Cross-enterprise Basic eReferral Workflow Definition (XBeR-WD) First TF Volume presented to the PCC Technical Committee Luca Zalunardo, Arianna Cocchiglia,

Cross-enterprise Basic eReferral Cross-enterprise Basic eReferral Workflow DefinitionWorkflow Definition

(XBeR-WD)(XBeR-WD)

First TF Volume presented to theFirst TF Volume presented to thePCC Technical CommitteePCC Technical Committee

Luca Zalunardo, Arianna Cocchiglia, Mauro ZanardiniLuca Zalunardo, Arianna Cocchiglia, Mauro ZanardiniFebruary, 6February, 6thth 2012 2012

PCC Technical CommitteePCC Technical Committee

The Problem

This profile proposal born as development of the ITI XDW profile to manage This profile proposal born as development of the ITI XDW profile to manage the Cross Enterprise Basic eReferral Workflow.the Cross Enterprise Basic eReferral Workflow.

Without an instrument which manage the workflow, the eReferral is only an Without an instrument which manage the workflow, the eReferral is only an order without any information about the status of the order itself. The order without any information about the status of the order itself. The definition of a workflow with definition of a workflow with fix rules and taskfix rules and task is needed in a scenario is needed in a scenario cross enterprise in which many actors are involved in the same processcross enterprise in which many actors are involved in the same process

We have estimated that only in the Veneto Region the introduction of the use We have estimated that only in the Veneto Region the introduction of the use of digital referral (eReferral) will entail a saving of about 56 million Euro of digital referral (eReferral) will entail a saving of about 56 million Euro thanks to:thanks to:

• a better quality control of the processa better quality control of the process• the reduction of the errors in the management of all clinical documents the reduction of the errors in the management of all clinical documents

and related workflows and related workflows • the increasing of the efficiency of the process itself.the increasing of the efficiency of the process itself.


XDW profile and Workflow Definition profile

Cross Enterprise Document Workflow is:Cross Enterprise Document Workflow is: a framework to manage workflowsa framework to manage workflows a platform upon which a wide range of specific workflows can be a platform upon which a wide range of specific workflows can be

defined with minimal specification and implementation efforts defined with minimal specification and implementation efforts workflow independentworkflow independent applicable on different document sharing infrastructuresapplicable on different document sharing infrastructures

Workflow Definition Profile is:Workflow Definition Profile is: the definition of a specific clinical processthe definition of a specific clinical process a set of rules and task definition which characterize the processa set of rules and task definition which characterize the process the definition of the actors involved in the process and their rolesthe definition of the actors involved in the process and their roles


Purpose and Scope

The creation of an eReferral by a GP opens a clinical process The creation of an eReferral by a GP opens a clinical process that involves many actors and that is a cross-enterprise that involves many actors and that is a cross-enterprise workflow.workflow.

This workflow is composed by many This workflow is composed by many clinical and clinical and organizationalorganizational steps steps

The purpose of the XBeR-WD profile is exactly define:The purpose of the XBeR-WD profile is exactly define: -the -the workflowworkflow associated with an eReferral Document associated with an eReferral Document

-the -the actorsactors involved involved-the -the digital documentsdigital documents related with this process (produced related with this process (produced in this process or produced in other clinical processes but in this process or produced in other clinical processes but interesting also in this one).interesting also in this one).


Basic eReferral Workflow

3-Admission 3-Admission of of

the patientthe patient

4- Start of 4- Start of the the

ConsultationConsultation5– End of the 5– End of the

consultation and consultation and creation of the creation of the clinical reportclinical report

6 – Possible 6 – Possible notification to the notification to the

GPGP

1-Visit and 1-Visit and production of production of

eReferraleReferral

The workflow within the organization is encapsulated into a single XDW step

2-Booking of 2-Booking of the visitthe visit


eReferral process flow


Use-case: basic eReferral workflow

REFERRED The specialist

performs the visit

The patient goes or calls the HPC to book the visit

The HIS can’t admit The patient

The patient is admitted in

hospital

The GP produce a eReferral document

eReferral Process is completed

correctly The specialist can’t perform the exam

A notification, the FailureReport, and the WD closed are sended to the GP and, if necessary, a new eReferral process is started

