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Application of Unified Modelling Language (UML) to the Modelling of Health

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Article  in  International Journal Of Healthcare Information Systems And Informatics · October 2010

DOI: 10.4018/jhisi.2008100103

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 Application of Unified Modelling Language (UML) to

the modelling of health care systems: an

introduction and literature survey

Christos Vasilakis1*, Dorota Lecnzarowicz2 and Chooi Lee3

1
Clinical Operational Research Unit, University College London

2
Harrow School of Computer Science, University of Westminster

3
Care for Elderly, Kingston Hospital NHS Trust

Submitted to the special issue on joint advances in IS and OR

*Corresponding author

Dr Christos Vasilakis
Clinical Operational Research Unit
University College London
4 Taviton Street
London WC1H 1BT
voice: +44(0)20 7679 4507
fax: +44(0)20 7813 2814
email: c.vasilakis@ucl.ac.uk
UML in health 1

Application of Unified Modelling Language (UML) to

the modelling of health care systems: an

introduction and literature survey

Abstract

The Unified Modelling Language (UML) comprises a set of tools for

documenting the analysis of a system. Although UML is generally used to

describe and evaluate the functioning of complex systems, the extend of

its application to the health care domain is unknown. The purpose of this

paper is to survey the literature on the application of UML tools to the

analysis and modelling of health care systems. We first introduce four of

the most common UML diagrammatic tools, namely use case, activity,

state and class diagrams. We use a simplified surgical care service as an

example to illustrate the concepts and notation of each diagrammatic tool.

We then present the results of the literature survey on the application of

UML tools in health. The survey revealed that although UML tools have

been employed in modelling different aspects of health care systems,

there is little systematic evidence of the benefits.

UML in health 2

Introduction

Health care systems are known to be complex and as a result difficult to

analyse and re-engineer (Berwick, 2005). Health system engineers often

rely on computer modelling and simulation to assist with the analysis of

existing systems and the pre-testing of suggested changes. To this

extend, a variety of software engineering techniques and tools has been

employed (Jun, 2007). Examples include data flow diagram (Pohjonen et

al., 1994), state transition diagram (Mehta, Haluck, Frecker, & Snyder,

2002), entity relationship diagram (Kalli et al., 1992), integrated definition

or IDEF (Hoffman, 1997), and more recently, Unified Modelling Language,

commonly known as UML (Object Management Group, 2005).

UML provides a comprehensive set of tools that can be used for

documenting the analysis of a system and for developing model

requirements. UML diagrams are graphical depictions that demonstrate

the flow of events within the system (Object Management Group, 2005).

Depending on the perspective chosen for the study (e.g. actor oriented,

activity oriented) different tools are available to the analyst. Due to its

versatility and the ability to analyse systems from different perspectives,

UML is said to be effective in describing and evaluating the functioning of

complex systems such as health care. (Kumarapeli, De Lusignan, Ellis, &

Jones, 2007) However, there seems to be very little systematic evidence

on its benefits.

The focus of the paper is to review the literature on the application of UML

tools to the analysis and modelling of health care systems. To this end we

first briefly introduce four of the most common UML diagrammatic tools,
UML in health 3

namely use case, activity, state and class diagrams. We use a simplified

surgical care service as an example to explain the notation and concepts

of each diagrammatic tool. Next, we present the results of the literature

survey on the application of UML in health. The survey revealed that

studies of the benefits of UML to health evaluation are an exception and

most studies have used UML without an evaluative component. We

conclude with a brief discussion of the results.

UML in health 4

UML diagrammatic tools

In theory, UML 2.0 has 13 types of diagrams, which can be categorised

hierarchically as follows (Object Management Group, 2005):

• Structure diagrams used to represent the elements of the system

being modelled. They include class, component, composite structure,

deployment, object, and package diagrams.

• Behaviour diagrams that allow the representation of what happens in

the modelled system in the activity, state, and use case diagrams.

• Interaction diagrams, a subset of behaviour diagrams, that allow the

representation of the control and data flow among the elements of the

system being modelled. These are communication, interaction

overview, sequence, and timing diagrams.

