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© 2002 Schattauer GmbH

Systems Analysis in Health Care:

Framework and Example
E. Ammenwerth1, F. Ehlers1, R. Eichstädter2, R. Haux1, U. Pohl3, F. Resch2
1
Department of Medical Informatics, University Medical Center Heidelberg, Germany
2
Department of Psychiatry, University Medical Center Heidelberg, Germany
3
Department of Dermatology, University Medical Center Heidelberg, Germany

Summary
Objectives: Due to the high complexity of structures
1. Introduction: Systems systems analysis in a health care institution
is the precondition for all activities aiming
and processes in health care, thorough systems analy- Analysis in Health Care at improving structures and processes in
ses in health care run the risk of becoming very com- health care, such as business process reen-
plex and difficult to handle. Therefore, we aimed to gineering, quality management, or the in-
support systematic systems analysis in health care by
1.1 Background and Motivation troduction of new information processing
developing a comprehensive framework that presents The complexity of information processing tools [3]. The more precise the analysis, the
and describes potential areas of analysis. in health care institutions is tremendous better the structures and processes of the
Methods: A framework for systems analysis in health due to the high complexity of their struc- institution can be redesigned, improved or
care was developed and applied in a health care set- tures and processes. Nearly everyone work- supported [7, 8].
ting. To provide a clear structure, the framework de-
ing in a hospital has an enormous demand Due to the high complexity and inter-
scribes the potential views and levels of systems anal-
yses in a health care environment. for information, which must be fulfilled to connectivity of workflow, information man-
Results: The framework comprises five views (roles guarantee excellent and efficient patient agement, communication and cooperation,
and responsibilities, information processing and tools, care [1, 2]. To achieve high-quality patient thorough health care systems analyses run
communication, business processes, teams structure care, different professional groups, such as the risk of becoming very complex and dif-
and cooperation) and five levels of analysis (overall physicians, nurses, and administrative staff, ficult to handle. If relevant parts are over-
organization, organizational unit, staff member, role, must communicate and cooperate closely looked, insufficient systems analyses may
task). The framework was successfully applied in an [3, 4]. The stakeholders’ issue is quite com- even lead to project failures [9, 10]. For ex-
analysis of the structures and processes of the Depart- plex [5]. Patient care aims must be dis- ample, an insufficient analysis of communi-
ment of Child and Adolescent Psychiatry of the Univer- cussed, decided upon and revised in treat- cation may lead to the failure of a new elec-
sity Medical Center Heidelberg. ment teams, which are made up of different tronic record system [11].
Conclusions: The proposed comprehensive framework
members for each patient. Processes are In our opinion, a description of the pos-
aims to structure the views and levels of systems anal-
ysis in the complex health care environment. Our first highly variable and flexible, standard sible views and levels of a systems analysis
experiences support the usefulness of such a frame- ‘reference’ patient care processes are diffi- in health care could help clearly define the
work. cult to define. Patients receive individual areas requiring analysis without overlook-
treatment – not only in emergency cases ing relevant parts.
Keywords that demand immediate care. Decisions Approaches used in more structured en-
Systems analysis, communication, coordination, must be made quickly and are often based vironments do not seem useful in assessing
patient care team, delivery of health care, process on incomplete information. Therefore, the complexity surrounding health care.
assessment systematic information management is of For example, available frameworks for
tremendous importance in order to plan, computer-based enterprise information
Methods Inf Med 2002; 41: 134–40 monitor and direct information processing systems – such as ARIS (Architecture of
in such a way that the information needs of Integrated Information Systems) [12], or
the various user groups are fulfilled in any the Zachmann framework [13], concentrate
situation and location [6]. on the computer-supported part of an in-
The quality of information management formation systems, often omitting, for ex-
can only be assessed by rigorous systems ample, an explicit analysis of the specific
analysis. The general aim of such an analy- complexity surrounding health care, such as
sis is to analyze the current state and weak- paper-based information processing, com-
nesses of organizational structures and munication and cooperation within the
processes in a defined area. A thorough health professional team.Thus, they are not
Received February 22, 2001
Methods Inf Med 2/2002 Accepted November 5, 2001
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Systems Analysis in Health Care

