The Feasibility of Deploying Business Process Management in Hospitals in Iran

Background: Business process management (BPM) systems can automate all processes in an organization. These systems provide the possibility of identifying, modeling, deploying, implementing, function managing, integrating with other information systems, monitoring and improving an organization’s business processes in a standard form. As far as the authors know, no related research has been performed in this field. Objective: This study investigated the feasibility of establishing BPM in hospitals in Iran. Methods: This qualitative research involved 13 participants selected by purposive sampling, including faculty members from medical universities and managers of hospitals. Data was collected through semi-structured interviews and analyzed using qualitative content analysis. Results: Interviewees were asked about the requirements for establishing BPM. To more easily understand the content, the interviewees responses were classified into two general categories: prerequisites for guidelines and procedures, and prerequisites for electronic healthcare records. Conclusion: Despite slight differences between the two groups of respondents (healthcare administrative experts and medical informatics management experts), there was a consensus among the experts about the effectiveness and efficiency of using BPM in healthcare organizations. Furthermore, respondents maintained that, even though numerous prerequisites would be needed for the establishment of this kind of processing reform given the current situation in Iran, some benefit could be gained from implementing to any extent possible this approach in Iran’s hospitals.

can lead to better clinical outcomes through following agreed-upon clinical policies and providing similar services.The end result of implementing BPM is the provision of IT-based solutions and a digital infrastructure that manages key functions and automates the processes of the organization. 11Furthermore, the examination of relevant literature shows that, by implementing BPM, a large number of hospitals, insurance companies, and other health organizations around the world have been able to automate their key business processes and have benefited from its advantages, such as reduced administrative workload and a greater influence on processes to manage and reform.For example, Chester County Hospital used BPM to automate and manage its various processes and achieved reduced manual workloads, increased speed and accuracy, and improved results. 12

Objective
Given that the deployment of this approach depends on the existence of legal and cultural requirements and that little research has been done on this subject, this study was conducted using a qualitative approach.This study investigated the feasibility of establishing BPM in hospitals in Iran.

Methods
This 2014 qualitative study was conducted with 13 participants including faculty members of the Isfahan School of Management and Information Sciences and Mashhad School of Health and managers of hospitals in Isfahan.The ages of participants ranged from 35 to 55 years with an average of 43 years; 10 subjects were men.Seven subjects had a PhD and 6 had a master's degree.Inclusion criteria were the minimum of a master's degree and two years of management experience in a healthcare organization.The sampling method was initially based on availability; then purposeful sampling was employed.Semi-structured interviews were conducted with faculty members and managers who had rich experiences and were willing to talk about them until data saturation. 13fter participants were informed about the purpose of the study, their informed consent to participate in recorded interviews was obtained.They were assured that anonymity and confidentiality would be maintained. 14Because of the participants' scientific and research expertise and their time constraints, individual semi-structured interviews were conducted by the researcher in Persian at each participant's workplace.Each interview lasted almost 80 minutes.Based on the purpose of the study, interviewees were asked general questions about the topic; then, based on their answers, the questions continued.The text of each interview was immediately transcribed word for word and analyzed using qualitative content analysis). 15After several readings for accuracy by the researcher, the texts of the interviews were analyzed using open coding to identify categories.Primary codes based on differences and similarities 16 were then reduced to sub-categories, abstract categories, and key concepts. 17At this stage, 477 codes were obtained and summarized and categorized based on conceptual similarities and differences.The categories were compared with the data again to ensure the accuracy. 18he unit of analysis was identified, and the initial codes were extracted based on the units of meaning from the participants' descriptions.They were then classified based on the differences and similarities of the initial codes. 19inally, based on the researcher's careful interpretation and continuous comparison of the data, key categories and concepts were extracted. 20The credibility and objectivity of the data were obtained when collecting data, diversity of participants, review of frequent data revisions, participants and two researchers' review. 21

Results
After reviewing the interviewees' responses, the prerequisites of BPM were classified into two main categories to facilitate study of the content.Finally, the experts' comments were classified in two general categories, each having seven sub-categories.The data is presented in Table 1.
The first category is requirements related to guidelines and procedures, and the second category is requirements related to electronic patient records.
Each of the studied components in the questionnaire with some comments of interviewees are provided below.

