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{{Paper
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|title=Transforming Chronic Disease Therapy with Telemedicine: A Single Case Study of Integrated Clinical Pathways for COPD Management Employing Telemedicine Technologies and BPM Methods
|pdfUrl=https://ceur-ws.org/Vol-3698/paper1.pdf
|volume=Vol-3698
|authors=Marek Szelągowski,Justyna Berniak-Woźny
|dblpUrl=https://dblp.org/rec/conf/balt/SzelagowskiB24
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==Transforming Chronic Disease Therapy with Telemedicine: A Single Case Study of Integrated Clinical Pathways for COPD Management Employing Telemedicine Technologies and BPM Methods==
https://ceur-ws.org/Vol-3698/paper1.pdf
Transforming Chronic Disease Therapy with Telemedicine:
A Single Case Study of Integrated Clinical Pathways for
COPD Management Employing Telemedicine Technologies
and BPM Methods⋆
Marek Szelągowski1,∗,† and Justyna Berniak-Woźny1,†
1 Systems Research Institute of the Polish Academy of Sciences, Newelska 6; 01-447 Warsaw, Poland
Abstract
This paper delves into the transformative potential of integrating telemedicine and business
process management (BPM) methods in chronic disease therapy, advocating for a shift beyond
traditional models. Through a single case study focusing on Chronic Obstructive Pulmonary
Disease (COPD), the research underscores the crucial need for collaborative efforts among
healthcare professionals, patients, and caregivers. It emphasises the potential of telemedicine
for personalised care and reduced healthcare costs. Additionally, it identifies key challenges
that stand in the way of the widespread adoption of the proposed approach, such as the lack of
regional digital healthcare systems and transparent legal and financial frameworks. However,
these challenges are not insurmountable. This research contributes significantly to the evolving
landscape of chronic disease management, advocating for a more patient-centric and
technologically driven approach that empowers individuals and facilitates collaborative care.
Keywords
Clinical pathways (CPs), diagnostic and therapeutic processes, telemedicine, business process
management (BPM), chronic disease therapy, illustrative case study 1
1. Introduction
The healthcare sector grapples with the challenge of delivering high-quality, individualised
care amidst resource constraints. This necessitates a fresh approach to diagnostic and
therapeutic processes that promotes a holistic patient-centric approach. Business Process
Management (BPM) and telemedicine technologies emerge as potential game-changers,
having already succeeded in optimising workflows across diverse sectors [1]. Within
healthcare, BPM holds promise for streamlining clinical processes and enabling
automated, continuous tracking of key health parameters without constant medical
Baltic DB&IS Conference Forum and Doctoral Consortium 2024
∗ Corresponding author.
† These authors contributed equally.
marek.szelagowski@dbpm.pl (M. Szelągowski); justyna.berniak@gmail.com (J. Berniak-Woźny);
0000-0002-5114-6793 (M. Szelągowski); 0000-0002-3156-5755 (J. Berniak-Woźny);
© 2023 Copyright for this paper by its authors. Use permitted under Creative Commons License Attribution 4.0 International (CC BY 4.0).
1
CEUR
ceur-ws.org
Workshop ISSN 1613-0073
Proceedings
intervention. However, broader clinical acceptance and robust research are crucial to
unlocking its full potential. The possible benefits of this approach are vast, including the
potential for improved patient outcomes, reduced healthcare costs, and a more
sustainable healthcare system.
Chronic conditions pose a significant and growing burden, impacting a substantial
portion of the European population [2]. Managing these long-term, often expensive
therapies demands coordinated interdisciplinary efforts. The evolving healthcare
landscape emphasises engaging patients and caregivers, aligning with rising telemedicine
adoption for remote, real-time health monitoring. However, effectively utilising
telemedicine requires a departure from traditional models, where doctors dictate
treatment and patients passively receive it. This shift is especially crucial for chronic
diseases, where long-term collaboration between patients, caregivers and doctors is
essential. Healthcare professionals must empower patients with knowledge, clearly define
their roles, and continuously adapt treatments based on real-time data and evolving
medical knowledge. This necessitates dynamically adjusting individual care pathways
(ICPs) through ongoing analysis of vital signs. The ICP approach fosters collaboration
among interdisciplinary teams with shared goals, roles, and communication channels,
adhering to evidence-based standards [3].
The evolving healthcare landscape necessitates collaborative efforts between
healthcare professionals, patients, and caregivers to address chronic disease challenges
effectively. This research explores the transformative potential of integrating telemedicine
and Business Process Management (BPM) methods in chronic disease therapy. Through a
single illustrative case study focusing on Chronic Obstructive Pulmonary Disease (COPD),
the authors investigate how an integrated ICP can enhance patient engagement, optimise
therapeutic processes, and improve health outcomes.