completely sufficient to describe and evalu-

ate the complex structures and processes 2. A Framework as well as communication and, especially,
cooperation within the health care profes-
surrounding information processing in hos- for System Analysis sional team have often been overlooked, al-
pitals. though information processing in health
We feel that a distinctive health care A framework is a supportive structure or care institutions often suffers from weak-
systems analysis framework presenting po- frame [14]. A framework for systems analy- nesses in these areas [15, 16].
tential areas for analysis could help define sis should, therefore, structure an analysis In order to include these important as-
the focus of such an analysis explicitly. This in health care. Our framework will focus on pects, we propose the following five main
may even improve the quality and com- the question: “What can be analyzed?” To views for systems analysis in health care in-
pleteness of systems analyses. answer this question, we differentiate stitutions:
between: Roles and responsibilities: Analysis of
● views of systems analysis in health care the roles of health care professionals, their
and activity profiles, their responsibilities, and
1.2 Aim of this Paper ● levels of systems analysis in health care. the organizational hierarchies and decision
The aim of this paper is to present a com- structures. Weaknesses that may be found
prehensive framework to support systems during systems analysis include unclear re-
analyses in health care institutions. It de- 2.1 Views of Systems Analysis sponsibilities, or conflicting roles.
scribes the potential views and levels of Information processing and information
such analyses to support a clear structure of
in Health Care processing tools: Representation of the in-
systems analysis. The theory of systems analysis proposes formation processing functions, such as reg-
Developing a health care-specific different views on a complex object and istering, storing and archiving information,
framework for systems analysis is a chal- supports the selection of one or more of as well as the used information processing
lenging task that requires long-term studies these views depending on the question of tools (paper or computer-based). Weak-
and evaluations of its own. In the present interest. It is helpful to find main views for nesses that may be found include redun-
paper, we illustrate our first attempt at pro- systems analysis that may then be refined dant documentation, insufficient number of
viding such a framework. A comprehensive to fit a concrete analysis. information processing tools, or violation
systems analysis of the Department of Most often information systems analysis of data integration.
Child and Adolescent Psychiatry of the focuses on views relevant for software engi- Communication between health care
Heidelberg University Medical Center neering, such as data flow, workflow, and professionals: Representation of the com-
served as a first application of the frame- the information processing tools used [7]. munication processes taking place between
work. We will present the framework and Health care-specific aspects, such as re- the various roles, both indirect and direct
discuss our experiences with its application. sponsibilities, decision-making processes, information exchange, including meetings,
briefings, postings, etc. Weaknesses that
may be found include redundant communi-
cation or communication breaches.
Business processes: Representation of
the logical and temporal sequences of ac-
tivities. Weaknesses that may be found in-
clude redundant work routines, unclear
process definitions, waiting times, or miss-
ing feedback of process results.
Team structure and cooperation within
the teams: Representation of the structures
of the multi-professional health care team,
description of the cooperation between
team members, and teams. Weaknesses that
may be found include a high effort for
cooperation, insufficient definition of team
aims, and an unclear team structure for a
particular patient.
Each view favors a particular perspec-
Fig. 1 Framework for systems analysis in health care: A systems analysis project can be described by the view tive and emphasizes certain aspects of in-
of analysis (roles and responsibilities, … teams and cooperation) and by the level of analysis (overall organization, …, formation processing in health care. Each
task). The gray boxes point out the examples of our project, which are described in Chapter 3. view represents a cluster of more refined

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systems analysis questions. Any systems Often, several views and/or levels will be Systems analysis was performed by
analysis may focus on one or more of the combined. combining standardized questionnaires,
views depending on the aims of the respec- Of course, some of the weaknesses of partially standardized interviews, and ob-
tive systems analysis project. the health care institution will appear in servations. The overall project began in Oc-
several views. For example, frequently miss- tober 1999. Over a time period of 8 months,
ing information during physician rounds approx. 60 interviews with nearly all of the
2.2 Levels of Systems Analysis may be reflected in the business process staff members and observations of 20 meet-
view, as well as in the information process- ings were conducted. 30 questionnaires
in Health Care ing view. were answered (return rate was approx.
Occupational psychology proposes analyz- For each view and level, specific analyti- 60%) and around 135 types of paper-based
ing an organization on different levels us- cal methods and descriptions may be useful forms were analyzed.
ing a stepwise approach: beginning with the and should be selected carefully before car-
level of the overall organization, and end- rying out the analysis. Some examples are:
ing with the analysis on each task [17]. This Roles and responsibilities could be de-
approach is also useful for analyzing scribed using organigrams or UML use cas-
3.2 Analysis Examples and Results
systems in health care. However, we pro- es [18], information processing and infor- In the next paragraphs, we will present dif-
pose adding the level of a role, as staff mation processing tools using the 3LGM ferent aspects of the project. We will focus
members in health care will often fill differ- [19], communication using speech act mod- on distinct areas of analysis. For each area,
ent roles simultaneously (e.g., a doctor who els [16], business processes using event- we will briefly describe the aims and means,
is senior physician, director of a depart- driven process chains or petri-nets, and and present some examples of the results to
ment, and a researcher).Thus, five different cooperation using action workflow models illustrate how our analysis fits into certain
levels of systems analysis can be identified: [20]. parts of the proposed framework (cp. also
● the overall organization (e.g., a depart- Fig. 1). A detailed presentation and discus-
ment); sion of methods used in the analysis and of
● an organizational unit (e.g. a ward or an the results are described in [21] (study
outpatient unit of a department);
● an individual staff member (e.g. a nurse
3. Example: Application plan) and [22] (study results).