We briefly introduce here the four UML diagrammatic tools that appear in

the surveyed literature, namely, use case and use case diagram, activity,

state and class diagram. A full description of the concepts and syntax of

UML diagrams is beyond the scope of this report. A plethora of user guides

and technical notes are available on the subject, with the monograph by

Amber (2004) a particularly useful introduction.

We illustrate the basic concepts and notation of each diagrammatic tool by

presenting simple models of a simplified care process of surgical

consultation with patient in outpatient clinic. In general, physicians refer

patients for surgical consultation if they believe the underlying health

problem is amenable to surgical intervention. Following the referral, the

outpatient clinic books the patient an appointment with the surgeon and
UML in health 5

also arranges for samples to be taken if further diagnostic tests are

required. At the consultation, the surgeon assesses the need for an

operation by evaluating symptoms and test results. Following a decision to

operate, the patient’s name is registered on a prioritised surgical wait list

so that appropriate time can be booked at the operating theatre of a

hospital. The patient may also be educated about the operation by a

specialist nurse. If an operation is not deemed suitable, then the patient

may be further referred for medical treatment.

USE CASES AND UML USE CASE DIAGRAMS

In software and system engineering, a use case is a technique for

capturing the functional requirements of a system (Object Management

Group, 2005). Each use case provides one or more scenarios that convey

how a specific part of the system interacts with the users (called actors)

to achieve a business goal or function. There is no standard format for

detailing use cases but some tabular layout is commonly used.

The UML use case diagram on the other hand allows the graphical

representation of a set of use cases. The UML standard sets out a specific

graphical notation (Object Management Group, 2005). Use cases and UML

use case diagrams not only provide clarity in terms of actors and

sequence of steps involved in the event but also serve as a useful tool to

present details of the actor’s progression in the system.

Figure 1 shows a use case diagram depicting the process of surgical

consultation with patient in outpatient clinic. Actors are represented by

stick figures and use cases by ovals. Associations between actors and use

cases are depicted by edges. The “uses” arrow points to a use case that is
UML in health 6

always invoked, while the “extends” to a use case that is conditionally

invoked. In the example, the surgeon always evaluates the patient

symptoms and the test results. The outpatient clinic nurse may order

additional tests when booking the appointment, which in turn, may

require taking samples (e.g. blood) from the patient. The actor “Patient

requiring surgical consultation” is a type of the generic actor “Patient”, an

example of the common construct of specialisation/generalisation.

[Figure 1]

UML ACTIVITY DIAGRAM

The purpose of the activity diagram is to depict the procedural flow of

actions that are part of a larger activity (Object Management Group,

2005). In projects in which use cases are generated, activity diagrams can

model a specific use case at a more detailed level. Activity diagrams can

be also used independent of use cases for modelling a function, such as

admission to hospital or discharge procedure. They can also be used to

model system functions, such as computerised physician order systems,

and complete patient pathways, such as from admission to hospital to

discharge. Activity diagrams also allow the depiction of parallel activities

that often occur in health systems.

In the UML activity diagram, which is based on the semantics of Petri

nets, each activity is represented by a rounded rectangle. An arrow

represents the transition from one activity to another. The starting point is

represented by a filled-in circle and the endpoint by a bull’s-eye. Activities

enclosed within parallel bars happen at the same time. Diamond shaped
UML in health 7

objects denote a decision mandated by conditions stated in the brackets

above the arrows.

Figure 2 shows a UML activity diagram that models the exemplar surgical

care process. Following the referral to the outpatient clinic, booking the

appointment and ordering of the diagnostic tests happen in parallel (for

the purposes of this example). Depending on the outcome of the

consultation, the patient’s name is registered on the surgical waiting list if

operation is deemed necessary and the patient may receive education

about the operation, otherwise the patient is referred for medical

treatment.

[Figure 2]

UML STATE DIAGRAM

The UML state diagram is essentially a Harel (1987) Statechart with

standardized notation that can describe any system that is (or can be

conceptualised as) reactive, from computer programs to business

processes. In this context, a reactive system –as opposed to a

transformational system– is a system that constantly responds to internal

and external stimuli by changing states or by performing some action.

Like state machines, a UML state diagram includes state-transition

diagrams that represent the operations of a system through discrete

states and transitions from one state to another. In addition, state

diagrams include notions of state hierarchy, parallelism, and event

broadcasting (Sobolev, Harel, Vasilakis, & Levy, 2008).