Reforms Related to Guidelines and Procedures
4.1.1.Integrate Hospital Health Information System, Electronic Patient Records, and Work Flow Medical treatment processes are representative of the main processes of healthcare centers and rely heavily on medical knowledge and specific case decisions.Decisions are made during the clinical process by interpreting certain patient data and are based on the medical knowledge of the medical team.To provide clinical decision support, patient-specific data and medical guidelines should be integrated in the hospital information system (HIS).Integrated medical knowledge, specific patient data, and complex decision support systems allow high flexibility in the treatment process. 22One interviewee said, "Through the integration of these systems, the physician could access related information; the patient's history and information was accurate, and medical errors were reduced." Another interviewee said, "This objective is in line with the targets of clinical governance; the integration of information systems could improve service quality and save time."

Removing Non-value Added Activities
In a domain such as healthcare, there are various legal restrictions and treatment guidelines that physicians must follow.Having the freedom to reorganize, remove nonvalue added activities, and revise mandatory procedures and medical information systems seems essential.Using the flexible principles of BPM is suggested.BPM and workflow software are commercially available; through regular changes they lead to a reduction in repeated human health errors.BPM is the planning, control, and monitoring of internal and external processes of an organization to make operational sequences and structures available, in accordance with the process continuous and frequent improvement. 23One interviewee said, "A fundamental point in the automation of processes is the high initial cost and time spent; so, continuous control and reform is appropriate." Regarding some clinical procedures, there is no agreement on the reduction of human errors.For example, CPOE (computerized physician order entry) that is virtually automated prescriptions is proven to reduce medical errors, but there is doubt in some other aspects, and in others there is the probability of errors of another type.Another interviewee said, "The design of EHR (electronic health record) is a kind of effective re-engineering that can help immensely in removing non-value added activities."

Using Declarative Modeling Languages Rather Than
Imperative Languages; Entrusting Immediate Decisions in Unforeseen Conditions to the Medical Team Current clinical guidelines are not flexible enough to deal with particular diseases or unexpected situations.In imperative modeling languages, users executing orders have no options in implementing the process.Even in the case of inappropriate procedures under certain conditions, BPM recommends the use of modeling language CIGD (declarative language).It identifies essential activities of the treatment process and the dependency between tasks without specifying the sequence of tasks or the emphasis; hence, the user has much freedom in choosing the treatment.Rules in declarative modeling languages are called mandatory limits which should be respected, and violating these boundaries is not allowed.Declarative language allows an immediate decision under certain types of unforeseen conditions.Moreover, it allows the possibility of improvement with the development of technology and knowledge. 24One interviewee said, "The final decision is up to the physician, and even red lines cannot choose the path for the physician; they can only give alarms."Another interviewee said, "There should be an alert in the treatment process, but it should not be imperative.Taking freedom from the medical team is to reduce the physician's incentive and accountability.Hierarchy, and imperative hierarchy, can be useful, i.e. at the lowest level (workers), guidelines are imperative, but at higher levels (physicians), guidelines are more declarative."4.1.4.Combination of Declarative and Imperative Languages One of the interviewees said, "Organizational positions should be taken into account; for example, guidelines are imperative for lower levels, and for higher levels they are declarative."

