BPMN vs. Patient Treatment Plans

Peter Schoof ran a discussion today on whether BPMN is compatible with ACM or not;  this was the subject of my talk at the ACM workshop. I responded by giving the justification for this position from my talk and the subsequent discussion.

When hearing the term “business process”, most people think of a static business process – that is one that is done the same way more than once. BPMN has been designed to use on processes that can be repeated — otherwise you would never bother.

With ACM, we talk about work which, in some cases, is never done the same way twice.  With ACM, these unpredictable processes must be planned and modified by the case manager.  This is about using BPMN for those processes planned or modified directly by the case manager as part of performing the case management.

Patient Treatment Plans

A good example of an ACM plan is a patient treatment plan. I am not talking about “Patient: I have a cold. Doctor: take two aspirins and call me in the morning.” I am talking about real patients with real problems, possibly a complication of an accident, or a combination of symptoms that are not found in a text book.

It is not uncommon for a doctor to come up with a treatment plan that is UNIQUE for that patient. Across millions of patients there are probably duplicates, but in a particular medical center this treatment plan may never have been prescribed exactly this way before, and it may never be needed again.

Treatment plans are important. Patients may have allergies to particular types of medication. There may be a combination of problems that prevent using the standard treatment. Each patient has different amounts of stamina and general health, which may make different approaches more promising. A doctor draws on many many sources of information (sometimes doing serious research on what is currently available). In the end the doctor must come up with a treatment plan, give it to the patient, and institute some means for following up.

Could this treatment plan be represented in BPMN: Yes.
Would it be accurate: Yes.
Would it be understandable: Yes.
Is it overkill: Yes.

Who here thinks that a doctor will be drawing a BPMN diagram for this treatment plan?

This is what we mean by an adaptive process: it is NOT static, it is modified by the professionals themselves. It may be saved and reused, but it is more often modified before use.

Maybe we just need to train the doctors? Maybe it is intelligence? Doctors are smart enough, but they have no time or need to learn BPMN diagrams. They are busy. If they had extra time, they would use it to find better medical treatment, not how to draw diagrams.

There is no real advantage to the doctor or to the patient of a BPMN diagram for a treatment plan.

This has nothing to do with the complexity of the treatment plan, or how complicated the BPMN diagram is. It is not because people drawing diagrams test to draw them in a complicated way.  Even if the treatment plan is just “take two aspirins” I can not imagine a doctor drawing a BPMN diagram of this. It would be silly.

But wait: can’t we have both?

That is: some treatment plans are drawn in BPMN, and others as a simple task list. The problem is that no treatment plan is 100% correct, and most have to be modified. If the doctor is not used to drawing BPMN diagrams, then the doctor will not be able to modify one either. Those treatment plans drawn in BPMN will remain static, and will not be adaptive.

If you think that a patient treatment plan is not a good example of an ACM case, then perhaps you don’t understand ACM.  Don’t give me a BPM example, and then say: look there is BPM.  You need to use an ACM example if you want to understand the reason that BPMN will not work for it.  ACM is designed to support people, like doctors, who think for a living.  ACM is for people who need to draw up plans on a daily basis, and regularly as part of what they do.  For these people ease of creating, ease of modifying trumps accuracy and completeness.  Instead of BPMN, what is needed is a way to describe processes that is designed for changing them, not for enforcing that they remains the same.

Doctors may make use of systems that use BPMN: of course. When I say that BPMN is incompatible with ACM, I mean that the actual case manager experience can not include BPMN for their own adaptive plans. Doctors will use many BPM systems based on BPMN for routine tasks. They will also use many traditional applications programmed in Java and C++.   I am not saying that everything they touch has to be BPMN free.  But the treatment plan, which is the ACM part of the medical experience, the part that the doctor is responsible for drawing up to fit a particular patient, will simply NOT be drawn in BPMN. Not now, not ever.

I am begging to be proven wrong: show me a medical center where a doctors are drawing up treatment plans in BPMN!


Some have thought that what I mean here is about underlying technology “under the covers”.   As if this was a discussion of whether Java or PHP is suitable for implementing an ACM system.  Please understand: what is used to implement the system is not the discussion here.  A programmer might use Java, C++, PHP, COBOL, SQL, UML, or even BPMN to implement the under the covers system.  That is a decision of the development team, and does not require the user to know Java, PHP, C++ or any of these other technologies.  That is programming, not performing Adaptive Case Management.