The visit is cancelled and the Referral document is made available for another booking step

The HIS can’t book the visit, detecting some problems or inconsistences in

the eReferral document

REQUESTED

FAILED

PERFORMED

ADMITTED

BOOKED

eReferral Process is ended in a failure

condition

Workflow DocumentWorkflow Document

Task Name: Task Name: REFERRAL REQUESTEDREFERRAL REQUESTEDTaskStatus: COMPLETEDTaskStatus: COMPLETEDAuthor: Mr.RossiAuthor: Mr.RossiTime: date/time/utcTime: date/time/utc

Inputs:Inputs:-> Lab Report-> Lab ReportOutputs:Outputs:-> eReferralDoc1-> eReferralDoc1

taskEventHistorytaskEventHistory

TaskEvent: 1TaskEvent: 1Status: Status: COMPLETEDCOMPLETEDInputs:Inputs:-> Lab Report-> Lab Report

Outputs:Outputs:-> eReferralDoc1-> eReferralDoc1

Status of the process: RequestedTask 1: Referral Requested TaskStatus 1: Completed



The specialist performs the visit


The HIS find some problem in the

eReferral document or in the visit booked


hospital



correctly The specialist find some problem in the eReferral document





REQUESTED

FAILED

PERFORMED

RECEPTION

BOOKED


condition

REFERRED


Task Name: Task Name: REFERRAL BOOKEDREFERRAL BOOKEDTaskStatus: COMPLETEDTaskStatus: COMPLETEDAuthor: HISAuthor: HISTime: date/time/utcTime: date/time/utc

Inputs:Inputs:-> eReferralDoc1-> eReferralDoc1Outputs:Outputs:->->


TaskEvent: 1TaskEvent: 1Status: Status: COMPLETEDCOMPLETEDInputs:Inputs:-> eReferralDoc1-> eReferralDoc1Outputs:Outputs:->->

REFERRAL REQUESTEDREFERRAL REQUESTED

Status of the process: bookedTask 2: Referral Booked TaskStatus 1: Completed


Use-case: basic eReferral workflowWorkflow DocumentWorkflow Document

Task Name: Task Name: REFERRAL REFERREDREFERRAL REFERREDTaskStatus: TaskStatus: IN-PROGRESSIN-PROGRESSAuthor: HISAuthor: HISTime: date/time/utcTime: date/time/utc



TaskEvent: 1TaskEvent: 1Status: Status: IN-PROGRESSIN-PROGRESSInputs:Inputs:-> eReferralDoc1-> eReferralDoc1Outputs:Outputs:->->


REFERRAL BOOKEDREFERRAL BOOKED

Status of the process: AdmittedTask 3: Referral Referred TaskStatus 1: in-progress



REFERRED The specialist

performs the visit





hospital



correctly The specialist find some problem in the eReferral document





REQUESTED

FAILED

PERFORMED

ADMITTED

BOOKED


condition


Task Name: Task Name: REFERRAL REFERREDREFERRAL REFERREDTaskStatus: TaskStatus: COMPLETEDCOMPLETEDAuthor: Specialist’s swAuthor: Specialist’s swTime: date/time/utcTime: date/time/utc

Inputs:Inputs:-> eReferralDoc1-> eReferralDoc1Outputs:Outputs:->ClinicalReport->ClinicalReport


TaskEvent: 2TaskEvent: 2Status: Status: COMPLETEDCOMPLETEDInputs:Inputs:-> eReferralDoc1-> eReferralDoc1Outputs:Outputs:-> ClinicalReport-> ClinicalReport



TaskEvent: 1TaskEvent: 1Status: Status: IN-PROGRESSIN-PROGRESSStatus of the process: Performed