In UML state diagrams rectangles represent states and arrows represent

transitions. An arrow may have a transition label that controls the

UML in health 8

transition. The label includes the events that trigger the transition, and

the condition that needs to be true for the transition to occur in square

brackets. The actions associated with the transition also appear on the

labels following the forward slash. Drawing states inside other states

represents hierarchy. Dashed rectangles symbolise parallel states.

Figure 3 shows a UML state diagram of patient states in the example of

surgical care service. Following the referral to clinic, the initial sub-states

called “Pending” of parallel states “Appointment” and “Diagnostic tests”

are activated. When the event “make booking” is fired and if there are

available slots in the clinic, the patient is considered to have the

appointment booked. Once the treatment has been decided and

depending on the outcome, the patient state transitions to ‘Surgical

waiting list’ and ‘Education’, or to ‘Waiting for medical treatment’.

[Figure 3]

UML CLASS DIAGRAM

A class diagram describes the static structure of a system by showing the

system's classes, their attributes and methods, and the relationships

between the classes (Object Management Group, 2005).

A class, indicated by a rectangle, can be thought of as a blueprint for

defining similar objects. Each object is an instance of a class and

encapsulates both state, in terms of attributes, and behaviour, in terms of

methods. Attributes (or properties) are shown in an optional compartment

below the class name. Each attribute is shown with at least its name, and

optionally with its type, initial value, and other information. The class

methods (or operations) appear in a second optional compartment. Each

UML in health 9

method is shown with at least its name, and additionally with its

parameters and return type. The association between two classes is

indicated by a line. The number of objects participating in the association,

known as multiplicity, is given by an optional notation at each end of the

line (‘0..1’ if none or only one object participates in the association, ‘1’

exactly one, ‘0..*’ zero or more, ‘1..*’ at least one).

In the example shown in Figure 4, a patient may have none, one or more

referrals (on different dates). Each referral has a priority, is made to

named surgeon and the appointment slot is updated once it has been

scheduled. Patient names are placed on the surgical list of a surgeon

following the consultation. A surgeon may be associated with no patients

or many. A class diagram may convey a lot more information that is

omitted here in the interests of brevity.

[Figure 4]
UML in health 10

Application of UML tools to health care

For the literature survey, we searched the medical literature for articles

that demonstrate the application of UML tools to the broad area of health

care. We included all articles that demonstrated the application of any of

use case and UML use case diagram, UML activity diagram, UML state

diagram, and UML class diagram. Eighteen papers were identified to be

relevant to this review, found via published (as listed in Pubmed) and grey

literature search. The literature survey identified use cases and use case

diagrams (11 papers), and activity diagrams (13) as the most common

UML tools of the four included in this survey used in health system

analysis. Some studies have reported on the use of class diagrams (3) but

none on the use of UML state diagrams. The search yielded very little

evidence of a systematic evaluation of the benefits of using UML in the

analysis of health care systems.

The retrieved literature can broadly be classified into three categories

according to the application domain: modelling health care processes,

evaluating and modelling clinical guidelines, and evaluating and

generating requirements of information systems in health care. We now

briefly review each collected article according to the these categories.

MODELLING HEALTH CARE PROCESSES

Recent work by Jun et al. (2005; 2007) aimed at providing the effective

application of various modelling methods to health care with the end goal

of enabling professionals and managers to understand care process more

clearly, manage risk and as a result improve patient safety. Among the

modelling methods evaluated was the swim lane activity diagram, which is
UML in health 11

a variation of UML activity diagram where activities are grouped according

to the actors involved or in a single thread. Three case studies were used

to illustrate the methods: patient discharge, diabetic care process in GP

practise and prostate cancer diagnosis process in the hospital. The

findings of the case studies were evaluated against benchmark goals of

enhancing understanding and validated via key user review of findings.

Cruz et al. (2002) reported on the experience of the using UML use case

diagrams as a tool to optimise hospital processes. The diagrams were

developed at two levels of abstraction: a global use case diagram to

represent the main processes of the care services examined, and detailed

use case diagrams to study parts of the system seen as critical

bottlenecks. Activity diagrams were to be developed in subsequent project

phases to model dynamic concepts of each detailed use case. Although

Cruz et al. (2002) concluded that UML helped in communication,

discussion and validation of the different steps of the project there was no

comprehensible evaluation of these benefits.