This paper addresses a critical research gap by investigating the reconfiguration of
diagnostic and therapeutic procedures for chronic disease management, exemplified by
Chronic Obstructive Pulmonary Disease (COPD), by integrating novel telemedicine
techniques. Additionally, the authors advocate for a patient-centric approach in
telemedicine, ultimately paving the way for a more effective and collaborative healthcare
landscape.
The paper begins by thoroughly reviewing relevant literature in the field. The authors
then outline the methodology employed in the study. Subsequently, the case study results
are presented. The final section encapsulates conclusions and practical recommendations
derived from the research.
2. Related Work
2.1. Application of Business Process Management in Healthcare
Business Process Management (BPM) is today's highly effective management concept [4].
Its application demands a focus on recipient needs, accountability of all participants,
transparency, and continuous improvement [5]. Traditional BPM falls short in healthcare
due to process unpredictability and outcome reliance on contextual knowledge
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application. Thus, the dynamic BPM, empowering process executors, is essential for
describing and implementing diagnostic and therapeutic processes [6].
Diagnostic and therapeutic processes, known as clinical pathways (CPs) or care chains, are
detailed at three levels:
• Level I: National/international guidelines developed by specialist teams.
• Level II: Clinical pathways at the healthcare unit level based on guidelines, unit
resources, and staff competencies.
• Level III. Individual Care Plans (ICPs) based on second-level pathways, considering
patient specifics [7].
Implementing BPM in healthcare necessitates ongoing consideration that the patient,
not the disease, is the focus of treatment; the patient and their caregivers should be
engaged in the treatment process; various CPs and supportive processes must form a
cohesive system; knowledge available in the form of CPs should be accessible and
reflected in available data on the everyday use of information technology and telemedicine
systems by all participants in the diagnostic and therapeutic process. Executing ICP
requires empowering process executors to make diagnostic and therapeutic decisions
based on their knowledge and the requirements of the clinical process context [8].
Decisions significantly impact the course and value delivered by these processes. More
excellent expertise and engagement of the patient and the therapeutic team reduce risks
during process execution and increase the likelihood of achieving the intended goals.
Diagnostic and therapeutic processes are typical knowledge-intensive business
processes (kiBPs) because their outcomes depend closely on the efficient use of the
knowledge and engagement of all process participants [9]. Due to their unpredictability, it
is essential to acknowledge that full, detailed knowledge about how they are executed is
unavailable during their modelling and design. Therefore, regardless of the form of the ICP
description, it is necessary to consider the possibility of dynamically directing the process
flow and making decisions that were not foreseeable during ICP's design.
In modelling such cases, utilising the capabilities provided by BPMN, such as the "ad
hoc subprocess" object, becomes natural. It allows for the incorporation of situations
where the process executor (including the patient) decides on the tasks to be performed,
their sequence, the potential number of repetitions, and the transition to the execution of
the next task or task group. If, for example, the Patient Diagnosis process is modelled in
this way, it concludes when the diagnostician deems that they have sufficient information
to make a diagnosis based on their knowledge. Each process execution may have a
different course (a different sequence of performed tasks) depending on the patient's
condition, the doctor's knowledge, initially available medical documentation, diagnostic
tests, consultation possibilities, or unforeseen events such as immediate patient
assistance.
Analysing executed ICPs verifies the correctness of conducted therapy and assesses the
usefulness and effectiveness of the knowledge used. It also facilitates the creation of new
knowledge based on the analysis of individual cases and the identification and analysis of
deviations from the standard CP [10]. From this perspective, ICP serves as a knowledge
repository, verifying existing knowledge and identifying new knowledge obtained directly
from the data of conducted therapy [5].
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2.2. Characteristics of Chronic Disease Management
In diseases characterised by prolonged disturbances leading to disability or dysfunction,
specialised supervision, care, and rehabilitation are essential, requiring a well-designed
and adapted treatment plan [11]. These diseases significantly impair functioning and often
progress over time. Enhancing therapeutic effects involves comprehensive information
flow between medical personnel, patients, and caregivers [11]. Involving patients as active
participants transforms their role from passive recipients to co-creators of therapy, aiding
in information gathering and treatment modification [12].
The treatment plan should include Level III clinical pathways (ICPs) tailored to each
patient, with clear goals and evaluation parameters. It should describe planned medical
care and patient participation, ensuring awareness of conditions, activities, and
therapeutic actions during consultations. Parameters for patient measurement,
presentation, reporting, and recommended levels should be outlined [12].