or a physician); of the Framework in a System Example 1: Analysis of Roles

● a role (e.g. the role of senior physician or
the role of a patient);
Analysis and Responsibilities
● a task (e.g. patient admission or clinical In the following example, we will present One part of this analysis described the roles
documentation). the use of the framework in a systems anal- in the department, together with their re-
ysis in a health care environment, and re- sponsibilities, and the typical activity pro-
These five levels can be used in each of the port some of the results. The aim is to dem- files of the staff members. The analysis of
five views of systems analysis described onstrate, how the framework helped to the activity profiles was carried out on a
earlier. structure an actual systems analysis project role level in form of interviews. The aggre-
in health care. gated activity profiles of some roles are
presented in Table 1.
2.3 A Framework for Time expended for coordinating care
was found to be very high.A further analysis
Systems Analysis in Health Care 3.1 Project Description of the daily activities of some roles showed
By combining the five views and the five We used the proposed framework to struc- extremely fragmented time schedules due
levels, 25 areas of systems analysis can be ture a broad systems analysis within an on- to firmly scheduled meetings and frequent
defined. Figure 1 shows the potential areas going reorganization project within the De- disturbances due to telephone calls.
of systems analysis proposed by this frame- partment of Child and Adolescent Psychia- The overall results of a more detailed
work. try of the Heidelberg University Medical analysis led to a proposal to reorganize the
The optimal combination of views and Center. The aim of the project was to find meetings in order to optimize free time for
levels must be chosen for each systems main weaknesses and to propose solutions patient treatment.
analysis according to the project aims. Each for a reorganization of the treatment pro-
combination of view and level must then be cess. In a first step, a detailed systems anal- Example 2: Analysis of Information
further refined to derive the concrete study ysis of the current state and weaknesses in
Processing and its Tools
questions for certain aspects (e.g., only the the organization of patient care was con-
computer-based information processing ducted, which was structured with the help For an analysis of this view, we focused on
tools may be of interest for one project). of the framework. the purpose and content of documentation,

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Table 1 Proportion of time spent during a typical week by the different roles on activities regarding patient treatment in Altogether, approximately 135 different
the Dept. of Child and Adolescent Psychiatry Heidelberg. The percentages and hours are mean estimates based on interviews. types of paper-based forms are available;
Only the activities regarding patient treatment are included, others (e.g. research) are not included. while many are rarely used, others have
even become obsolete. Some main docu-
mentation (e.g., therapeutic documenta-
tion) is conducted using an unstructured,
hand-written manuscript instead of using
forms. The overall results of a more de-
tailed analysis led to a proposal to intro-
duce a multi-professional electronic patient
record, which should minimize paper-based
forms and improve the availability of infor-
mation.

Example 3: Analysis of Communication

For a communication analysis, we focused
on the communication between roles, their
structure, purpose and the tools used for
communication. Analysis was mainly con-
ducted on the role and staff member level
by observing meetings, conducting inter-
views, and using questionnaires. Overall, we
found that much inter- and intra-profes-
sional communication is needed inside the
the forms and information processing tools ent professional groups use their own docu- multi-professional health care team. Staff
used, the structure of patient records and mentation systems. Information is spread members in different roles judge the rele-
how they were archived, since some weak- over several media and over several main vance of communication as very high. How-
nesses were expected in this area.This anal- patient records, hindering fast access and ever, no clear communication concept is
ysis was conducted both on the overall or- resulting in high time losses during the available for how and when to use the dif-
ganizational level (e.g., which forms and IT- search for necessary information. ferent communication types and media,
tools are generally used) and on the task As an example of our results, Table 2 such as synchronous telephone communi-
level (e.g., which forms are used for a given shows the overall number of different types cation, pagers and mobile phones, meetings
task). Our results showed that a complete of paper-based forms available to support and seminars, as well as asynchronous com-
computer-based patient record is currently patient care. Many forms are primarily spe- munication by voice mailbox, fax, and con-
not available in the department. While part cific to this department, whereas the ad- ventional and electronic mail. The amount
of the documentation is conducted elec- ministrative forms and order entry forms of written communication was analyzed for
tronically, most is still paper-based. Differ- are mostly standardized hospital-wide. the most important roles. Figure 2 presents
some examples of the results.
This detailed analysis of the communi-
cation behavior of individual staff members
Table 2
in their roles led to a proposal to restruc-
Number of different types of
paper-based forms available ture the communication media, and to in-
in the Dept. of Child and troduce workflow management facilities
Adolescent Psychiatry Hei- within the planned electronic patient
delberg, sorted by main record in order to better support communi-
patient treatment tasks.
cation.