The point I am trying to make is about what the case manager must know and use.  The case manager does not need to know Java, to use a Java program.  I have no issue with using BPMN to implement a system such that the case manager does not need to know BPMN.  But ACM is the practice of planning and achieving goals, and has nothing to do with whether the system was implemented in Java or not.  We discuss only the process visible to the case manager.

10 thoughts on “BPMN vs. Patient Treatment Plans

  1. Hi, Keith!
    Good post, thanks! And good example.
    Healthcare example is good for explanation where BPMN doesn’t work. But it is not conclusive proof that ACM does.
    “…the doctor is responsible for drawing up to fit a particular patient, will simply NOT be drawn in BPMN. Not now, not ever.”
    I’d be say that it not be drawn no in BPMN neither something like this. It won’t drawn at all. The treatment plan will be kept in doctor’s head only, and the facts – in case history. As if it’d save data in a disk folder and use them any time we need. All of we need is a context search.
    What do you think the doctor should do, we could say he works in ACM?

    • I would have a hard time trusting a doctor who keeps the treatment plan entirely in his head. I would expect, at the very least, that a doctor would take some notes on what he determines is the right course of action at that time. I visit the dentist every 6 months, and the first thing he does is consult the notes written from the previous visit. When I say that the doctor will make a treatment plan, I am imagining something very close to those notes, except designed to be shared. A simple checklist of things to be done, what medicine to take, how often, what tests to run, when to return for an examination, that sort of stuff. That checklist could be shared with the patient, and there might even be a way for the patient (or other technicians) to mark when the task is completed. Nothing elaborate, but something efficient for the doctor to enter, and helps guide people to the right end results. A simple context search might be just the right thing to implement this ACM.

      When you you say “It won’t drawn at all” do you specifically mean, as I do, that this will not be recorded in a “drawn two-dimensional diagram?” Or do you really mean to say that the doctor will not do something like make a list of action items either?

      Does this “prove that ACM works”. My answer will seem a bit circular. ACM is defined as the approach that helps the doctor be more effective: it is defined by the outcome, not by any particular technique. You might ask instead “Does ACM exist? Is there any technique that can make a doctor more effective?” I believe that there are many examples of such systems which are effective at helping knowledge workers be more effective. However I agree with you that showing that BPMN is ineffective for knowledge workers does not prove anything about ACM.

      • “I visit the dentist every 6 months, and the first thing he does is consult the notes written from the previous visit” – sure, Keith. It is what I mean when I say that he keeps the facts in the case history but not in diagram. But they’ve always done so, even when they didn’t have computers. They were having ACM all the time, they just did not know about that! 🙂
        I think that in this case they become more efficient owing to computer but not owing to ACM.

  2. Julia, I think we are basically in agreement but I want to be very precise about the terms. “Case Management” is a practice that has been around for 30 years or more. ACM is a practice that brings this to current technology infrastructure: computers, networks, and standards.

    My dentist literally writes notes on a piece of paper, and because of that he is not using an ACMS nor practicing ACM. This is case management, but it is not ACM. ACM is about moving this to a system that specifically supports the setting of goals, the tracking of progress, in a shared environment that helps to keep everyone up to date. You are absolutely right that this is the same thing that people have been doing on paper for many decades. ACM is a practice to bring this same behavior, with multiplied benefits, to information systems.

    • Kate, this phrase exactly highlights the difference between case management and ACM. ACM is about technology. And I agree with you completely. It would be good if it been understood by those who are trying to hide behind ACM their inability to manage the processes that can be formalized. As we discussed in Tallinn, one does not replace the other. But they could be well supplement each other.

  3. Bruce Silver jumped into the fray with this post:

    He say that tall this nonsense about a doctor using ACM to create a treatment plan is nonsense, and that this job should really go to programmers. And, programmers like to use BPMN. So, therefor, BPMN is the perfect thing for ACM.

    I thought this was a good opportunity to do a good bit of yelling, so I am copying my response here 🙂

    Go back and read the book! We spend lots of time talking about knowledge workers. You know: doctors, lawyers, detectives, judges, social workers. Then we talk about how ACM is for (you guessed it) KNOWLEDGE WORKERS! That is, doctors, lawyers, detectives, judges, etc.

    A lot of people read this, but they just don’t believe it. They think, for some reason, we are talking about programmers and system designers. We are not, read the book.

    We talk about how knowledge workers need to construct their plans while they work. They need to set goals, add new goals, complete goals. This is what the knowledge worker does, you know, doctors, lawyers, judges, detectives, etc.

    Some crazy people keep saying: but wait a minute, you want systems designers, and you want to create process diagrams, etc. Go back and read the book. We never said that the processes, the list of goals, was designed by a process designer. We ALWAYS said that the knowledge worker does this sort of thing themselves. And knowledge workers are doctors, lawyers, judges, social workers, etc.