Goossen et al. (2004) looked at the feasibility of mapping and modelling

of nursing care process information to some international standards. They

represented the nursing care process as a dynamic sequence of phases,

each containing information specific to the activities of the phase, and

used UML to represent this domain knowledge in models. A UML activity

diagram was developed as a model of a generic nursing care process.

After creating a structural model of the information collected at each stage

of the nursing process, various working groups mapped that information

to other standards as a means of validation. An activity diagram of a

generic nursing process was also developed as a problem solving

UML in health 12

approach to patient care and a UML class diagram enhanced this view and

demonstrated further the care process from a nursing perspective. The

authors concluded that their study produced a good model of the nursing

care process but that improvements can still be made. However, despite

all the self critique of the study the authors did not evaluate the UML

activity and class diagram benefits and drawbacks as a means to study

health care processes.

Spyrou et al. (2005) proposed an extension of UML to model processes in

the health care domain using workflow modelling techniques. The work

presented in the article extends the UML activity diagram to support

workflow characteristics as well as standardised clinical documents that

are handled by the processes. The extended notation was then used to

model the flow of patients in a regional health system. No evaluation of

the benefits was reported.

Lyalin and Williams (2005) aimed at improving the way cancer registration

and other processes are described through enhancements in the notation

of UML activity diagrams. The article illustrates a UML activity diagram

used to describe the process of cancer registration and which was

enhanced by allowing the depiction of timeline, duration for individual

activities, responsibilities for individual activities, and descriptive text. The

authors claim that this provides for clarification of the process of cancer

registration and can broaden its understanding among different

specialists. Lyalin and Williams (2005) includes extensive description of

benefits and weaknesses of activity diagrams and a comprehensive

activity diagram of death clearance process at cancer registry. The

authors conclude that the enhancements add value to the tool and cite the
UML in health 13

positive response they received after using the enhanced UML activity

diagrams in a cancer registry best practices development workshop.

Similarly, Saboor et al. (2005) aimed at improving UML activity diagram

by developing and testing a process modelling method which included

details of clinical processes necessary for a systematic and even

semiautomatic quality assessment. The premise of the authors’ work was

that UML is only a descriptive tool that does not allow for comprehensive

quality assessment. Subsequently, Saboor et al. (2005) proposed a new

modelling method based on the UML activity diagram with extra notations

to allow for evaluation. The method was validated by modelling various

versions of the process of ordering a radiological examination. It was

suggested that further evaluation of improvements on the UML activity

diagram are needed.

EVALUATING AND MODELLING CLINICAL GUIDELINES

Sutton et al. (2006) developed a computerised system to allow

hypertensive patients to be monitored and assessed without visiting their

family doctors. The web-based system, created using PROforma, made

recommendations for continued monitoring and for changes in medication.

PROforma is a language that allows clinical guideline to be expressed in a

computer-interpretable manner. The study concluded that PROforma

proved adequate as a language for the implementation of the clinical

reasoning but lacked notational convenience. Hence, UML activity

diagrams were employed instead to create the models that were used

during the knowledge acquisition and analysis phases of the project.

Sutton et al. (2006) also reported on the application of UML activity

UML in health 14

diagram to represent the clinical guidelines in the management of

hypertensive patients. The authors praised the notational convenient of

UML but did not systematically evaluate its benefits.

In similar fashion, Hederman et al. (2002) compared a technique for

representing and sharing clinical guidelines (GLIF) with UML activity

diagram. The authors concluded that there are clear potential benefits in

using a mainstream modelling language such as UML as opposed to a

specific clinical guideline representation technique such as GLIF. The

potential benefits include availability of modelling tools, the ability to

transfer between modelling tools, and to automate via business workflow

technology. However the authors provided no systematic evaluation of the

benefits of employing UML tools in health systems, but rather focused on

the utility of UML activity diagram in general.

EVALUATING AND GENERATING REQUIREMENTS OF INFORMATION SYSTEMS

Maij et al. (2002) looked at the problem of alignment between information

and communication technology (ICT) infrastructure and business

processes in health care organisation. The paper investigated if the

combination of Dynamic Essential Modelling of Organisations that is a

business process modelling methodology with UML can solve the problem.

