New methods for clinical pathways-Business Process Modeling Notation (BPMN) and Tangible Business Process Modeling (t.BPM).

PURPOSE: Clinical pathways (CP) are nowadays used in numerous institutions, but their real impact is still a matter of debate. The optimal design of a clinical pathway remains unclear and is mainly determined by the expectations of the individual institution. The purpose of the here described pilot project was the development of two CP (colon and rectum carcinoma) according to Business Process Modeling Notation (BPMN) and Tangible Business Process Modeling (t.BPM). METHODS: BPMN is an established standard for business process modelling in industry and economy. It is, in the broadest sense, a computer programme which enables the description and a relatively easy graphical imaging of complex processes. t.BPM is a modular construction system of the BPMN symbols which enables the creation of an outline or raw model, e.g. by placing the symbols on a spread-out paper sheet. The thus created outline can then be transferred to the computer and further modified as required. CP for the treatment of colon and rectal cancer have been developed with support of an external IT coach. RESULTS: The pathway was developed in an interdisciplinary and interprofessional manner (55 man-days over 15 working days). During this time, necessary interviews with medical, nursing and administrative staffs were conducted as well. Both pathways were developed parallel. Subsequent analysis was focussed on feasibility, expenditure, clarity and suitability for daily clinical practice. The familiarization with BPMN was relatively quick and intuitive. The use of t.BPM enabled the pragmatic, effective and results-directed creation of outlines for the CP. The development of both CP was finished from the diagnostic evaluation to the adjuvant/neoadjuvant therapy and rehabilitation phase. The integration of checklists, guidelines and important medical or other documents is easily accomplished. A direct integration into the hospital computer system is currently not possible for technical reasons. CONCLUSION: BPMN and t.BPM are sufficiently suitable for the planned modelling and imaging of CP. The application in medicine is new, and transfer from the industrial process management is in principle possible. BPMN-CP may be used for teaching and training, patient information and quality management. The graphical image is clearly structured and appealing. Even though the efficiency in the creation of BPMN-CP increases markedly after the training phase, high amounts of manpower and time are required. The most sensible and consequent application of a BPMN-CP would be the direct integration into the hospital computer system. The integration of a modelling language, such as BPMN, into the hospital computer systems could be a very sensible approach for the development of new hospital information systems in the future.

Crystal-packing-induced antiferromagnetic interactions of metallocenes: cyanonickelocenes, -cobaltocenes, and -ferrocenes.

The cyano-substituted metallocenes [M(C5H4CN)2] (M=Fe, 1; Co, 2; Ni 3) and [M(C5Me5)(C5H4CN)] (M=Fe, 4; Co, 5; Ni, 6) were synthesized in yields up to 58 % by treating K(C5H4CN) or Tl(C5H4CN) with suitable transition-metal precursors. Cyclic voltammetry indicated that the oxidation and reduction potentials of all the cyanometallocenes were shifted to positive values by up to 0.8 V. Single-crystal X-ray structure analysis showed that 1 had eclipsed ligands, formed planes in the lattice, and--unlike usual metallocenes--lined up in stacks perpendicular to these planes. Powder X-ray studies established that 1 and 2 are isotypic. The 1H and 13C NMR spectra were recorded for all the new compounds. Signal shifts of up to delta=1500 ppm were recorded for the paramagnetic molecules 2 and 3 and were, at a given temperature, strikingly different for solution and solid-state spectra. These results pointed to antiferromagnetic interactions as a consequence of molecular ordering in the lattice, as confirmed by magnetic measurements. The temperature-dependent susceptibilities were reproduced by Heisenberg spin-chain models (H=-J sum n- 1 i=1 SiSi+1), thus yielding J=-28.3 and -10.3 cm(-1) for 2 and 3, respectively, whereas J=-11.8 cm(-1) was obtained for 3 from the Ising spin-chain model. In accordance with molecular orbital (MO) considerations, much spin density was found to be delocalized not only on the cyclopentadienyl ligand but also the cyano substituents. The magnetic interaction was interpreted as a Heitler-London spin exchange and was analyzed based on how the interaction depends on the singly occupied MOs and the shift of parallel metallocenes relative to each other.