    That is why, when we talk about whether BPMN is suitable for an ACM user, we are talking about whether a typical knowledge worker would be able to use it. And remember, the people who use ACM are knowledge workers, that is: doctors, lawyers, judges, detectives, etc.

    Don’t tell me that we SHOULD be talking about. Your examples are BPM examples, and for that BPMN is fine. You are an expert in BPMN and I don’t think we disagree on what BPMN is useful for. But why is it that you have to redefine ACM to be a kind of BPM? ACM is NOT used by system designers, it is used by knowledge workers. You know: doctors, lawyers, etc.

    “ACM should really be about the repeatable (and yes, extensible) logic, not just the ad hoc.” The whole point is that it is ADAPTIVE. Adaptive means that the knowledge worker themselves change and modify the sequence of goals to meet the need of the case. This is not just Ad-Hoc, but it is not predefined either. It is lists of goals that can be reused, but that are also completely malleable by the users. If the user can’t edit BPMN, then they can not adapt the plans for their case. And, don’t forget, the users are knowledge workers and knowledge workers are doctors, lawyers, managers, directors, case workers, etc.

    How many times do we have to say: ACM is NOT about a programmer designing a perfect process and everyone using it. That is BPM. If you want to talk about BPM, please do so, but don’t pretend that is it ACM.

    Many people talking about ACM, particularly those claiming that it is the same as BPM, simply don’t understand that ACM is about an environment where the knowledge worker is in complete control. Some claim that ACM is just a made up term that means BPM, but we want to be cool and call it something different than BPM.

    ACM is not BPM. It is an approach where the lists of goals, the steps of the process, the things that are done in the case, and DESIGNED and MODIFIED by knowledge workers. And knowledge workers are doctors, lawyers, judges, etc.

    “a case in ACM is likely to contain structured processes” Look, a case will contain MS Word documents, and for that the case manager will use MS Word. A case might contain excel spreadsheets, and for that the case manager will use Excel. A case may need to make use of a BPM process, and for that the case manager WILL USE BPM. Yes, case managers are people too, and they will use BPM. They will probably use a smart phone as well. Because case managers use these things, does not mean that ACM is about implementing BPM processes.

    Many pundits believe we just made up the term ACM and another name for BPM so that we can sound cool. PLEASE people, I don’t have so much time that I can waste it making up a new name for an old topic. Give us the benefit of the doubt: it is something new and different.

    “If it’s just Dr House winging it, that’s not really ACM.” Actually, this is EXACTLY what ACM is about. Read the book! Why do learned people keep saying that it is really about BPM? ACM is about a way that knowledge workers construct plans, lists of goals, that they can reuse, and track, and share status. They do this directly because they know their own field better than anyone else. Their knowledge is changing on a daily basis, and there is no time to explain it all to a programmer. The knowledge worker must be in DIRECT control of the list of goals at all times. And knowledge workers are doctors, lawyers, policemen, rescue workers, legislators, etc.

    Quite REDEFINING ACM as BPM, and then making statements about what is good for it!

    You are an expert at BPMN, and I am sure we agree, then, that doctors will not use BPMN to create a treatment plan. And doctors are knowledge workers, the archetype user for ACM.

    I don’t know how to say it more clearly: ACM is an approach that allows knowledge workers to create lists of goals, and track them to completion. And knowledge workers are doctors, lawyers, politicians, rescue workers, detectives, board members, executives, managers, judges, nurses, social workers, etc.

  4. Pingback: BPM Quotes of the week « Adam Deane

  5. Copied from the discussion site:

    The book was called “Mastering the Unpredictable”. That is because it was a proposed technique to handle unpredictable work patterns.

    Doubting Thomas: “You can’t really be talking about unpredictable things. You must be talking about regular old routine processes, but just saying it this way to make it sound fancy.”

    No really, we are talking about knowledge workers, and a way that each knowledge worker can specify their own pattern of goals, adding and removing goals as they need it.

    Doubting Thomas: “You can’t really be talking about knowledge workers doing this, you must really mean programmers and system designers. They are the only ones who draw BPMN diagrams.”

    No really, this is not about routine processes. It is about work situations that are different everytime, and for which the knowledge worker brings unique knowledge to.

    Doubting Thomas: “You can’t be really talking about work where the process is different every time. You SHOULD be talking about repeatable, routine processes, which can be diagrammed with a prescriptive language, and are done over and over again the same way.”

