities) should be overcome to make the care process more effective and efficient. IT enabling integration To achieve process integration it is important to share data. To be able to do so data terminology should be defined and standardized and communication standards should be used. Data is shared by database access and communication support. This shapes the operation model of the DM organization [7]. DM & IT 7

14 Theoretical Framework Further integration can be achieved by adding infrastructure applications, like modules that support workflow, planning & logistics, decision support applications, and access to data at the patient and patient group level, and also with related additional non-clinical data (e.g. planning, finance, logs). - Solutions to meet the requirements DM organizations try to fit in complex environments. We will here draw solutions which are constructed from encountered cases and from literature. In describing factors that constitute process integration we make an abstraction of some important integration enablers and inhibitors: (1) The extent to which data is integrated and thus shared enabling integration. (2) The extent to which the IT infrastructure enables integration. (3) The extent to which organizations and representative professionals are integrated. Figure 2.5 Explanation of the figures below PCP: Primary Care Physician; H: Hospital; T: Home Care; IS: information system; DM: Disease Management. Rods represent the DM primary process. The hexagons indicate the information system / databases (IS) of the organization(s). Data is integrated in one database when ISs are drawn in one hexagon. The red bar represents the IT infrastructure. Finally, the ellipse indicates an organization. Overlapping ellipses are organizations which are working closely together. Merged organizations are drawn in one ellipse. The icon-design is based on models found in Ross and Weill [19], with some adjustments. - Scenario 1: Virtual electronic patient record (EPR) in a fragmented environment The PCP organization, hospital and homecare are fragmented in the region, and have data silos that connect to a national infrastructure (the red bar in the bottom) This IT infrastructure enables a virtual EPR showing diagnostic findings and entries of physicians and nurses. This scenario is suitable when limited integration is required. Figure 2.6 Disease management support - Scenario 2: work towards additional integration The Dutch national infrastructure strives to integrate data of the individual patient, however, a patient group oriented and learning DM organization requires additional integration. Then, DM & IT 8

15 Theoretical Framework regional initiatives provide further integration. Infrastructural capabilities and the organizational aspects will determine if the organization is DM compliant. - Scenario 3: Highly integrated regional environment PCP, H and T are governed by one organization. IT provides further integration by a shared database and an IT infrastructure with workflow management support. This enables the partners to develop true DM, especially when the organization culture and structure resemble a learning organization. Figure 2.8 Highly integrated regional environment - Scenario 4: high level IT maturity A theoretical scenario of the future. The IT maturity has reached its highest level leading to seamless connection between other agile organizations [19]. Technology and information are no longer inhibitors for DM. Figure 2.9 Environment with mature IT - Scenario 5: Carved-out and Carved-in In carved-out disease management a vendor is responsible for all elements of DM [20]. This approach works around a fragmented regional healthcare and provides the opportunity to design its own disease -tailored information system with its own infrastructure applications, decision support and data mining tools. In the figure two alternatives are drawn denoted by the dotted rectangles, A and B: Scenario 5A: Carved-out: the carved out organization has dedicated caregivers. This dedication has a disadvantage: As the focus is on a specific disease, it neglects multi- or co-morbidity to a degree. This focus causes communication silos resulting in fragmented care [21]. Scenario 5B: Carved-in. In this variation a DM dedicated information system is implemented (bought by a carved-in vendor). Only part of the caregiver s activities is dedicated to the DM & IT 9

16 Theoretical Framework program, which might inhibit a learning organization culture. It does enable a more holistic approach of the patient than in (A). Figure 2.10 Carved-out (A) and Carved-in (B) - Disadvantages of multiple regional disease management initiatives Multiple DM initiatives of different diseases can lead to fragmentation and complexity. For example in the abovementioned 5B version the caregivers may participate in multiple DM initiatives next to their regular workflow, each with their own infrastructure, database and EPR. This results in a high administrative burden, with multiple EPRs to maintain. A solution might be the mutual development of one DM IT infrastructure being at the base of many DM programs in the region, as is done in New Zealand [22]. Or, when DM programs are already in place, new initiatives could augment existing programs, with new data and align with existing infrastructures [23]. Support of DM elements In contemporary healthcare many sophisticated applications have been developed that have functionalities to support the patient, caregivers and manager and the interactions between them. However, it is important that these applications are orchestrated: DM elements (and IT support) have got more effect when combined. For example: education in isolation has limited effect compared with additional efforts for self-management [24]. Whether and how to apply a specific tool is determined by many factors, notably disease characteristics, population characteristics, and local healthcare characteristics. - Tools & Classifications Exploration of an overview of IT solutions for DM resulted in a collection of articles which categorize solution differently. These are summarized in appendix B. Here we give a brief overview of some solutions. They are categorized by the different levels of the learning organization (figure 2.3). The patient Support of patient empowerment and self management. Optimal communication with the care team. A personal health record (PHR) has the opportunity to support directed patient education, patient empowerment and self management. A PHR could be used to communicate with the care team, offer selected information for education, register selfmeasurements and complaints and answer questionnaires about health status. Access to the patient record could also be provided. DM & IT 10