Definition of Social Rules for Interactions Within the Organization When Someone Does not Have the Ability to Do Something
The introduced approach follows a normative system and includes defining social rules and roles to facilitate interactions in abnormal situations where borders are ignored and red lines are crossed.Social norms represent the capabilities of human interaction within organizations and can be effective under unusual conditions when following rules and guidelines may not protect the patient's interests. 25One of the interviewees said, "According to Iranian rules, the physician can do anything if he accepts the consequences." Another interviewee said, "In Iran, follow-up depends on the level of power.In such cases, the physician may take some actions with confidence and take other actions with greater caution." Another interviewee said, "Saving the patient's health and life in any state should be important, and measures should be taken towards this goal." 4.1.6.Exploring the Processes Activities designed to explore the processes consist of three stages: reviewing the results of the processes, comparing them with the predicted results, and discovering deviations.This information is very useful for reforming processes.In some cases, deviations from the specified processes lead to better results which can be assessed using the exploring process. 26One interviewee said, "It is not bad that people give suggestions for process reform, but reforms should be ratified in formal meetings and with the participation of experts."Another interviewee said, "The exploring process can be considered as a link in the process chain." 4.1.7.Learning From Problems and What Happened During the Implementation Process and Predicting Future Events and Ongoing Process Reforms Accordingly The continuous improvement of processes is possible with the use of the learning process.The learning process is a closed-loop model that includes set major and minor objectives, determines exceptions and incomplete states at the time of implementation, and automatically matches the process with discovered states.The purpose of the learning process is not only to learn from problems that have arisen during implementation, but also to adapt to changes in technology and to environmental requirements such as new rules, policies, and initiatives. 27One of the interviewees said, "Regarding the increase of development of technology and its application in the healthcare system, the learning process for users of technology in these systems should be planned and organized."Another interviewee said, "With this, in fact, we inject economy into health.By learning from the problems and self-assessment of the medical team, many errors can be avoided and the system performance enhanced."

Reforms Related to Electronic Patient Records 4.2.1. Web-Based Electronic Records
A current challenge to health information systems is personalizing patient data and providing an efficient information flow between different healthcare providers by reducing human errors and increasing the quality of services. 28One interviewee said, "One of the fundamental measures to reforming the process is to use the web through which patient information can be access at any time or place.With this access, there is greater control over the treatment process."

Recording the Content of Process-Centric Electronic Records, not on the Basis of Data Collection
The existing information system is data-centric and therefore sufficient solutions are not provided.It is suggested that a process and patient-based information system be provided.In BPM, the flexible design of electronic patient records is suggested that allows both providers and patients access to information of past and future, as well as awareness of future developments. 29One interviewee said, "Being process-driven in the field of information and action can be very helpful in improving the patient."

Requirements to Control and Access to the Contents of the Patient Records
Today, the focus is on nationalizing electronic health records to reduce costs and improve performance by increasing efficiency.Some countries have attempted to nationalize EHR by centralizing services carried out individually in databases; however, this focus leads to new problems for the safety and protection of the confidentiality of patient information.For this reason, new access control approaches that consider the privacy and security of patient information is introduced herein. 72.4.Careful Access Control for Electronic Health Record Access With the introduced method, the patient is the owner of his information records and allows access to information contained in it to trusted users.One weakness of this method is the patient's lack of expertise in identifying the data required for any user.30 One interviewee said, "It seems that patients' rights are considered in this method, but a lack of knowledge may create risks for the patient." 4.2.5.Control mandatory access for Electronic Health Record Access With this method, access rules are determined through the system, and the patient does not interfere with entrusting the user in cases where confidentiality is not respected.31 One interviewee said, "There should be a link between different levels of treatment and the family physician.Family physicians should be the ones to collect the patient's information and give access to it to other physicians." 4.2.6.Control Role-Based Electronic Health Record Access With this method, users are allowed access to patient data based on their role in the patient treatment process. 32One interviewee said, "The patient should not decide; this seems reasonable in the case of a clear policy."

Combining the Above-Discussed Methods for an Access Control System
The combination of these three methods is used for an access control system, because none of these three methods alone meets the information security and confidentiality requirements. 33One interviewee said, "Especially for a combination in which the patient's opinion and selection is important to access, there should be enough culture and training already."