    That is just it: the name of the book is “Mastering the Unpredictable” because it is not about predictable, repeatable processes. BPM is for predictable processes.

    Doubting Thomas: “There you go again, saying it is not BPM. We know that this is BPM, and it is about predictable processes, but you just keep on confusing us by saying it is about something else. When are you going to quite lying.”

    But we said at the very beginning, in the TITLE of the book, that it is about work pattern that don’t repeat. We said that traditional approaches of pre-defining the process map will not work, and that is the reason we need to look for an approach that has different design criteria.

    Doubting Thomas: “It’s all about executing a process to reach a result. Only processes might differ in characteristics and might be managed in different ways to get there. Therefor you are really just talking about BPM and giving it another trumped-up name.”

    We called it “Mastering the Unpredictable” because it really really is about work situations that are unique, and don’t repeat.

    Doubting Thomas: “That is just silly. All work repeats. No one ever does anything new. We come to work and we do exactly the same thing all day long. Process designers just need to write down the process and it will all be automated.”

    But not knowledge workers. These are people who think for a living. These are people who figure out by themselves what the right thing to do next. Consider Dr. House (the fictional TV character) who has to come up with innovative treatments and often changes the treatments mid-way through.

    Doubting Thomas: “If all we are talking about is people winging it on the fly. Why are we even talking about it? We should be talking about repeatable, predictable processes that have logic and fixed procedures. ACM should really be about the repeatable (and yes, extensible) logic, not just the ad hoc.”

    You are welcome to talk about routine, predictable processes all you want. But ACM is about unpredictable processes that can not be (fully) defined in advanced. ACM is about “Mastering the Unpredictable” when you don’t have the luxury of a repeating process. What do you do then?

    Doubting Thomas: “That’s just ad hoc, a checklist made up on the fly. And even with less ingenious practitioners we have it already: it’s called the patient chart.”

    Many people do this today with paper and pencil, but the vision with ACM is that there is a better way. Paper does not communicate over long distances and to large groups of people when needed. Paper does not allow for aggregate analysis across many cases to see what approaches are working. Paper does not inform remote people of things that need to be done, and remind them as deadlines approach. In many ways, ACM will act like that paper patient chart, and the doctor will see it very might analogous to that, but it has some nice characteristics beyond just paper, or beyond just a Google doc.

    Doubting Thomas: “But you said this was about work, and work is organized, done the same way every time. I really want to talk about repeatable work processes. Why do you get off on slapping BPMN down anyway?”

    You are welcome to talk about BPM and repeatable processes all you want. However, ACM is about unpredictable processes, ones that are not routine, and are performed differently every time. That is why we called the book “Mastering the Unpredictable”. I don’t have anything against BPMN if you have repeatable processes. My point was to show that it is unsuitable for knowledge workers who have to change the process all the time.

    Doubting Thomas: “whether we execute work in a BPMS or with an ACMS, or any other kind of computer system, we are doing just that designing and developing a software system, and do do so requires a more detailed level of procedure to be described. Again an ACM just like any other system needs that level of detail. So no real difference here then.”

    From the beginning, I have said that knowledge workers have to specify their own goals, their own procedures, their own sequences of tasks. They can’t do this “up front” and that the definition of the process (the set of goals) emerges out of the working activity. I am not just making this up. The situation is defined as this one where you can’t define the exact sequence up front in ANY level of detail. This seems to imply to me that we are not just “designing and developing a software system.” If you can achieve the goal of handling unpredictable processes that way, then I am all ears. But so far, instead of talking about how to support unpredictable processes, people keep telling me that we should focus on predictable, routine processes.

    Doubting Thomas: “I don’t think companies care if their process is ACM or ‘normal bpm’. They just want it to work for their situation.”

    Well, yes, they don’t care. The point is that there is a situation of unpredictable processes. How does that get supported? There is no evidence that unpredictable situations can be supported with an approach that requires the process to be designed in advance.

    Doubting Thomas: “Bottom line, BPMN is one way to represent a process and as long as that representation is accurate, the semantics from others on slicing and dicing to the nth degree is moot.”

    The critical issue is not accuracy. Next time you go to the grocery store, draw a BPMN diagram in advance of EVERYTHING you are going to do. Do it in advance, or do it while you shop, but don’t do anything that is not on the diagram. I am completely safe in knowing that NOBODY will do this, because it is ridiculous amount of overhead. But the BPMN diagram will be accurate. It could be complete. It is obviously a great way to represent the shopping process. Why then, you must ask, don’t people use BPMN diagrams to plan their grocery shopping?