Task 3: Referral Referred TaskStatus 2: completed



C

D

A

The GP produces the eReferral

Creation of the eReferral Document

Creation of the Workflow Document

Workflow Document

Task name: Referral Requested Task Status: Completed Author: Mr.Rossi Time: date/time/utc Inputs: -> Lab Report Outputs: -> eReferralDoc1

The specialist admits the patient and starts the

consultation

Updated of the Workflow Document

Workflow Document

REQUESTED

taskEventHistory

Task name: Referral Referred Task Status: In Progress Author: HIS Time: date/time/utc Inputs: -> eReferralDoc1 Outputs: ->

TaskEvent: 1 Task Status: Completed Inputs: -> Lab Report Outputs: -> eReferralDoc1

The specialist completes the consultation and produce the report

Creation of the Clinical Report


Workflow Document

REQUESTED

Task name: Referral Referred Task Status: Completed Author: Mr.Brum Time: date/time/utc Inputs: -> eReferralDoc1 Outputs: -> ClinicalRepDoc2

taskEventHistory

TaskEvent: 1 Task Status: In Progress Inputs: -> eReferralDoc1 Outputs: ->

taskEventHistory

TaskEvent: 1

TaskEvent: 2 Status: Completed Inputs: -> eReferralDoc1 Outputs: -> ClinicalRepDoc2

BOOKED

B

The HCP books the visit for the patient


Workflow Document

REQUESTED

Task name: Referral Booked Task Status: Completed Author: HIS Time: date/time/utc Inputs: -> eReferralDoc1 Outputs: ->

taskEventHistory

TaskEvent: 1 Task Status: Completed Inputs: -> eReferralDoc1 Outputs: ->

BOOKED

Workflow Step

Clinical actions

Technical actions

Evolution of shared Workflow Document


Use-case: basic eReferral process flow

3.Provide&Register Document Set-b (eRef,WD) [ITI-41]

GP

1.Creation Doc. eReferral

Document Repository

Document Registry

HIS/Specialist sw (Content Updator/

Content Consumer)

4.Register Doc Set-b (eRef,WD) [ITI-42]

2.Creation Workflow Doc.

15.Register Doc Set-b (WD) [ITI-42]

14.Provide&Register Doc Set-b (WD) [ITI-41]

Patient

Perform the visit

Legend WD: Workflow Document eRef: eReferral Document RD: Report Document Transaction XDS Internal Transaction Action

13.Update Workflow Doc

5.Registry Stored Query [ITI-18] (WD,eRef)

12.Retrieve Doc Set [ITI-43] (WD,eRef)

The patient books the visit

10.Register Doc Set-b (WD) [ITI-42]

9.Provide&Register Doc Set-b (WD) [ITI-41]

7.HCPbooks the visit

8.Update Workflow Doc.


Patient is admitted into the Hospital


23.Register Doc Set-b (RD,WD) [ITI-42]

22.Provide&Register Doc Set-b (RD,WD) [ITI-41]

20. Creation Report Doc



16.The doctor starts the visit

21.Update Workflow Doc

19.The doctor performs the exam

C

B

D

A


Booking cancellation process:Booking cancellation process:




hospital



correctly



The specialist find some problem in the eReferral document





REQUESTED

FAILED

PERFORMED

ADMITTED

BOOKED


condition

REFERRED


Task Name: Task Name: REFERRAL REQUESTEDREFERRAL REQUESTEDTaskStatus: TaskStatus: COMPLETEDCOMPLETEDAuthor: HISAuthor: HISTime: date/time/utcTime: date/time/utc



TaskEvent: 1TaskEvent: 1Status: Status: COMPLETEDCOMPLETEDInputs:Inputs:-> eReferralDoc1-> eReferralDoc1Outputs:Outputs:->->



Status of the process: eReferral AvailableTask 3: Referral Requested TaskStatus 1: completed