17 Theoretical Framework Decision support tools with warnings, advice and feedback can be used to empower the patient, make the patient self-manageable and support the patient in its role as a key recourse in its own care process. Domotica supports the patient to be able to reside at home. The care team The care team can be supported by integrating tools such as shared data access and communication services. Decision support can be used to support pro-activeness, so driving the process. This includes decision support based on predictive rules found by the manager and scientist, so preventing derailment of disease. Self evaluation and feedback about patient satisfaction, effectiveness and efficiency can be provided by Management Information systems. The Management Logistic tools and workflow engines to control and drive the process. Management Information System (Decision Support) to measure the efficiency and effectiveness of the organization. Data mining tools to find patterns and identify new markets. The scientists A nationwide (virtual) data warehouse to use in data mining and other scientific research creating new knowledge that can be applied in the care process. Target patients PHRs or for eliciting information used in scientific research. 2.2 Frailty and falls In this section, we present (1) the relationship between fall accidents and frailty, (2) risk factors and interventions and (3) DM and frailty Fall accidents and frailty A fall is not a disease. Instead, it is usually the expression of a variety of combinations of underlying factors [25]. These factors together constitute a state of frailty. Frailty is an elusive concept, and many tried to define this concept [26] but it essentially conveys that the state in which a frail person resides is associated with a higher risk of an adverse event than for a non-frail person. A contemplation about the ideal definition of frailty should include prediction of falls and causally relate to disability and co-morbidity [27;28]. These causal factors also relate to fall accidents [29]. Figure 2.11 shows causal relationships between the concepts underlying these terms. It shows a vicious circle between falls and frailty [29]. Figure 2.11 A simple representation of the causal relationship between frailty and falls Frailty and falls 11

18 Theoretical Framework Therefore, in the DM concept, the phrase DM of fall accidents does not seem logical, since fall accidents are not a disease. However, the term refers to managing frailty, with focus on falls as its expression, and although frailty is more a state than a disease, the concepts underlying DM are very well suited for managing frailty Risk factors and interventions Causes of falls can be categorized into intrinsic and extrinsic factors. (1) Intrinsic factors, e.g. a past history of falls, visual disorders, diabetes, arthritis, confusion, depression, gait and balance impairment, muscle weakness, sensory impairment, functional deficits, dizziness, fear of falling and polypharmacy [30;31]. (2) Extrinsic factors, e.g. environmental hazards, such as poor lighting, slippery floor surfaces, loose carpets. Most falls are caused by the interaction between environmental hazards, host related situational or behavioral factors, and disease conditions. The risk of falling increases dramatically as the number of risk factors increase [31;32]. Health improvement is achieved by influencing modifiable risk factors and the impact of a fall. In particular this includes: a) medical treatment of intrinsic factors; b) rehabilitation e.g. exercises, footwear, ambulation devices, c) environment adjustment e.g. extrinsic factors and compensations for functional disabilities, d) addressing psychosocial issues e.g. depression, fear of falling and social isolation, e) education directed at behavior, and f) injury reduction (e.g. hip protections, emergency response systems) [31] Issues in disease management and frailty In the design of a frailty DM program, relevant issues influencing the program s design include patient characteristics, such as vitality and adaptability and their ability to learn; disease characteristics and relevant co-morbidity; and patient heterogeneity. These factors contribute to the complexity of this healthcare service, requiring relatively more collaboration and coordination efforts and tailored care. A useful inclusion criteria for patients to access the DM of the frail elderly population is that their risk factors are modifiable. 2.3 General approach In this study we used several modeling techniques for describing processes. Literature search, interleaved with preliminary analysis, was conducted to determine the analytic tools for describing and scrutinizing the processes. This section describes that theory, followed by our findings after applying this theory in this study The theory: describing processes Our literature search discovered two sources that we found most suitable in this study. Burg describes five steps in describing processes [33]. Aguilar helps us choose the modeling technique [34]. Five Steps Burg defines five steps in describing processes. 1. Determine goals for describing processes 2. Choose the right describing technique General approach 12