    Doubting Thomas: “That is completely unfair. Shopping isn’t work! Work is stuff that is repeatable, regularly, and done the same way every time. Shopping is all messy and complicated. I am getting different things every time. Sometimes I need a few special ingredients for something I am planning to cook. Other times I have to replace staples normally well stocked but eventually ran out. Sometimes I even figure out what I am going to cook based on what I see in the store. This is just not at all a description of a business process because it is so UNPREDICTABLE.”

    That is the point. Many of the things that knowledge workers do is like shopping. You have a goal (a shopping list), and the goal can even change while you are shopping, but you just figure out while you are there exactly what to do. This is what we mean by an emergent process.

    Doubting Thomas: “The argument as to whether business people would be able to construct BPMN diagrams is moot, intelligent people can learn to do almost anything. ”

    Of course, an intelligent person can create a BPMN diagram in advance of grocery shopping, but they WON’T, and the reason is fairly obvious.

    Doubting Thomas: “But then you don’t need a BPM system at all. You need a shopping list. BPMN would be comlete overkill.”

    That is my conclusion as well. BPMN is incompatible with what knowledge workers, the users of an ACM system, will need to do.

    Doubting Thomas: “OK, but some programmer might use BPMN inside the system, and completely hide it so that the knowledge worker does not even know they are using it. The end-users will never touch BPMN any more than they would have to in a BPMS deployment.”

    Yes, that is true. The system might be built using BPMN internally. But remember, that we called the book “Mastering the Unpredictable” because the processes can not be specified in advance. The idea is that the knowledge worker must create the goals and steps as they work. That list of goals, or steps to achieve them, is the real process in the work case. It is that process that drives the case forward, and it is that process that can not be specified in BPMN. If you are talking about pre-defined processes embedded in the system, then that is a BPM system, and certainly case managers, knowledge workers will also use BPM systems. But don’t get confused: those pre-defined processes don’t address the problem of “Mastering the Unpredictable”.

    Doubting Thomas: “But talking about confusing. Why make ACM so special (people have been doing their jobs acm style for ages)and place it against ‘normal bpm’.”

    We have never said that ACM is BPM in any way at all. The title of the book was “Mastering the Unpredictable”. Some people really don’t believe this. Some don’t believe that there is any such thing as an unpredictable process. Some people think this is a marketing stunt.

    However, I urge those who are interested to consider: what does it really mean to support work that is different every time. Different like the way that you visit a grocery store is different every time. You might say: “Yeah, but I wouldn’t use BPM for that!” I agree.

  6. Case management has been around for years.

    Some of the content at a case is the result of following process fragments, other content is the result of ad hoc interventions where, except to the person performing the interventions, it may seem that there is no connection between one step and the next, but that is rarely the situation..

    I regard both ACM and BPM as methodologies and consider their combined use to be better than either alone.

    “Treatment Planning” is complex. We could go on for days.

    Basically a patient acquires one or more diagnoses and there usually are available hospital “best practices” for each diagnosis. The range of best practices is the result of documenting different approaches (modalities) that are known to work for a diagnosis. The problem is a particular modality may work for one patient and not another. And, as one modality yields improvement in symptoms/signs, ongoing use of this modality could cause other symptoms/signs unrelated to the diagnosis to worsen, resulting in a need to switch. Another problem is no patient has all of the features of his/her diagnosis and many patients have symptoms/signs that are not features of a patient diagnosis for which a treatment plan is being evolved.

    Bottom line, blended treatments are usually needed when there is more than one diagnosis and there are so many variations that it may appear that each patient ends up with a unique treatment plan. ACM/BPM can handle blended treatment plans.

    Medical specialists need to be able to develop, evolve, manage and own their processes. Nothing wrong with getting some assistance from IT for testing the process logic and building rule sets.

    Accordingly, I don’t see medical specialists (or knowledgeworkers in general) gaining any benefit whatsoever from using BPMN. Of course if they know BPMN and have software that requires it, the only thing to worry about is whether there might be faster/better ways to map out processes.

    You can build complex flowgraphs using a drag and drop approach using a small number of constructs and once you have an improved process map, the only “person” who needs to look at the map is a software system compiler that carves up the steps into individual steps (“what”), each with a skill attribute (“who”), any needed forms for collecting run time data, plus local instructions (“how), leaving only “when” and “where” to be determined at run time. Long term outcomes data analysis across patient populations allows processes to be improved and versioned.

    No one today should spend a lot of effort developing process execution environments when there are off-the-shelf auto-resource allocation, leveling and balancing software solutions that allow orchestration/governance and are able to provide interoperability.

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