Loading presentation...
Prezi is an interactive zooming presentation

Present Remotely

Send the link below via email or IM

Copy

Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.

DeleteCancel

Make your likes visible on Facebook?

Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.

No, thanks

BPMN: Diabetes Continuing Care

No description
by

Travis Stenerson

on 1 December 2015

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of BPMN: Diabetes Continuing Care

Pool: Diabetes Screening
Actors: Patient's GP and Clinic Staff
Collect Patient Data:
Actor: GP
Data output:
Patient's
Years since last screen? (int)
Age (int)
Gender (M/F)
BMI (float)
Waist circumference (float)
Exercise? (boolean)
Eat Vegetables? (bool)
Hypertension? (bool)
Hx Gest DM (bool)
Hx large baby (bool)
Family Hx DM (bool)
Ethnicity (string)
Education level (string)

Calculate CANRISK:
Data input:
Patient's data
Data output:
High/Medium/Low

Calculate Need for Screening:
Data input:
Patient's age
years since last screening
CANRISK
Data output:
Yes or No

Screening Gate:
Type:
exclusive
Conditions:
Age >40
Years since last screening>3
OR CANRISK = High


Send for Blood testing:
Message to lab:
Measure HbA1C, fasting plasma glucose or 2hr OGTT


Determine if normal:
Input :
Lab data
Output:
Abnormal/Normal


Blood glucose gate:
Type :
Exclusive
Conditions:
HbA1C > 7 OR FPG > 11.1 mmol/L


Diagnose DM type II
Actor : GP
Data output: DMII = True
Message:
Referral to Chronic Disease Management for DMII, including lab values


Schedule Next Appointment:
Actor:
Clinic Staff
Pool: Chronic Disease Management for DMII
Actors:
Diabetes Specialist
Diabetes Care Center Staff
Lane:
Diabetes Center Initial Assessment
Determine Severity:
Data input:
HbA1C or FPG
Data output:
Urgent/Semi-urgent/Routine


Initial Assessment wait gate:
Type:
Exclusive



Initial Assessment:
Actor:
Diabetes Specialist
Output:
full blood and urine evaluation requisition
Medical and social history
Smoker(binary)
Exercise (binary)



Chronic Disease Management Gate:
Type:
Parallel
All paths are taken by each patient



Following All care paths..

Recieve Message:
Message:
follow up period

Book Appointment:
Actor:
Diabetes Center Staff



Pool: Laboratory
Actor: Lab technician

Lane: Blood Sugar Management
Actors:
Diabetes Specialist
Diabetes Care Center Staff

Determine A1C Target:
Actor:
Diabetes Specialist
Data output:
A target value for HbA1C
This depends on numerous factors and is a decision for the specialist. They consider things like age, life expectancy, comorbidities, risk of hypoglycemia.
Typical value is <7.0%


Compare A1C to Target A1C:
Input:
Target A1C, Patient's current A1C
Data output:
A1C > Target or A1C = Target


Self Measured Blood Glucose Subprocess:
Actors:
Target A1C, Patient's current A1C
Process: All patients diagnosed with DMII must self measure blood glucose to determine if the treatment is working. Patient's with very bad diabetes must measure more frequently. The
Specialist
determines the rate of measurement and prescribes strips/monitor
The
staff
trains on how to measure


A1C Target Gate:
Type:
inclusive
Conditions:
A1C > Target


Prescribe Metformin:
Actor:
Diabetes Specialist
Output:
Metformin prescription - First line agent to lower blood sugar



Consider Second Antihyperglycemic:
Actor:
Diabetes Specialist
Output:
For patients with very high blood sugar, the specialist considers a second prescription



CALL (thick outline) Lifestyle Counselling:
Destination: Lifestyle Counselling Lane
Flow:
All patients regardless of A1C



Give follow up blood test requisition
Actor:
Specialist

Determine follow up time
Calculation:
If medications changed, follow up time = 3 months, else = 6 months
Lane: Vaccination Assessment
Actors:
Diabetes Educator
Ask if patient received influenza vaccine this year:
Actor
:
Diabetes Educator
Data output:
Yes/No

Gateway: Annual flu vaccine?
Type:
Inclusive
Condition:
Influenza vaccine within past year?

Lane: Kidney Function Management
Actors: Diabetes Specialist
Examine Blood/Urine Results:
Actor: GP
Data output:
Patient's
Urine Albumin:Creatinine Ratio
Creatinine

Calculate eGFR:
(Glomerular Filtration Rate)
Data input:
Patient's Creatinine
Data output:
eGFR in mL/min

Kidney Function Gate:
Type:
exclusive
Conditions:
ACR > 2.0 mmol/L
eGFR < 60 ml/min

If No - No evidence of Chronic Kidney Disease, reassess in one year


Patient Hypertensive Gate:
Type: inclusive
Conditions:
Hypertensive (Y/N)

If no, all patients move to

Severe Kidney Disease Gate
Type: exclusive
Conditions:
eGFR< 30 or ACR >20

If yes - Diagnose CKD (Actor - specialist then refer to Nephrologist)

If no, patient qualifies for a condition called "microalbuminuria, indicating subtle kidney damage