19 Theoretical Framework 3. Give an overview of all processes to be described 4. List and number all processes 5. Describe the processes at the appropriate level of detail Step 1, 2 and 5 implies that decisions are made and are of interest in this paragraph. Step 1 &2: Determine goal and choose the right technique Aguilar describes four purpose based categories of business process models. Two of them are most relevant in this study. (1) Descriptive models for learning; (2) Descriptive and analytical models for decision support to process development and design. The other two are (3) enactable or analytical models for decision support during process execution, and control; and (4) enactment support models to Information Technology. She continues describing a number of techniques and places them in a matrix. Approach In the next paragraph we apply the theory. We address step 1, 2 and 5 of Burg s five step approach, use the article of Aguilar as a guide and elaborate on our choices. We recall the structure of this thesis in the figure below Findings: application of the theory We identified and describes five purposes for process modeling used in this study. For each purpose we chose a technique (based on the theory) and determined the level of detail. We describe our results below (table 2.1 summarizes this) (1) Goal. Understand the current situation. This corresponds to the first category of Aguilar: Descriptive models for learning. We have a focus on a) the business process b) information sources, and c) roles. Since we were not familiar with the process, we aimed at a modeling tool with a high level of detail, and in which information sources and roles can be recognized. Solution. We used unified modeling language activity diagrams (UML-AD). These diagrams are widely used and are a de facto standard in many fields. They have the ability to intuitively visualize tasks and messages at various levels of detail. We added remarks denoting accessed information sources. We added Eriksson Penker Business Extension (EPBE) [35] which is an extension to UML to place the process in the context of its business environment. Evaluation. We found the combination of UML-AD and EPBE to be useful and effective. However, we sensed the need for determining the boundaries of the process and process steps, as these were only partly formalized. (2) Goal. Identify the boundaries of the process and process steps which are implementation independent. This goal is used to support the previous goal, but also advances to the analysis. Solution. Searching the literature, we found a tool and technique that claims to describe the business in terms of essential, implementation independent processes: Dynamic General approach 13

20 Theoretical Framework Essential Modeling of Organizations (DEMO) [36]. Tange et al use this technique describing a generic model of clinical practice for use in the medical domain [37]. Evaluation. Our experience has been positive. We discovered the essential process steps and the process boundaries. Inherent to finding the essential process steps is the analysis of communication patterns which exposed additional bottlenecks. (3) Goal. Present our findings (the current situation, analysis) in a comprehensive way at the right level of detail. Solution. We reuse the EPBE extensions, but on a straightforward (low) level. We also used intuitive models. Our findings are mostly presented in textual explanations. Evaluation. We successfully used this technique in our thesis and focus group presentations. (4) Goal. Analyze the current situation (in order to improve it). Solution. Our technique for improving processes is Business Process Reengineering (BPR) [38]. BPR neglects current organizational boundaries and existing structures in order to fundamentally redesign processes. We used this approach because we aim to describe true DM. The gap between the current situation and DM is however large, suggesting a reengineering approach. We therefore need to zoom out of the irrelevant details towards a high level view. Additionally we reused the models described at goal 2 and goal 3 for analysis. Evaluation. We successfully discovered opportunities which we believe to be at the right level of detail, and described a target situation. (5) Goal. Validate elicited information. Solution. Scenario descriptions. Evaluation. The scenario s were found to be understood quickly by the subjects. Table 2.1 Summary of the above-mentioned findings # Goal Aguilar Modeling technique Level of detail category 1 Understand 1 UML-AD (2.0) + EPBE extensions Scenario s High High #2ab 2a Define process / process steps boundaries 1&2 DEMO/generic model low 2b Communication patterns 2 DEMO/generic model low 3 Present findings 1 EPBE extensions low 4 Analysis 2 Reuse EPBE extensions #2ab low 3 low 2a(b) 5 Interview feedback 1 Scenario s High Conclusion Although we did not strictly comply to Aguilar s matrix (DEMO and EPBE are not mapped in the matrix), we found the underlying thought to be useful. However, another approach may also have been successful. We also sensed that the chosen technique may depend on environment characteristics such as the process maturity. DEMO s claim to recognize implementation-independent process steps persuaded us to apply that technique in this environment. Our experience with the DEMO methodology and the generic model of general practice has been positive. It helped us recognize essential process steps. The graphical DEMO model, however, did not prove to be useful for quick explanation to stakeholders. General approach 14

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