Clinical Practice Guidelines
2.0.0 - STU2 International flag

Clinical Practice Guidelines, published by HL7 International / Clinical Decision Support. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/cqf-recommendations/ and changes regularly. See the Directory of published versions

Mapping and Other Formalisms

Knowledge Representation Formalisms

In addition to the FHIR-based L3 representation formalisms that are the focus of this implementation guide, the BPM+ family of knowledge representation standards from Object Modeling Group (OMG) are being used to represent clinical guideline and pathway content. This section describes potential approaches for using the BPM+ standards in coordination with this implementation guide. Readers of this section are expected to have some level of familiarity with the BPM+ standards, specifically BPMN, CMMN, and DMN.

Within the overall framework of levels of knowledge, the visual representation aspects of the BPM+ family of standards fit within L2, diagrams, workflows, and process models, while the executable aspects of these standards range into L3 and even L4, given systems that are capable of executing BPMN, CMMN, and DMN content.

TODO: Diagram depicting placement of BPMN, CMMN, DMN along-side the FHIR-based specifications

In particular, this implementation guide defines 3 layers of process-modeling structures:

  1. Pathway - BPMN/CMMN (Leaning towards BPMN)
  2. Strategy - BPMN/CMMN (Leaning towards CMMN)
  3. Recommendation - BPMN/DMN (Leaning towards DMN)

Of course, this correspondence is a rough equivalence, there are aspects of process- and decision-modeling throughout each of the layers, but this provides a starting point for approaching integrated use of these standards.

BPMN and FHIR

Focusing on process semantics, this section provides mappings between BPMN and PlanDefinition, informed by the workflow patterns work done at the Eindhoven University of Technology and Queensland University of Technology, and applied to FHIR by a joint project between the University of Applied Sciences Upper Austria ("FH Hagenberg") and CGM Clinical Austria for a prototype for medical boards (project "KIMBo").

The definition of a Process is specified using either BPMN or a FHIR PlanDefinition, then the Atlas Transformation Language (ATL) can be used to transform between the two, using the Control Flow and Data Flow patterns as a metamodel.

Workflow Pattern Transformations

The following sections consider specific patterns and the BPMN and PlanDefinition representations of each.

Business process is manually created as plan defintion. The patterns explain how an automated transformation towards BPMN and a graphical representation can be solved.

Sequence Flow

Sequence Flow

Definition A sequence flow is a directed arc from one source node to exactly one target node.

BPMN Start-Event, End-Event, Sequence
PlanDefinition PlanDefinition.relatedAction, Before-Start

BPMN Representation

<?xml version="1.0" encoding="UTF-8"?>
<bpmn:definitions xmlns:dc="http://www.omg.org/spec/DD/20100524/DC" xmlns:bpmndi="http://www.omg.org/spec/BPMN/20100524/DI" xmlns:bpmn="http://www.omg.org/spec/BPMN/20100524/MODEL" xmlns:di="http://www.omg.org/spec/DD/20100524/DI" xmlns:xmi="http://schema.omg.org/spec/XMI" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" targetNamespace="http://aist.fh-hagenberg.at/msbpmn">
    <bpmn:process isExecutable="true" id="Process_d1fe3661-9a23-44ad-b6c3-0abe614324ee" name="Process_d1fe3661-9a23-44ad-b6c3-0abe614324ee">
        <bpmn:endEvent id="end4" name="end">
            <bpmn:incoming>sf_ad_3_end4</bpmn:incoming>
        </bpmn:endEvent>
        <bpmn:sequenceFlow id="sf_ad_1_ad_2" targetRef="ad_2" sourceRef="ad_1"/>
        <bpmn:sequenceFlow id="sf_ad_2_ad_3" targetRef="ad_3" sourceRef="ad_2"/>
        <bpmn:sequenceFlow id="sf_ad_3_end4" targetRef="end4" sourceRef="ad_3"/>
        <bpmn:sequenceFlow id="sf_start3_ad_1" targetRef="ad_1" sourceRef="start3"/>
        <bpmn:startEvent id="start3" name="start">
            <bpmn:outgoing>sf_start3_ad_1</bpmn:outgoing>
        </bpmn:startEvent>
        <bpmn:userTask id="ad_2" name="Task 2">
            <bpmn:incoming>sf_ad_1_ad_2</bpmn:incoming>
            <bpmn:outgoing>sf_ad_2_ad_3</bpmn:outgoing>
        </bpmn:userTask>
        <bpmn:userTask id="ad_3" name="Task 3">
            <bpmn:incoming>sf_ad_2_ad_3</bpmn:incoming>
            <bpmn:outgoing>sf_ad_3_end4</bpmn:outgoing>
        </bpmn:userTask>
        <bpmn:userTask id="ad_1" name="Task 1">
            <bpmn:incoming>sf_start3_ad_1</bpmn:incoming>
            <bpmn:outgoing>sf_ad_1_ad_2</bpmn:outgoing>
        </bpmn:userTask>
    </bpmn:process>
</bpmn:definitions>