Use-case: eReferral workflow Manage of a nonlinear situation


Use-case: eReferral workflow Manage of the failed situations

Failure booking step:Failure booking step:




hospital



correctly








REQUESTED

FAILED

PERFORMED

ADMITTED

BOOKED


condition

REFERRED


Task Name: Task Name: REFERRAL BOOKEDREFERRAL BOOKEDTaskStatus: FAILEDTaskStatus: FAILEDAuthor: HISAuthor: HISTime: date/time/utcTime: date/time/utc

Inputs:Inputs:-> eReferralDoc1-> eReferralDoc1Outputs:Outputs:-> FailureReport-> FailureReport


TaskEvent: 1TaskEvent: 1Status: FAILEDStatus: FAILEDInputs:Inputs:-> eReferralDoc1-> eReferralDoc1Outputs:Outputs:->FailureReport->FailureReport


Status of the process: Booking FailedTask 2: Referral Booked TaskStatus 1: failed


Failure reception step:Failure reception step:




hospital



correctly

The HIS can’t admit the patient






REQUESTED

FAILED

PERFORMED

ADMITTED

BOOKED


condition

REFERRED


Task Name: Task Name: REFERRAL REFERREDREFERRAL REFERREDTaskStatus: TaskStatus: FAILEDFAILEDAuthor: HISAuthor: HISTime: date/time/utcTime: date/time/utc

Inputs:Inputs:-> eReferralDoc1-> eReferralDoc1Outputs:Outputs:->FailureReport->FailureReport


TaskEvent: 1TaskEvent: 1Status: Status: FAILEDFAILEDInputs:Inputs:-> eReferralDoc1-> eReferralDoc1Outputs:Outputs:->FailureReport->FailureReport



Status of the process: Admission failedTask 3: Referral Referred TaskStatus 1: failed



Failure visit performing step:Failure visit performing step:

REFERRED The GP produce a eReferral document



hospital



correctly



The specialist can’t perform the visit





REQUESTED

FAILED

PERFORMED

RECEPTION

BOOKED


condition


Task Name: Task Name: REFERRAL REFERREDREFERRAL REFERREDTaskStatus: TaskStatus: FAILEDFAILEDAuthor: Specialist’s swAuthor: Specialist’s swTime: date/time/utcTime: date/time/utc

Inputs:Inputs:-> eReferralDoc1-> eReferralDoc1Outputs:Outputs:->FailureReport->FailureReport


TaskEvent: 2TaskEvent: 2Status: Status: FAILEDFAILEDInputs:Inputs:-> eReferralDoc1-> eReferralDoc1Outputs:Outputs:-> FailureReport-> FailureReport



TaskEvent: 1TaskEvent: 1Status: Status: IN-PROGRESSIN-PROGRESS

Status of the process: Performation failedTask 3: Referral Referred TaskStatus 2: failed




Each time there is a failing situation, a Each time there is a failing situation, a notification is sended to the GP. notification is sended to the GP.

IF NECESSARYIF NECESSARY the GP can start a new the GP can start a new process process producing a new eReferral producing a new eReferral document.document. In the new workflow document the In the new workflow document the GP can track the link to the failure report and GP can track the link to the failure report and the reference to the previous process aborted the reference to the previous process aborted in the INPUT of the first task. in the INPUT of the first task.


Task Name: Task Name: REFERRAL REQUESTEDREFERRAL REQUESTEDTaskStatus: COMPLETEDTaskStatus: COMPLETEDAuthor: Mr.RossiAuthor: Mr.RossiTime: date/time/utcTime: date/time/utc

Inputs:Inputs:-> Lab Report-> Lab Report-> Failure Report-> Failure Report->FolderID->FolderIDOutputs:Outputs:-> eReferralDoc1-> eReferralDoc1


TaskEvent: 1TaskEvent: 1Status: Status: COMPLETEDCOMPLETEDInputs:Inputs:-> Lab Report-> Lab Report->Failure Report->Failure Report->FolderID->FolderIDOutputs:Outputs:-> eReferralDoc1-> eReferralDoc1