Example 4: Analysis of Business Processes

The aim of the business process analysis
was to define and describe the most impor-
tant business processes of the department.
The analysis was carried out on the task

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Fig. 2 Content, frequency and media of the main written communication between different roles involved in patient care in the Dept. of Child and Adolescent Psychiatry Heidelberg. The
communication is described from one distinct physician’s point of view. The communication media used is indicated by: M = by conventional mail, E = by e-mail. The frequency of communication
is indicated by: m = monthly, w = weekly, d = daily.

level by conducting interviews and obser- cesses, such as therapy planning. This be-
vations. Major processes were then ana- came apparent, for example, in different 4. Discussion
lyzed on a more detailed level. Figure 3 views mentioned by the respondents on
presents an example of a modeling excerpt how certain processes should flow. The We presented a framework for systems
of the first steps of the admission process. analysis of activities and business processes analysis in health care, which offers five
One of the results of business process led to a proposal to define and then reorga- views and five levels of analysis. In our
analysis was that no clear agreement was nize some of the main business processes, opinion, this framework can support
defined in regard to some important pro- such as admission and therapy planning. systems analysis projects by suggesting a

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In using the suggested framework, it be-

came clear that certain weaknesses may oc-
cur in different views. For example, unclear
decision structures occur in the roles and
responsibilities view and again in the de-
tailed view of individual business processes.
This does not question the framework, but
rather reinforces the need for a clear defini-
tion of the aims targeted by the analysis. In
any systems analysis project, the views and
levels most important to the project must
be determined. A broad analysis, covering
all 25 aspects, will rarely be of use.
Our work was based on the assumption
that the complexity in health care organiza-
tions requires a distinct analysis frame-
work. While this assumption can be dis-
cussed, we found the stronger focus on non-
technical aspects of roles and communi-
cation and cooperation, in contrast to
‘traditional’ systems analysis frameworks,
as very useful to our project.
Of what use could the presented frame-
work be? First, it can support the prepara-
tion of systems analysis projects by helping
Fig. 3 Example of a business process: the first steps of the admission process in the Dept. of Child and Adolescent to find adequate views and levels of the
Psychiatry Heidelberg, modeled using an UML activity diagram. analysis, and to structure it. Second, the
framework can help compare analysis pro-
jects by illustrating the views and levels of
structure to describe and organize an analysis and ending with ‘teams and cooperation’, analysis used in each. This may help, for ex-
in a health care environment.The framework seemed useful. We did not overlook any ample, to find similar projects and learn
was used to plan a systems analysis in a views or levels in the framework during our from their methods or procedures. Third,
department of the University Medical Center project. However, the framework was de- the framework may be used to arrange spe-
of Heidelberg. We presented some results veloped for a specific project, thus its appli- cific methods of analysis for certain views
of this analysis to show how the proposed cation in our project is no proof of its com- or levels, which may help the project man-
framework reflects different aspects of such pleteness. The framework must now be ager select suitable methods.
an analysis. Only some results have been used to structure future systems analysis
presented, the overall analysis included projects to further evaluate its usefulness
more analysis aspects of the selected views and completeness.
and levels than could be presented here.
Our examples illustrate that our first ex-
The proposed framework focuses on
views and levels of an analysis, not on the
5. Conclusion
periences have been positive in using this methods and procedures that can be ap- In this paper, we presented a framework for
framework in a structured systems analysis plied. We did not recommend special meth- systems analysis by combining five views
of a cooperative health care environment. ods on how to analyze a specific level or a and five levels of investigation. Our first ex-
Identifying five views helped us find a bet- specific view in the best way. The focus of a periences support the usefulness of this
ter structure for various aspects of systems systems analysis and which methods are ap- framework. It is important to stress that our
analysis. Of course, selecting an adequate plied depend on the specific questions of proposed framework does not represent a
view(s) is only the first step towards a more interest and the basic project aims. How- guideline for an overall systems analysis.
detailed study plan which further describes ever, presenting possible methods would be Depending on the research aims, separate
the study aims and study questions.The five helpful when planning a systems analysis. analysis areas should be defined and appro-
levels we proposed helped us select the cor- Thus, further work in this area may be very priate parts of the framework selected and
rect level of analysis. From our experience, interesting and may lead to a systematic further refined.
a predefined order of analysis, beginning guideline for planning and executing The framework should now be verified
with the area ‘roles and responsibilities’, systems analyses in health care. in other cooperative health care institu-

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tions.We hope that this framework will also 6. Winter A, Ammenwerth E, Bott O, Brigl B, Bu- 17. Dunckel H, Volpert W, Zölch M, Kreutner U,
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