Discussion
Two significant differences between healthcare organizations, especially hospitals, and other organizations are the consumer of the organizations' services and the sensitivity to the quality of services provided by these organizations.Since consumers of hospital procedures are patients who require special attention because of dramatic conditions, and since there is the possibility of errors occurring at any stage of service delivery including the likelihood of irreparable injury or even death, the need to manage and improve hospital processes can be clearly understood.A review of the literature related to the implementation of BPM in healthcare organizations indicated that BPM is an interesting technology that, by turning today's organizations into process-driven organizations, provides them with many benefits. 34ecause of the poor management of processes in most hospitals, personnel spend a lot of time doing non-value added activities, and patients frequently complain of long waits for service delivery.The current study investigated the feasibility of deploying BPM in hospitals in Iran using a qualitative study and semi-structured interviews.In the process of qualitative content analysis, information is collected and analyzed at the same time. 35One reason for this kind of interview is to collect information about not only the attitudes and beliefs of the participants, but also their experiences and viewpoints.Other reasons are its low-cost, flexible, and stimulating features interviews and its capability to obtain valuable information. 36n the treatment process, the main method of patienthealthcare system communication is in-person visits in which the patient's information is recorded by the physician or nurse interviewing him.In addition to the possibility of errors, this method is costly and time consuming.Buisman et al presented a method that considers the importance of integrating information systems, the patient and work flow 37 ; using their method, significant advances have been made. 38,39Their results confirm the results of the current study.
A workflow management system (WfMS) consists of software components for storing and interpreting the meanings of the process, creating and managing the flow of work in the implementation, and controlling its relationship with members and functions of work flow.Work therapy is defined as duties associated with the treatment observed in the patient conduct path.Using WfMS for workflow management of the treatment was presented for the first time by Dadam et al. 40 Wakamiya and Yamauchi presented five basic requirements for implementing electronic treatment: notes in EHR, record statistics and variances, CPOE, checklist of editable activities, and models.The information was consistent with the views of the interviewees in this study. 41In a review by Gooch and Roudsari, it was found that HIS studies can be divided into 10 main clusters.They showed that the development of therapeutic path-based clinical decision systems occurs through semantic networks, combined official, clinical, and organizational ontologies, and the use of WfMS. 42n past decades, researchers have looked for ways to reduce unnecessary visits and long waits in hospitals and clinics.The method introduced by Kirk et al and Dessertine provided the possibility of monitoring patients who suffer from chronic diseases such as diabetes or asthma from a distance. 43,44Kaish provided a method that, in addition to the above, showed advances in the treatment process. 45rown introduced a method which had an advantage over the previous methods in that appropriate training was provided to the patient. 46A patient's health information was transferred to the physician by a network, and after analysis, an appropriate training program was provided to the patient via electronic message.This method verifies the results of this study regarding the importance of training.
In accordance with the interviewees' comments, Mulyar et al showed that computer-interpretable guideline (CIG) modeling languages not only match with languages of traditional work flow in terms of flow control, but are also able to cover more models of work flow, leading to higher flexibility in making difficult decisions. 47roviding access to patient information and maintaining the confidentiality and safety of the patient's medical records are new challenges for health management in today's world.Access to medical information for the patient, his relatives, and health authorities (including the physician, nurse, and other medical team members) was provided by the method introduced by Buxey et al, 48 but the safety and confidentiality of records remains a controversial issue.
For a network of recording patient information, providing necessary training for the patient, ensuring treatment process follow-up, and maintaining the safety and confidentiality of patient information, Jacobson presented the inefficiency of the worldwide web, emphasizing the study's results on access control to patient records, careful access control for electronic health records, and the importance of the possibility of training in the network. 49

Conclusion
It seems there is a general agreement on deploying BPM in healthcare organizations as a new method of reforming processes in Iran.However, given that deploying such approach depends on prerequisites based mainly on legal and cultural requirements, budget limitations, and the country's current situation, Iran is still far from localizing the approach that can provide deployment advantages.

Limitations of the Study
Unfortunately, due to their personal concerns and despite repeated follow-ups by the researchers, some managers and professors provided no opportunity for the researchers to visit and interview them.

Table 1 .
Categories of Interviewees' Comments in Original Forms With Sub-categories Abbreviations: HIS, hospital information system; EHR, electronic health record.