PlanDefinition Representation

<PlanDefinition xmlns='http://hl7.org/fhir'>
    <id value='protocol-example'/>

    <text>
        <status value='generated'/>
    </text>

    <!--  The status of the protocol.draft | active | retired  -->
    <status value='draft'/>

    <action>
        <id value='ad_1'/>
        <title value='Task 1'/>

        <!-- related action definition -->
        <relatedAction>
            <actionId value='ad_2'/>
            <relationship value='before-start'/>
        </relatedAction>
    </action>

    <action>
        <id value='ad_2'/>
        <title value='Task 2'/>

        <!-- related action definition -->
        <relatedAction>
            <actionId value='ad_3'/>
            <relationship value='before-start'/>
        </relatedAction>
    </action>

    <action>
        <id value='ad_3'/>
        <title value='Task 3'/>
    </action>

</PlanDefinition>

Parallel Split

Parallel Split

Definition A parallel split is separating the sequence flow in parallel branches that are executed concurrently.

BPMN ParallelGateway
PlanDefinition PlanDefinition.groupingBehavior, PlanDefinition.selectionBehavior

Remarks A merge element is created implicitly

BPMN Representation

<?xml version="1.0" encoding="UTF-8"?>
<bpmn:definitions xmlns:dc="http://www.omg.org/spec/DD/20100524/DC" xmlns:bpmndi="http://www.omg.org/spec/BPMN/20100524/DI" xmlns:bpmn="http://www.omg.org/spec/BPMN/20100524/MODEL" xmlns:di="http://www.omg.org/spec/DD/20100524/DI" xmlns:xmi="http://schema.omg.org/spec/XMI" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" targetNamespace="http://aist.fh-hagenberg.at/msbpmn">
    <bpmn:process isExecutable="true" id="Process_7883a5c7-7ab9-40fc-ab09-b55ac064d172" name="Process_7883a5c7-7ab9-40fc-ab09-b55ac064d172">
        <bpmn:endEvent id="end8" name="end">
            <bpmn:incoming>sf_ad_4_end8</bpmn:incoming>
        </bpmn:endEvent>
        <bpmn:parallelGateway id="join_of_par_group" name="join">
            <bpmn:incoming>sf_ad_2_join_of_par_group</bpmn:incoming>
            <bpmn:incoming>sf_ad_3_join_of_par_group</bpmn:incoming>
            <bpmn:outgoing>sf_join_of_par_group_ad_4</bpmn:outgoing>
        </bpmn:parallelGateway>
        <bpmn:parallelGateway id="par_group" name="par_group">
            <bpmn:incoming>sf_ad_1_par_group</bpmn:incoming>
            <bpmn:outgoing>sf_par_group_ad_2</bpmn:outgoing>
            <bpmn:outgoing>sf_par_group_ad_3</bpmn:outgoing>
        </bpmn:parallelGateway>
        <bpmn:sequenceFlow id="sf_ad_4_end8" targetRef="end8" sourceRef="ad_4"/>
        <bpmn:sequenceFlow id="sf_start7_ad_1" targetRef="ad_1" sourceRef="start7"/>
        <bpmn:sequenceFlow id="sf_ad_1_par_group" targetRef="par_group" sourceRef="ad_1"/>
        <bpmn:sequenceFlow id="sf_par_group_ad_2" targetRef="ad_2" sourceRef="par_group"/>
        <bpmn:sequenceFlow id="sf_ad_2_join_of_par_group" targetRef="join_of_par_group" sourceRef="ad_2"/>
        <bpmn:sequenceFlow id="sf_ad_3_join_of_par_group" targetRef="join_of_par_group" sourceRef="ad_3"/>
        <bpmn:sequenceFlow id="sf_join_of_par_group_ad_4" targetRef="ad_4" sourceRef="join_of_par_group"/>
        <bpmn:sequenceFlow id="sf_par_group_ad_3" targetRef="ad_3" sourceRef="par_group"/>
        <bpmn:startEvent id="start7" name="start">
            <bpmn:outgoing>sf_start7_ad_1</bpmn:outgoing>
        </bpmn:startEvent>
        <bpmn:userTask id="ad_1" name="Task 1">
            <bpmn:incoming>sf_start7_ad_1</bpmn:incoming>
            <bpmn:outgoing>sf_ad_1_par_group</bpmn:outgoing>
        </bpmn:userTask>
        <bpmn:userTask id="ad_4" name="Task 4">
            <bpmn:incoming>sf_join_of_par_group_ad_4</bpmn:incoming>
            <bpmn:outgoing>sf_ad_4_end8</bpmn:outgoing>
        </bpmn:userTask>
        <bpmn:userTask id="ad_2" name="Task 2">
            <bpmn:incoming>sf_par_group_ad_2</bpmn:incoming>
            <bpmn:outgoing>sf_ad_2_join_of_par_group</bpmn:outgoing>
        </bpmn:userTask>
        <bpmn:userTask id="ad_3" name="Task 3">
            <bpmn:incoming>sf_par_group_ad_3</bpmn:incoming>
            <bpmn:outgoing>sf_ad_3_join_of_par_group</bpmn:outgoing>
        </bpmn:userTask>
    </bpmn:process>
</bpmn:definitions>