Prescribe ACEI or ARB:
Actor: Diabetes Specialist
Output:
Presciption for first line agents for hypertension or kidney damage in diabetes

Order Blood/Urine test:
Message:
Blood and urine test requisition

Receive message:
Output:
Fasting Blood Glucose, HbA1C, Lipid panel (total, HDL, LDL, TG)
Urine ACR, Creatinine



Reassess in three months:
Actor: Diabetes Specialist
Output:
Necessary reassessment time (because of medication change) 3 months

Inform Staff
Message:
Next appointment: 3 months

Lane:
Blood Pressure Management
Actors:
Diabetes Specialist, Diabetes Center Staff
Choose Cuff and Measure BP:
Actor: Diabetes Clinic Staff
Input:
Patient's arm circumference
Data output:
Patient's
Systolic and Diastolic BP

Blood Pressure Gate:
Type:
exclusive
Conditions:
BP < 130/80 OR
BP > 210/120 OR
BP > 130/80 and < 210/120




Gate Result:
BP Normal:
Reassess at next visit
BP Moderate:
Task:
Recheck BP twice
Actor:
Diabetes Clinic Staff
BP Severely elevated:
Task:
Assess for end organ damage
Actor:
Diabetes Specialist
Specialist examines patient for certain symptoms such has headache, altered mental status, epistaxis, etc
Data output:
Evidence for organ damage(boolean)

Organ Damage Gate:
Type:
exclusive
Conditions:
Evidence for damage Yes or No
If Yes: Refer to emergency room immediately





Prescribe ACEI or ARB:
Actor: Diabetes Specialist
Output:
Presciption for first line agents for hypertension in diabetes

Moderate Blood Pressure Gate:
Type:
exclusive
Conditions:
BP > 150/90




If BP > 150/90:
Task: Consider second line antihypertensive
Actor: Diabetes Specialist
Output:
Presciption for second line agent(CCB or HCTZ)

HINF 6101 Business Process Modelling Notation Project

Diabetes: Chronic Disease Management in Nova Scotia
Alanna Clarke
Travis Stenerson

Diabetes: The Burden of Disease in Nova Scotia
In particular we'll be looking at the inital care workflow for a newly diagnosed adult with diabetes type II (non gestational)
Source: Canadian Diabetes Association: https://www.diabetes.ca/CDA/media/documents/publications-and-newsletters/advocacy-reports/canada-at-the-tipping-point-nova-scotia-english.pdf
Diabetes Continuing Care:
The Full BPMN Diagram

Software:
GenMyModel

Advantage: quick, easy, web based, can include data ER modelling, won't drive you crazy

Disadvantage: Can not execute like Bonita, small fee(5$)

Sources:
Clinical Guidelines:
Canadian Diabetes Association Clinical Guidelines. http://guidelines.diabetes.ca/
Workflow Guidelines:
Diabetes Care Program of Nova Scotia.
http://www.novascotia.ca/healthguidelines/programs.asp#diabetes
Billing Requirement Guidelines:
Nova Scotia Medical Services Insurance: Physician's Manual.
http://www.medavie.bluecross.ca/static/MSI/PhysicianManual.pdf
About the model:
Diabetes is a chronic condition with a heavy burden across Canada and is projected to worsen
Many provinces have chronic care programs and incentive programs for caregivers
Modelled here is Nova Scotia's Diabetes Care program with the clinical guidelines for a newly diagnosed adult with type II uncomplicated diabetes.
For diabetes care 8 factors must be considered:
Sugar control
Cholesterol management
Blood pressure management
Monitor kidney function
Eye care
Foot care
Lifestyle modification
Vaccinations
The following slides will step us through the entire BPMN sequence flow
Lane: Cholesterol Management
Actor:
Diabetes Specialist
Review Blood Work Results:
Actor:
Diabetes Specialist


Examine lipid profile:
Actor:
Diabetes Specialist
Data input:
HDL, LDL, triglycerides, total cholesterol (double)
Data output:
LDL > diabetic target (2.0 mmol/L) (boolean)
Determine need for pharmacological intervention:
Actor:

Diabetes Specialist
Data input:
LDL > Target
Data output:
Need for pharmacological intervention


Gateway: Start Statin
Type:
Inclusive
Conditions:
Needs medication or not
Prescribe Statin:
Actor:

Diabetes specialist
Data output:
Statin prescription(first line drug for high cholesteol)
Send for Lifestyle Counselling:
Actor:
Specialist
Sequence flow:
all patients
Destination lane:
Lifestyle Counselling
Give patient follow up blood test requisition:
Actor:
Specialist
Data output:
blood test requistion
Determine follow up time:
Calculation: if medication change
time to follow up = 3 months
else 6 months
Inform staff of follow up time:

Message:
Appointment timeframe

Ask if patient has received pneumococcal vaccine in last five years:
Actor
:
Diabetes Educator
Data ouput:
Yes/No
Gateway: Pneumovax?
Type:
Inclusive
Condition:
Pneumococcal vaccine within five years
Give pneumococcal vaccine:
Actor:
Diabetes Educator
Data output:
Vaccination

Reassessment in one year:
Actor:
Diabetes Educator
Data output:
One year follow up
Lane: Eye Assessment
Actors:
Diabetes Educator,

Ask if patient has had ophthamological exam this year:
Actor:

Diabetes Educator
Data output:
Eye exam within past year?