Following integrated care and personalised medicine principles, the treatment plan
serves as an agreement between the therapeutic team and the patient, fostering mutual
responsibilities and health education [11]. Understanding ongoing therapy and involving
patients is crucial for chronic diseases, which present long-term challenges to daily life.
COPD, the most prevalent chronic respiratory ailment in adults, is a leading cause of
mortality globally, with cases often undiagnosed or detected late [13]. With ageing
populations and environmental threats, COPD cases are expected to rise continuously.
2.3. Telemedicine
The American Telemedicine Association defines telemedicine as a revolutionary force in
healthcare, enabling remote delivery of services through information and communication
technology (ICT) [14]. It encompasses diverse clinical services utilising various ICT
mediums like the Internet, wireless satellite, telephone, and sensors to enhance healthcare
accessibility. Telemedicine has evolved over the past century from the telegraphic
transmission of clinical data to NASA monitoring astronauts' health [15]. Despite
substantial technological advancements, such as improved platforms, health devices, and
innovations in AI, telemedicine integration into daily practice was historically limited [16].
Factors like reimbursement challenges, legislation, state restrictions, stakeholder
awareness, and privacy concerns contributed to this. In primary care, telemedicine has
surged, especially during the COVID-19 pandemic, from rarity to standard practice [17].
Despite pre-pandemic barriers like digital literacy, its expansion in 2020 saw significant
increases in virtual visits globally, benefiting patient empowerment and engagement [18].
In long-term care (LTC), telemedicine's significance has grown due to technological
advancements and value-based care trends. The pandemic accelerated its adoption,
addressing exposure risks and ensuring care for older people, with bureaucratic
challenges temporarily relaxed [19]. Telemedicine's evolving role facilitates collaborative
decision-making, presenting new opportunities and challenges in healthcare delivery. Its
transformative potential reshapes healthcare decisions, paving the way for improved
outcomes and holistic care.
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3. Methodology
This article aims to demonstrate and evaluate the reconfiguration of diagnostic and
therapeutic procedures, emphasising a patient-centric approach by incorporating
innovative telemedicine techniques. Specifically, the authors illustrate how BPM methods
can be utilised to develop comprehensive ICPs for treating COPD, one of the most
prevalent chronic diseases.
In pursuit of our objectives, we employed an illustrative case study method, utilising a
descriptive, in-depth, context-rich approach to offer visually detailed insights crucial for
supporting the research process and understanding its outcomes [20]. This approach is a
guideline for interdisciplinary teams comprising health professionals, patients, and
caregivers, leveraging the latest telemedicine technology to optimise treatment
effectiveness and enhance healthcare system efficiency.
The complexity and deviation from routine CPs make this case particularly intriguing
for exploration [21]. The study not only illustrates the development of an ICP as a process
but also identifies the benefits arising from the application of telemedicine technologies,
enabling the ongoing monitoring of various patient characteristics and parameters.
4. Results
In treating chronic diseases, significant importance is attributed to increasing the patient's
role in the ongoing, daily control of essential parameters defined in IPC and taking
independent therapeutic actions based on them without needing direct consultation with
a doctor each time. A crucial aspect is the conscious, active prevention of exacerbations by
the patient and their caregivers by identifying the threat of their occurrence and taking
preventive actions appropriately early. Therefore, IPC must be prepared in collaboration
with and agreed upon with the patient and, in case of doubts, should be the subject of
specific negotiations between the patient and the therapy provider [13].
For effective and systematic collaboration between the patient, caregivers, and
members of the therapeutic team, it is essential to use a tool understandable to both
parties for assessing significant parameters of the patient's actual health status and
comparing them with the levels recommended, cautionary, or alarm specified in IPC.
These conditions are met by ICPs describing in a clear, graphical manner the assumed
course of the implemented therapy, tasks of individual participants, and significant health
parameters requiring monitoring that may impact even sudden changes in how the
treatment is conducted.
Telemedicine devices radically change the clinical pathway - "The therapeutic care
process" (Figure 1). Its central point is no longer the doctor’s consultations but the task
"Ongoing IPC execution and monitoring of health parameters." The patient and their
caregivers are responsible for this task. Support by telemedicine devices allows for
immediate signalling of exceeding essential parameters of the patient's health or sudden
accidents (e.g. patient falling). However, this requires, especially in the case of chronic
diseases, that patients always have a telemedicine device with them. Therefore, they must
meet two primary conditions: the patients must be able (and willing) to use them, and the
patients must have such a device or be able to obtain it quickly.
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Figure 1: The therapeutic care process (a patient's process in which the doctor and others
participate).