PlanDefinition Representation

<?xml version="1.0" encoding="UTF-8"?>
<PlanDefinition xmlns="http://hl7.org/fhir">
    <id value="protocol-example"/>

    <text>
        <status value="generated"/>
    </text>

    <!--  The status of the protocol.draft | active | retired  -->
    <status value="draft"/>
    <action>
        <id value="ad_1"/>
        <title value="Task 1"/>
        <!-- related action definition -->
        <relatedAction>
            <actionId value="par_group"/>
            <relationship value="before-start"/>
        </relatedAction>
    </action>

    <action>
        <id value="par_group"/>
        <title value="par_group"/>
        <groupingBehavior value="logical-group"/>
        <selectionBehavior value="all"/>
        <action>
            <id value="ad_2"/>
            <title value="Task 2"/>
            <relatedAction>
                <actionId value="par_group"/>
                <relationship value="before-end"/>
            </relatedAction>
        </action>
        <action>
            <id value="ad_3"/>
            <title value="Task 3"/>
            <relatedAction>
                <actionId value="par_group"/>
                <relationship value="before-end"/>
            </relatedAction>
        </action>
        <relatedAction>
            <actionId value="ad_4"/>
            <relationship value="before-start"/>
        </relatedAction>
    </action>

    <action>
        <id value="ad_4"/>
        <title value="Task 4"/>
    </action>

</PlanDefinition>

Exclusive Split

Exclusive Split

Definition An exclusive choice is an element where the sequence flow is split into two or more branches, whereas only one of the branches can be activated with respect to a specified condition on the exclusive choice element.

Remarks A synchronization element is created implicitly

BPMN EclusiveGateway, ExtensionElement, TaskListener
PlanDefinition PlanDefinition.groupingBehavior, PlanDefinition.selectionBehavior