It used the example of a screening case study on management of the

preoperative centres and focused on developing an efficient information

system. Maij et al. (2002) used UML use cases in the case study to derive

the functionality of the information systems. It also provided a use case

diagram and description for a transaction at the preoperative centre. The

authors concluded that the combination of the two techniques is useful in

UML in health 15

aligning business processes and functional features of ICT infrastructure

and should help the end-user to develop a better understanding with

regards to the relationship between the two areas. Although the paper did

include a brief discussion of UML, it did not provide a systematic

assessment of its utility in health care.

Lee et al. (2006) briefly reported on the use of UML tools (use case,

activity and sequence diagrams) to store and present the functional

requirements of a handheld-based decision support system for morbid

obesity screening and management. The authors stated that UML is useful

in depicting processes related to management of clinical based guidelines,

facilitating discussion and agreement in developing data model and in

aiding the design of web-based prototype.

Lunn et al. (2003) reported using UML activity diagram to model various

processes of monitoring care and use case diagrams to generate

requirements for the development of an information system intended to

support planning in the provision of elderly care services. The study is a

good example of application of UML tools in health but provides little

guidance in terms of actual benefits and weaknesses.

Weber et al. (2001) aimed at developing a tool to support clinical trial

centres in developing trial specific modules for the computer-based

documentation system of paediatric oncology. The research carried out an

object-oriented business process analysis for a clinical trial conducted at a

German hospital. The results comprised a comprehensive business

process model consisting of UML diagrams and use case specifications,

which included use case diagrams ("manage trial", "plan trial", "conduct
UML in health 16

trial", "document course of therapy" and documentation view of the latter)

and an example of use case specification. Weber et al. (2001) concluded

by recommended the use of object-oriented analysis in the context of

therapeutic trials but did not carry out the an evaluation.

LeBozec et al. (1998) described a UML-based approach to the designing of

a case-based medical imaging retrieval system for pathologists. The

authors created UML use case and class diagrams to illustrate the steps of

the case-based reasoning systems methodology used to develop sound

knowledge systems in pathology. The diagrams were used to visualize the

relevant objects and to evaluate the model before implementation, and

included use case diagram of the image retrieval system and use case

with corresponding scenarios chart. The authors concluded that, although

further evaluation is required, UML seems to be a promising formalism

improving the communication between the developers and users.

Aggarwal (2002) highlighted the benefits of the UML in specifying,

visualising, constructing, documenting, and communicating the model of a

health care information system. It illustrated the usage of use cases and

use case diagram, activity and class diagram by employing simplified

examples of a nurse submitting a blood-count order, a physician order

system, and of an emergency room.

Ganguly and Ray (2000) discussed the development of a methodology for

the design of interoperable telemedicine systems based on UML. Their

research focused on the feasibility of the development of agent-based

interoperable telemedicine systems and used the example tele-

electrocardiography in the case study. Among the tools suggested for

UML in health 17

system design, Ganguly and Ray (2000) used a UML use case diagram to

describe a distributed electrocardiogram system.

Finally, Hoo et al. (2000) had as an objective to develop software that

facilitates more efficient and effective utilisation of medical images and

associated data in biomedical research. The area of focus was assisting

clinicians in pre-surgical evaluation of patients with medically refractory

epilepsy as an example. The authors drafted use cases to summarize

operational scenarios of clinicians using the system and used UML class

diagrams to describe object-oriented concepts of the system.

UML in health 18

Discussion

In this paper we introduced four common UML diagrammatic tools (use

case, activity, state, and class diagrams) and used original models of a

simplified example of surgical service to illustrate their usage. We also

presented the findings of a literature survey on the application of these

tools to the modelling of health care systems. The survey identified a

number of articles in which UML tools were used but very limited

systematic evaluation of their benefits.

One notable exception is the recent work by Jun (2007) where a variety of

modelling methods, including a variation of UML activity diagrams, was

evaluated for their utility in modelling health systems. Jun (2007)

identified that only a limited number of modelling methods have been

considered or evaluated for purpose of use in health care settings.

