# Process-Aware Enactment of Clinical Guidelines through Multimodal Interfaces
## 3 Enactment of Clinical Guidelines with TESTMED  
The main challenge tackled by the TESTMED project was to reduce the gap between the fully automated solutions provided by the BPM community and the clear difficulties of applying a traditional process management approach in the healthcare context. To realize this vision, the major outcome of the project was the development of a clinical PAIS, referred to as a TESTMED system, enabling the interpretation and execution of CGs and their presentation to doctors and medical staff through multimodal user interfaces. The TESTMED system is thought to be used when a patient suffering from a medical condition (amenable to a CG) asks for a visit. Doctors are provided with a tablet PC (supporting touch and vocal interaction) that runs the TESTMED system. Thus, the doctor is enabled to select, instantiate, and carry out specific CGs. For example, in the case of chest pain, the doctor starts filling a survey for determining the severity of the patient's medical condition, which is expressed through a chest pain score (cf. also Section 2.3). The survey is presented to the doctor on the graphical user interface (GUI) of the tablet PC where the TESTMED system is installed (see Figure 4a). The interaction can be performed by exploiting the touch features of the tablet, or, vocally, through integrated speech synthesis and recognition. The grey icon with a microphone that is located at the top-right of the GUI in Figure 4a is shown only when the interaction shifts from touch to vocal. It serves as a visual feedback that the vocal interaction is properly working. The vocal interaction requires that the doctor wears a headset (The use of a headset guarantees both a higher quality of the vocal interaction in a noisy environment like the hospital ward's one, and that the privacy of the visited patient is preserved) with a microphone linked to the tablet; s/he can listen to the questions related to the survey and reply vocally by choosing one of the speech-synthesized possible answers. Each answer is associated with a specific characteristic and provides an associated rate. Figure 3: The list of clinical characteristics to calculate the chest pain score. Once the survey is completed, the TESTMED system elaborates a dedicated therapy including a sequence of clinical treatments and analysis prescribed to the patient. The therapy is structured in the form of a _care pathway_. As an instance, when the chest pain score is greater than 4, the suggested care pathway is the one shown in Figure 5. For the sake of readability, we have modeled the care pathway in the _Business Process Modeling Notation_ (BPMN is a standard ISO/IEC 19510:2013, cf. [[https://www.iso.org/standard/62652.html](https://www.iso.org/standard/62652.html)]([https://www.iso.org/standard/62652.html](https://www.iso.org/standard/62652.html)), to model business processes). The reader should notice that BPMN is not the notation employed to concretely represent and encode a CG in the TESTMED system (to this aim, we used PROforma language [34], as explained in Section 4), but it is used here to show (in a comprehensive way) how care pathways usually look like. Figure 4: The multimodal GUI adopted by doctors. The care pathway in Figure 5 includes, first of all, that the patient is subjected to some general blood analysis, which must be repeated for a second time after four hours. Once the analysis results are ready, the doctors assess them to decide if the patient should be hospitalized or not. Specifically, if the results are not good, the care pathway in Figure 5 provides instructions on performing further tests to the patient (in this case, a hemodynamics consulting and a coronary catheterization) and, based on the results obtained, to activate a further procedure concerning the hospitalization of the patient.