BPMN Representation

<?xml version="1.0" encoding="UTF-8"?>
<bpmn:definitions xmlns:dc="http://www.omg.org/spec/DD/20100524/DC" xmlns:bpmndi="http://www.omg.org/spec/BPMN/20100524/DI" xmlns:bpmn="http://www.omg.org/spec/BPMN/20100524/MODEL" xmlns:di="http://www.omg.org/spec/DD/20100524/DI" xmlns:xmi="http://schema.omg.org/spec/XMI" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" targetNamespace="http://aist.fh-hagenberg.at/msbpmn">
    <bpmn:process isExecutable="true" id="Process_aaa0c995-5dfd-43bc-bb05-3c08bda5f900" name="Process_aaa0c995-5dfd-43bc-bb05-3c08bda5f900">
        <bpmn:endEvent id="end12" name="end">
            <bpmn:incoming>sf_ad_4_end12</bpmn:incoming>
        </bpmn:endEvent>
        <bpmn:exclusiveGateway id="xor_group" name="Xor_group">
            <bpmn:incoming>sf_ad_1_xor_group</bpmn:incoming>
            <bpmn:outgoing>sf_xor_group_ad_2</bpmn:outgoing>
            <bpmn:outgoing>sf_xor_group_ad_3</bpmn:outgoing>
        </bpmn:exclusiveGateway>
        <bpmn:exclusiveGateway id="join_of_xor_group" name="join">
            <bpmn:incoming>sf_ad_2_join_of_xor_group</bpmn:incoming>
            <bpmn:incoming>sf_ad_3_join_of_xor_group</bpmn:incoming>
            <bpmn:outgoing>sf_join_of_xor_group_ad_4</bpmn:outgoing>
        </bpmn:exclusiveGateway>
        <bpmn:sequenceFlow id="sf_xor_group_ad_2" targetRef="ad_2" sourceRef="xor_group">
            <bpmn:conditionExpression id="sf_xor_group_ad_2_condition"/>
        </bpmn:sequenceFlow>
        <bpmn:sequenceFlow id="sf_ad_2_join_of_xor_group" targetRef="join_of_xor_group" sourceRef="ad_2"/>
        <bpmn:sequenceFlow id="sf_ad_3_join_of_xor_group" targetRef="join_of_xor_group" sourceRef="ad_3"/>
        <bpmn:sequenceFlow id="sf_join_of_xor_group_ad_4" targetRef="ad_4" sourceRef="join_of_xor_group"/>
        <bpmn:sequenceFlow id="sf_ad_4_end12" targetRef="end12" sourceRef="ad_4"/>
        <bpmn:sequenceFlow id="sf_xor_group_ad_3" targetRef="ad_3" sourceRef="xor_group">
            <bpmn:conditionExpression id="sf_xor_group_ad_3_condition"/>
        </bpmn:sequenceFlow>
        <bpmn:sequenceFlow id="sf_ad_1_xor_group" targetRef="xor_group" sourceRef="ad_1"/>
        <bpmn:sequenceFlow id="sf_start11_ad_1" targetRef="ad_1" sourceRef="start11"/>
        <bpmn:startEvent id="start11" name="start">
            <bpmn:outgoing>sf_start11_ad_1</bpmn:outgoing>
        </bpmn:startEvent>
        <bpmn:userTask id="ad_4" name="Task 4">
            <bpmn:incoming>sf_join_of_xor_group_ad_4</bpmn:incoming>
            <bpmn:outgoing>sf_ad_4_end12</bpmn:outgoing>
        </bpmn:userTask>
        <bpmn:userTask id="ad_2" name="Task 2">
            <bpmn:incoming>sf_xor_group_ad_2</bpmn:incoming>
            <bpmn:outgoing>sf_ad_2_join_of_xor_group</bpmn:outgoing>
        </bpmn:userTask>
        <bpmn:userTask id="ad_3" name="Task 3">
            <bpmn:incoming>sf_xor_group_ad_3</bpmn:incoming>
            <bpmn:outgoing>sf_ad_3_join_of_xor_group</bpmn:outgoing>
        </bpmn:userTask>
        <bpmn:userTask id="ad_1" name="Task 1">
            <bpmn:incoming>sf_start11_ad_1</bpmn:incoming>
            <bpmn:outgoing>sf_ad_1_xor_group</bpmn:outgoing>
        </bpmn:userTask>
    </bpmn:process>
</bpmn:definitions>

PlanDefinition Representation

<?xml version="1.0" encoding="UTF-8"?>
<PlanDefinition xmlns="http://hl7.org/fhir">
    <id value="protocol-example"/>

    <text>
        <status value="generated"/>
    </text>

    <!--  The status of the protocol.draft | active | retired  -->
    <status value="draft"/>
    <action>
        <id value="ad_1"/>
        <title value="Task 1"/>
        <!-- related action definition -->
        <relatedAction>
            <actionId value="xor_group"/>
            <relationship value="before-start"/>
        </relatedAction>
    </action>

    <action>
        <id value="xor_group"/>
        <title value="Xor_group"/>
        <groupingBehavior value="logical-group"/>
        <selectionBehavior value="exactly-one"/>
        <action>
            <id value="ad_2"/>
            <title value="Task 2"/>
            <condition>
                <kind value="applicability"/>
                <expression>
                    <description value="Some short description of the expression"/>
                    <language value="EL"/>
                    <expression value="$name==2" />
                </expression>
            </condition>
            <relatedAction>
                <actionId value="xor_group"/>
                <relationship value="before-end"/>
            </relatedAction>
        </action>
        <action>
            <id value="ad_3"/>
            <title value="Task 3"/>
            <condition>
                <kind value="applicability"/>
                <expression>
                    <description value="Some short description of the expression"/>
                    <language value="EL"/>
                    <expression value="$name==1" />
                </expression>
            </condition>
            <relatedAction>
                <actionId value="xor_group"/>
                <relationship value="before-end"/>
            </relatedAction>
        </action>
        <relatedAction>
            <actionId value="ad_4"/>
            <relationship value="before-start"/>
        </relatedAction>
    </action>

    <action>
        <id value="ad_4"/>
        <title value="Task 4"/>
    </action>

</PlanDefinition>

Timed Start

Timed Start

Definition A TimedStartEvent is a special StartEvent that has a TimerEvent associated with it, which defines when the process has to be executed.