Following systematic evaluation by health care professionals, Jun (2007)

concluded that there is no single method preferred by all users or

applicable to all areas but there is a strong case for using a variety of

modelling techniques in enhancing the understanding of care process

among practitioners. This work is to our knowledge the only

comprehensive evaluation of different process mapping tools in health

care and provided a clear insight to the benefits those methods can offer

to the system, practitioners and the patient. Similar evaluation may also

be needed for all UML tools before firm recommendations can be made as

to their applicability.

Despite the obvious analytical applicability, as pointed to by Jun (2007),

state diagrams have not been used in the analysis of health care systems.
UML in health 19

The closest case is in an analysis of biological systems by Roux-Rouquie et

al. (2004) where the utility of UML state diagrams to describe and specify

biological systems and processes was examined. Roux-Rouquie et al.

(2004) mapped biological concepts to UML ones and presented state

diagrams with states and sub-states of the active and inactive enzymes;

and with concurrent sub-states at molecular and phenotype levels.

Outside the UML notation, the original Statecharts notation that forms the

basis of the UML state diagram notation has recently been used in the

modelling and simulation of a cardiac surgical service (Vasilakis, Sobolev,

Kuramoto, & Levy, 2007; Sobolev et al., 2008).

UML in health 20

Conclusion

It is apparent from this literature survey that UML has a role in the

analysis of the health care systems. There are clear benefits, especially in

terms of clarity of communication and repeatability, if a standardised and

rigorous notation is employed broadly. However, the application of UML to

the modelling of health care systems is probably not as prevalent as in

other application domains, at least as it is documented in the medical

literature. Therefore, it is essential to conduct a thorough evaluation of

the use and potential benefits of UML in a health care context if more wide

spread application is to be recommended.

UML in health 21

Acknowledgement

This work was partially supported by an award from the Strategic

Promotion of Ageing Research Capacity (SPARC) initiative. The authors

acknowledge the support they received from the Harrow School of

Computer Science, University of Westminster, as well as the generous

advice they received from Prof Peter Millard, Prof Peter Lansley and Dr Elia

El-Darzi.
UML in health 22

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UML in health 25

List of figure captions

Figure 1. UML use case diagram of a simplified surgical care service

(surgical consultation in outpatient clinic).

Figure 2. UML activity diagram of the care process of a simplified surgical

care service (surgical consultation in outpatient clinic).

Figure 3. UML state diagram of patient states in a simplified surgical care

service (surgical consultation in outpatient clinic).

Figure 4. UML class diagram of a simplified surgical care service (surgical

consultation in outpatient clinic).

UML in health 26

Figure 1

Surgical Consultation
Order tests
«extends»
«extends»
Book appointment

Take samples

Register on surgical waiting list

Nurse
«extends»
Educate on operation

Decide on treatment
Patient requiring surgical consultation
«uses»

Surgeon

«uses» Evaluate symptoms and test results

Report on samples
«uses»

Patient
Analyse samples

Lab technician
UML in health 27

Figure 2

Referral to clinic

Booking of appointment with surgeon Ordering of diagnostic tests

Consultation with surgeon

[Operation is deemed necessary] [Otherwise]

Referral for medical treatment

Registration on surgical waiting list Education about operation

UML in health 28

Figure 3

Patient at surgical consultation in outpatient clinic

Waiting for referral to clinic

referral to clinic

Appointment Diagnostic tests

Pending Pending

make booking [slots available] take samples

Samples taken
Booked

patient presents at clinic

At consultation

treatment decided

[operation deemed necessary] [otherwise]

Surgical waiting list Education

Pending Pending

register educate Waiting for medical treatment

On waiting list Educated

book operation referral for medical treatment

 UML in health 29

Figure 4.

Patient
-name
placed -dob is made for
-gender
1 1
+add patient()
+remove patient()

1
has
0..* 0..*
0..*
Surgical waiting list Referral
Diagnostic test
-patient name -patient name
-type of operation -test -date
-priority -patient name -priority
-surgeon name -surgeon name -surgeon
-placement date -result -appointment date
-removal date -date ordered +add referral()
-date of result +remove referral()
+add patient name()
+remove patient name() +add order() +update appointment date()
+audit waiting list() +update result()

0..* 0..*
0..* orders

Surgeon
operates on -name consults with
-specialty
1 +add surgeon() 1
+remove surgeon()

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