New Workflow Document


XDW Actors

XDW Actors: XDW Actors: XDW Content Creator:XDW Content Creator: creates new workflow producing the Workflow Documentcreates new workflow producing the Workflow Document XDW Content Updator:XDW Content Updator: replaces exixting workflow document with the updated onereplaces exixting workflow document with the updated one XDW Content Consumer:XDW Content Consumer: obtains and reads a Workflow Documentobtains and reads a Workflow Document

The Workflow Document is managed by XDW actors, and is The Workflow Document is managed by XDW actors, and is shared and exchanged using a document infrastructure (XDS, shared and exchanged using a document infrastructure (XDS, XDR, XDM…)XDR, XDM…)


XDS XDS InfrastructureInfrastructureContent

CreatorContent Creator

XDS Document Source

XDS Document Source

GP’s sw

Content ConsumerContent

Consumer

XDS Document Consumer


HIS1. Producing of the WDWith one task ˮREFERRAL REQUESTEDˮ and referencing of it to the XDS Infrastructure

2. Query for the patient WD active

3. Retrieve of the WD to check the status of the eReferral

Content UpdatorContent Updator

XDS Document Source

XDS Document Source

4. Updating of the WD adding a new task ˮREFERRAL BOOKEDˮ

5. Referencing of the new version of the WD to the XDS Infrastructure


Consumer



HIS


XDS Document Source

XDS Document Source

6. Query for the patient WD active


8. Updating of the WD adding a new task ˮREFERRAL REFERREDˮ with status IN-PROGRESS



Consumer



Specialist’s sw10. Query for the

patient WD active



XDS Document Source

XDS Document Source

12. Updating of the WD adding a new taskEvent (completed)



eReferral Process Entities

• A A Process EntityProcess Entity:: Is a logical actorIs a logical actor Acts in a higher level compared to physical actors or XDW/XDS actorsActs in a higher level compared to physical actors or XDW/XDS actors Is defined to better understand the role of an actor in the processIs defined to better understand the role of an actor in the process Is responsible for a specific transition between tasksIs responsible for a specific transition between tasks

-Referral Requester-Referral Requester: is the entity that produces the eReferral and the related Workflow : is the entity that produces the eReferral and the related Workflow Document starting the eReferral process.Document starting the eReferral process.

-Referral Booker-Referral Booker: is the entity responsible for the booking process. This entity can book : is the entity responsible for the booking process. This entity can book or cancel the visit, updating the Workflow Document.or cancel the visit, updating the Workflow Document.

-Referral Performer-Referral Performer: is the entity responsible for the reception of the patient and the : is the entity responsible for the reception of the patient and the execution of the visit. This entity can produce the report of the visit, and can terminate execution of the visit. This entity can produce the report of the visit, and can terminate the eReferral process. the eReferral process.

-Failure Manager-Failure Manager: is the entity that manages the failure condition of the process, : is the entity that manages the failure condition of the process, terminating the wrong process producing the Failue Report. terminating the wrong process producing the Failue Report.


eReferral Process Entities:Referral Requester

Skills:Skills: Can create the eReferral document and the Workflow Document relatedCan create the eReferral document and the Workflow Document related

Physical interpreter:Physical interpreter: GP’s softwareGP’s software

XDW/XDS actors grouped:XDW/XDS actors grouped: XDW Content CreatorXDW Content Creator XDS Document SourceXDS Document Source




REQUESTED Referral

RequesterReferral

Requester


eReferral Process Entities:Referral Booker

Skills:Skills: Can check the status of the eReferral document and, updating the WD, is Can check the status of the eReferral document and, updating the WD, is

responsible for the booking process.responsible for the booking process.