BPMN Start-Event, End-Event, Sequence
PlanDefinition PlanDefinition.relatedAction, Before-Start

Remarks As PlanDefinition does not offer a specific action for either start or end, these BPMN-Elements are to be created implicitly. Whilst the start Event is based on the Elements in the first action in the list of actions in the PlanDefinition

BPMN Representation

<?xml version="1.0" encoding="UTF-8"?>
<bpmn:definitions xmlns:dc="http://www.omg.org/spec/DD/20100524/DC" xmlns:bpmndi="http://www.omg.org/spec/BPMN/20100524/DI" xmlns:bpmn="http://www.omg.org/spec/BPMN/20100524/MODEL" xmlns:di="http://www.omg.org/spec/DD/20100524/DI" xmlns:xmi="http://schema.omg.org/spec/XMI" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" targetNamespace="http://aist.fh-hagenberg.at/msbpmn">
    <bpmn:process isExecutable="true" id="Process_efb1f872-e958-4e7d-949f-a4bbf0f6c58f" name="Process_efb1f872-e958-4e7d-949f-a4bbf0f6c58f">
        <bpmn:endEvent id="end16" name="end">
            <bpmn:incoming>sf_ad_3_end16</bpmn:incoming>
        </bpmn:endEvent>
        <bpmn:sequenceFlow id="sf_ad_1_ad_2" targetRef="ad_2" sourceRef="ad_1"/>
        <bpmn:sequenceFlow id="sf_ad_2_ad_3" targetRef="ad_3" sourceRef="ad_2"/>
        <bpmn:sequenceFlow id="sf_ad_3_end16" targetRef="end16" sourceRef="ad_3"/>
        <bpmn:sequenceFlow id="sf_start15_ad_1" targetRef="ad_1" sourceRef="start15"/>
        <bpmn:startEvent id="start15" name="start">
            <bpmn:outgoing>sf_start15_ad_1</bpmn:outgoing>
            <bpmn:timerEventDefinition id="sampleTriggerDef">
                <bpmn:timeDate id="sampleTriggerDef_timeDate"/>
            </bpmn:timerEventDefinition>
        </bpmn:startEvent>
        <bpmn:userTask id="ad_1" name="Task 1">
            <bpmn:incoming>sf_start15_ad_1</bpmn:incoming>
            <bpmn:outgoing>sf_ad_1_ad_2</bpmn:outgoing>
        </bpmn:userTask>
        <bpmn:userTask id="ad_3" name="Task 3">
            <bpmn:incoming>sf_ad_2_ad_3</bpmn:incoming>
            <bpmn:outgoing>sf_ad_3_end16</bpmn:outgoing>
        </bpmn:userTask>
        <bpmn:userTask id="ad_2" name="Task 2">
            <bpmn:incoming>sf_ad_1_ad_2</bpmn:incoming>
            <bpmn:outgoing>sf_ad_2_ad_3</bpmn:outgoing>
        </bpmn:userTask>
    </bpmn:process>
</bpmn:definitions>

PlanDefinition Representation

<PlanDefinition xmlns='http://hl7.org/fhir'>
    <id value='protocol-example'/>

    <text>
        <status value='generated'/>
    </text>

    <!--  The status of the protocol.draft | active | retired  -->
    <status value='draft'/>

    <action>
        <id value='ad_1'/>
        <title value='Task 1'/>

        <trigger>
            <type value="periodic"/>
            <name value="sampleTriggerDef"/>
            <timingTiming>
                <event value="2015-02-07T13:28:17"/>
            </timingTiming>
        </trigger>


        <!-- related action definition -->
        <relatedAction>
            <actionId value='ad_2'/>
            <relationship value='before-start'/>
        </relatedAction>
    </action>

    <action>
        <id value='ad_2'/>
        <title value='Task 2'/>

        <!-- related action definition -->
        <relatedAction>
            <actionId value='ad_3'/>
            <relationship value='before-start'/>
        </relatedAction>
    </action>

    <action>
        <id value='ad_3'/>
        <title value='Task 3'/>
    </action>

</PlanDefinition>