The data collected in telemedicine devices or online and sent to healthcare systems
allow therapists to reconstruct changes in vital parameters of the patient's health post
factum based on process mining techniques. In the case of AI, the current analysis of the
available data may enable the prediction of impending exacerbations of the patient's
condition (e.g. in the case of COPD). This allows for taking actions in advance to eliminate
or mitigate threats. The ability to track essential parameters of the patient's health
6
continuously and prevent acute conditions significantly increases patient safety during
therapy.
Figure 2: Telemedicine-supported therapy (the implementation of treatment for a patient
with a chronic disease).
As shown in the diagram of the "Telemedicine-supported therapy" process (Figure 2),
based on the IPC prepared by specialist doctors, including current data from telemedicine
devices, AI can autonomously, without the doctor's participation, analyse the data on an
ongoing basis and communicate the recommended treatment to the patient. With this
ability to use AI, the patient's doctor can schedule follow-up consultations at longer
intervals without compromising the quality or safety of the therapy. Data analysed:
• can be obtained from telemedicine devices equipped with various built-in sensors
or communicating with the device on which the application is installed via
Bluetooth or the Internet,
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• if required by the IPC recommendations, and there are no autonomously operating
sensors available, they can also be entered manually by the patient or their
caregivers (this applies, for example, to the monitoring of medication intake),
• if required by IPC recommendations, environmental data, such as atmospheric
pressure or other weather data, can be obtained from indicated reliable external
sources, e.g. via the Internet.
5. Conclusions
This paper aimed to showcase and assess the reconfiguration of diagnostic and
therapeutic procedures, facilitating a patient-centric therapy organisation through
incorporating novel telemedicine techniques. The authors demonstrate the impact of the
implementation of BPM and telemedicine in the following areas:
1. Patients’ empowerment:
• Telemedicine devices and CPs enable patients to actively participate in monitoring
their health and taking actions based on defined parameters.
• Telemedicine devices facilitate early detection of potential exacerbations through
continuous monitoring, allowing for prompt preventive measures to be taken.
• Continuous monitoring and timely interventions contribute to improved patient
safety and potentially reduce the need for hospitalisation.
2. Healthcare delivery transformation:
• Telemedicine devices make personalised preventative measures accessible to a
broader audience, potentially reducing the burden on healthcare systems.
• Real-time data from telemedicine devices enables healthcare professionals to
monitor and analyse remotely, allowing for more informed decision-making.
• AI can analyse data and recommend adjustments to CPs (or even ICPs), potentially
reducing the need for frequent specialist consultations.
• Telemedicine can streamline workflows and improve communication between
patients and healthcare providers, potentially reducing costs.
However, authors point to specific challenges, such as:
• Ensuring all patients access necessary telemedicine devices is crucial for equitable
implementation.
• Patients and caregivers need adequate training to use telemedicine tools and
understand their data effectively.
• Robust data protection measures are essential to ensure patient privacy and trust
in telemedicine systems.
• Seamless integration of telemedicine data into existing healthcare infrastructure is
vital for effective utilisation.
The primary conditions for the widespread use of telemedicine already exist.
Telecommunications infrastructure, widespread availability and literacy of smartphones
and telemedicine devices, and even AI algorithms that enable real-time determination of
expected warning and alarm values and monitoring of current patient health parameters
already exist. To fully exploit their potential, the following are missing:
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• regional or national digital healthcare systems for data collection and analysis,
• legal basis for the use of telemedicine, e.g. regarding anonymisation and data
sharing,
• rules for financing the use of telemedicine by healthcare providers, for whom, for
example, the cost of a multi-day hospital stay in a patient with acute COPD is readily
accepted. Still, financing telemedicine to avoid exacerbation is not accepted.
A significant limitation of this work is its conceptual nature. Despite the availability of
telemedicine technologies and the current relevance of COPD treatment during the COVID-
19 pandemic according to GOLD guidelines, further studies are essential to investigate the
effectiveness of the proposed CP and its impact on accelerating the development of
medical knowledge. An especially critical area for future research, with substantial
implications for COPD treatment effectiveness, involves data-driven analysis of
exacerbation causes or signals. The authors and pulmonologists in the study anticipate
that analyses of extensive Big Data from conducted treatments will lead to the proposal of
new CP variants, aiming to mitigate the risk of exacerbations. Simultaneously, conducting
economic analyses to highlight the potential reduction in direct costs of COPD treatment
(e.g., hospital visits for exacerbations) and long-term costs (e.g., social costs associated
with patients leaving the labour market or expenses related to long-term care) will
prompt swift changes in healthcare rules and regulations, facilitating their widespread
implementation.
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