Physical interpreter:Physical interpreter: HISHIS

XDW/XDS actors grouped:XDW/XDS actors grouped: XDW Content ConsumerXDW Content Consumer XDW Content UpdatorXDW Content Updator XDS Document ConsumerXDS Document Consumer XDS Document Source XDS Document Source R

eferral B

oo

kerR

eferral B

oo

ker


eReferral Process Entities:Referral Performer

Skills:Skills: Can check the status of the eReferral document, can update the WD and can Can check the status of the eReferral document, can update the WD and can

terminate the process producing a Report and changing the status of the WD terminate the process producing a Report and changing the status of the WD (WorkflowStatus =ˮCLOSEˮ)(WorkflowStatus =ˮCLOSEˮ)

Physical interpreter:Physical interpreter: HIS, Specialist’s softwareHIS, Specialist’s software

XDW/XDS actors grouped:XDW/XDS actors grouped: XDW Content ConsumerXDW Content Consumer XDW Content CreatorXDW Content Creator XDS Document ConsumerXDS Document Consumer XDS Document SourceXDS Document Source

The specialist

performs the visit


hospital


eReferral document

PERFORMED

RECEPTION Referral

PerformerReferral

PerformerReferral

PerformerReferral

Performer


eReferral Process Entities:Failure Manager

Skills:Skills: Can terminate the process changing the status of the WD (WorkflowStatus=ˮCLOSEˮ), Can terminate the process changing the status of the WD (WorkflowStatus=ˮCLOSEˮ),

producing a Faliure Report and sending a notification to the GPproducing a Faliure Report and sending a notification to the GP

Physical interpreter:Physical interpreter: HIS,specialist’s softwareHIS,specialist’s software

XDW/XDS actors grouped:XDW/XDS actors grouped: XDW Content ConsumerXDW Content Consumer XDS Document ConsumerXDS Document Consumer



hospital





A notification, the FailureReport, and the WD closed are sended to the GP and, if necessary,

a new eReferral process is started



REQUESTED

FAILED

RECEPTION

BOOKED


condition

Failure ManagerFailure

ManagerFailure ManagerFailure

Manager


Manager


Manager

XDW Content CreatorXDW Content Creator XDS Document SourceXDS Document Source


Discussion

The value statement of this proposal is:The value statement of this proposal is:•the use of an instrument, the ITI XDW profile, which provides a the use of an instrument, the ITI XDW profile, which provides a shared shared solution with different processsolution with different process which guarantees the interoperability which guarantees the interoperability between the different workflows and their management.between the different workflows and their management. •The The standardization standardization of clinical and organizational of clinical and organizational workflowworkflow involved in involved in eReferral processeReferral process•The The contextualizationcontextualization of the of the data set of rulesdata set of rules specific for the eReferral specific for the eReferral Workflow Definition Profile.Workflow Definition Profile.

The specification of The specification of Workflow DefinitionsWorkflow Definitions is distinct from the XDW Profile, is distinct from the XDW Profile, out of the scope of the ITI Domain and is currently best handled with a out of the scope of the ITI Domain and is currently best handled with a natural language expression, it natural language expression, it is specific duty of each domainis specific duty of each domain to define to define the workflow definition profile to manage the different specific workflow.the workflow definition profile to manage the different specific workflow.

This is a simple process which can provide the basis to the definitions of This is a simple process which can provide the basis to the definitions of other more complex clinical workflows.other more complex clinical workflows.


Proposed Standards & Systems

• Afferent IHE DomainsAfferent IHE Domains– IT Infrastructure, Patient Care CoordinatorIT Infrastructure, Patient Care Coordinator

• Afferent IHE ProfilesAfferent IHE Profiles: : – XDW, XDS.b, XDM, XDR, DSUB, NAV, XCA, BPPC, ATNA, XUAXDW, XDS.b, XDM, XDR, DSUB, NAV, XCA, BPPC, ATNA, XUA

• Other standards itemsOther standards items: : – OASIS HumanTaskOASIS HumanTask

• Stability and robustnessStability and robustness: : – No new transaction are introducedNo new transaction are introduced– No XDS Metadata extension expected, but specific rules about No XDS Metadata extension expected, but specific rules about

Metadata content for the workflow DocumentMetadata content for the workflow Document

Documents

Cross-enterprise Basic eReferral Workflow Definition (XBeR-WD) First TF Volume presented to the PCC Technical Committee Luca Zalunardo, Arianna Cocchiglia,