Gateway:
Condition:
Eye exam in last year
Refer to ophthalmologist:
Message:
Referral to ophthalmologist


Reassess in one year:
Actor:

Diabetes Educator
Data output:
One year follow up
Give flu shot:
Actor
:
Diabetes Educator
Data output:
Influenza vaccination
Lane: Foot Risk Assessment
Actors:
Diabetes Specialist, Foot Care Specialist

Examine feet:
Actor:
Diabetes Specialist
Data output:
Skin abnormalities
Structural deformities
Vascular problems
Protective sensation intact
Limited mobility
Skin breakdown
Ulcers



Calculate foot risk:
Data input:
Foot symptoms from exam
Data output:
Low, moderate, high foot risk
Foot Risk Gate
Type:
Exclusive
Conditions:
Foot risk low or moderate or high

Provide low risk foot diabetes information sheet:
Actor:
Diabetes Educator
Data output:
Low risk diabetes information sheet

Provide moderate risk foot diabetes information sheet:
Actor:
Diabetes educator
Data output:
Moderate risk diabetes information sheet


Provide high risk foot diabetes information sheet:
Actor:
Diabetes Educator
Data output:
High risk diabetes information sheet
Reassessment in one year:
Data output:
One year follow up
Refer to foot specialist:
Message:
Referral to foot specialist with foot risk data

Lane: Lifestyle Counselling
Actors:
Dietician, Diabetes Educator
Gateway:
Smoker
Type:
Inclusive
Conditions:
Yes/No response to smoking
Advise patient on benefits of quitting:
Actor
:
Diabetes Educator
Data output:
Behaviour modification
Offer pharmacological smoking intervention:
Actor:
Diabetes Specialist
Data output:
Smoking cessation medication prescription

Nutrition counselling from dietician:
Actor:

Dietician
Data output:
Diet plan
Ask patients' current level of activity :
Actor:
Diabetes Educator
Data output:
Activity level: None, some, or regular
Gateway:
Acitivity level
Conditions:
None, some, regular

Ask if patient is ready to begin exercising:
Actor:
Diabetes Educator
Data output:
Modification of exercise routine
Gateway:
Ready for exercise
Type:
Exclusive
Condition:
Yes/no response
Advise on benefits of exercise:
Actor:
Diabetes Educator

Plan for regular physical activity:
Actor:
Diabetes Educator
Data output:
Exercise plan
Add introductory resistance training:
Actor:
Diabetes Educator
Data output:
Resistance training routine
Progress aerobic activity:
Actor:
Diabetes Educator
Data output:
Continued active lifestyle
Add advanced resistance training:
Actor:
Diabetes Educator
Data output:
Incorporate weight training routine
Lane: Foot Specialist
Actor:
Foot Specialist

Foot Examination:
Actor:
Foot Specialist
Data ouput:
Skin abnormalities
Structural deformities
Vascular problems
Protective sensation intact
Limited mobility

Gateway: Foot risk
Type:
Exclusive
Condition:
Moderate/high foot risk
Book specialist reassessment 4-6 months:
Actor:
Foot Specialist
Data output:
Follow appointment in 4-6 months
Examine foot for skin breakdown:

Actor:
Foot Specialist
Data output
Skin barrier intact (bool)
Ulcers(bool)


Gateway:
Skin breakdown
Type:
Exclusive
Condition:
Skin break down/no skin break down
Book specialist reassessment in 1-4 months:
Actor:
Foot Specialist
Data output:
Follow up appointment date
Consider antibiotic therapy:
Actor:
Foot Specialist
Data output:
antibiotic prescription
Conclusion
Diabetes is a multisystem disorder that, for proper intervention, must involve the care of educators, specialists and general practicioners
Many body systems and behaviors must be addressed
A major challenge was dissecting clinical guidelines to fit them into the work flow, often guidelines would include decisions that are made at future assessments
Combining workflow and clinical guidelines into a process model shows the intersection of all aspects of diabetes care
Plan to reduce sedentary time:
Actor:
Diabetes Educator

How we made the model
First, we looked at billing requirements in Nova Scotia in the MSI Physician's manual to get a conception of what is required for complete diabetic care

Then we examined the workflow documents available in Nova Scotia to understand what individual actors are responsible for and how diabetes care centers work

Once workflows were understood on a paper model, we added clinical decisions and guidelines from the Canadian Diabetes Association

Occasionally, we used some logic to fill in certain actors that were not explicitly shown in the workflows (ie a specialist writes a prescription)

Calculation tasks were added where automated calculations can be done and most calculations have tools already available on the CDA Guidelines

Most of the data is produced in clinical patient exams and histories, and some comes from the lab, the slides will explain what data is produced and where it is used
Regular activity flow
No activity flow
Not ready for activity flow
Some activity or ready for activity flow
Full transcript