Cross-enterprise Document Workflow (XDW) Brief Profile Proposal for 2009/10 presented to the IT Infrastructure Planning Committee Charles Parisot, Claudio

Cross-enterprise Document WorkflowCross-enterprise Document Workflow(XDW)(XDW)

Brief Profile Proposal for 2009/10Brief Profile Proposal for 2009/10presented to thepresented to the

IT Infrastructure Planning CommitteeIT Infrastructure Planning Committee

Charles Parisot, Claudio Saccavini, Luca Zalunardo, Charles Parisot, Claudio Saccavini, Luca Zalunardo, Arianna CocchigliaArianna CocchigliaOctober, 18October, 18thth 2010 2010


XDW - Key Elements

This proposal focuses on the Cross-Enterprise Workflow for This proposal focuses on the Cross-Enterprise Workflow for Document Sharing in support of workflow document and Document Sharing in support of workflow document and status management.status management.

Key elements:Key elements:• Managing workflow specific status with relationship to one or Managing workflow specific status with relationship to one or

more documentsmore documents• Tracking the health care entity that change a status Tracking the health care entity that change a status

associated to a workflow stepassociated to a workflow step• Tracking the past steps of the workflow related to specific Tracking the past steps of the workflow related to specific

clinical eventclinical event


Necessity:Necessity:• it is now becoming essential by the increase of the use by it is now becoming essential by the increase of the use by

different sectors of these document sharing related IHE different sectors of these document sharing related IHE profiles with their different types of documents and profiles with their different types of documents and information.information.

• Many different worldwide projects have as goals to Many different worldwide projects have as goals to paperless of documents and digitalization of clinical paperless of documents and digitalization of clinical processes. At the bases of all these projects there is the processes. At the bases of all these projects there is the management of ePrescription and eReferral for theirmanagement of ePrescription and eReferral for their– Variuos and structures workflowVariuos and structures workflow– Clinical, economic, social and organizational impact valuesClinical, economic, social and organizational impact values

XDW - Necessity


Alignment with the bisiness healthcare: Italian example

To have a scale of the problem, an analysis has been To have a scale of the problem, an analysis has been performed on some Italian data:performed on some Italian data:•550 million prescriptions issued each year (paper and electronic 550 million prescriptions issued each year (paper and electronic today). today). •the lack of the lack of a workflow management for ePrescriptions/eReferrals results in a workflow management for ePrescriptions/eReferrals results in some of these to be dispensed/performed twice, some of these to be dispensed/performed twice, or not dispensed/performed. This causes a loss of about 7‐or not dispensed/performed. This causes a loss of about 7‐8% of the National Healthcare budget (about 14 billion of Euro).8% of the National Healthcare budget (about 14 billion of Euro).•Considerable saving by the introduction of a Considerable saving by the introduction of a better quality control of the process and the better quality control of the process and the reduction of the errors.reduction of the errors.


Algnment with governaments/national

programsAustria

Veneto RegionItaly

FranceDMP

InFSEItaly

Electronic Transfer of

ePrescriptionAustralia

European Project

12 Coutries

Projects of the Department of

Health and Human Services


2-Booking the visit2-Booking the visit

Use Case: an example of eReferral workflow

Ordered Ordered Placed Placed

PlacedPlacedIn ProgressIn Progress

In ProgressIn ProgressCompletedCompleted

OrderedOrdered

3-ADT3-ADTAdmission of Admission of the patientthe patient

4- RX Exam4- RX Exam5- Production of 5- Production of

the Clinical the Clinical ReportReport

6- Publication 6- Publication of RX reportof RX report

7-Notification 7-Notification to the GPto the GP

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

eReferraleReferral



Ordered

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

eReferraleReferral

Clinical steps:Clinical steps:• A patient attends a A patient attends a

consultation with his GPconsultation with his GP• The GP examines him and The GP examines him and

generates an eReferralgenerates an eReferral

Technical steps:Technical steps:• Creation of an eReferral DocumentCreation of an eReferral Document• Creation of a Workflow Document (WD)Creation of a Workflow Document (WD)• Provide a Document Folder (the 2 objects are grouped using Provide a Document Folder (the 2 objects are grouped using

XDSFolder mechanism)XDSFolder mechanism)• Provide the eReferral Doc and WDProvide the eReferral Doc and WD


2-Booking the visit2-Booking the visit


Ordered Ordered Placed Placed

Clinical steps:Clinical steps:• The patient calls an hospital to book his visitThe patient calls an hospital to book his visit• The HCP cunsults the eReferral Doc and WD associeted The HCP cunsults the eReferral Doc and WD associeted

and books the visitand books the visit

Technical steps:Technical steps:• Query and Retrieve of the eReferral Doc and WDQuery and Retrieve of the eReferral Doc and WD• Modify the status associated whit eRefferral inside the Modify the status associated whit eRefferral inside the

Workflow Document (WD)Workflow Document (WD)• Replace the WDReplace the WD



PlacedPlacedIn ProgressIn Progress

3-ADT3-ADTAdmission of Admission of the patientthe patient

4- RX Exam4- RX Exam

Clinical steps:Clinical steps:• The patient is admitted at the hospitalThe patient is admitted at the hospital• The HCP cunsults the eReferral Doc The HCP cunsults the eReferral Doc

and WD associetedand WD associeted• The visit takes placeThe visit takes place

Technical steps:Technical steps:• Query and Retrieve of the eReferral Doc Query and Retrieve of the eReferral Doc

and WD and WD • Modify the status associated with eRefferral Modify the status associated with eRefferral

inside the Workflow Document (WD)inside the Workflow Document (WD)• Replace the WDReplace the WD



In ProgressIn ProgressCompletedCompleted

5- Production of 5- Production of the clinical the clinical

reportreport

6- Pubication 6- Pubication of RX reportof RX report

Clinical steps:Clinical steps:• The doctor generates the clinical report of the examThe doctor generates the clinical report of the exam

Technical steps:Technical steps:• Creation of the Clinicl Report DocCreation of the Clinicl Report Doc• Modify the status associated with eRefferral inside the Modify the status associated with eRefferral inside the

Workflow Document (WD)Workflow Document (WD)• Replace the WDReplace the WD• Provide the Clinical Report Doc associated with eReferral in Provide the Clinical Report Doc associated with eReferral in

the same Folderthe same Folder



7-Notification 7-Notification to the GPto the GP

Clinical steps:Clinical steps:• There is the possibility to send a There is the possibility to send a

notification about the pubblication notification about the pubblication of the Report associeted with the of the Report associeted with the eReferral that he has produced eReferral that he has produced beforebefore

• However at anytime during this However at anytime during this process, the GP may consult the process, the GP may consult the WD and access related new WD and access related new documents produceddocuments produced


Analysis of different solutions

Alternative Solutions Why or why not?

Management of the different status inside the CDA of the Clinical Document

Not possible because at the moment of publication the CDA is elettronic signatured and so not more modificable

Manage of the status with new addictional metadata

Not possible to manage the history of the changes and also this is not a flaxible solution for different requirements.

Status Machine This solution is possible but not the best solution because it is not flexible to the different clinical scenarious and into collaborative systems and communities

Document Workflow This is the best solution because it allow to manage the status of related documents with the possibility to manage the historical changement of documents’ status. Moreover this document will become a clinical document ad so it’s correct to structure it as a CDA


The structure of the Workflow Document

Section 1Section 1

General and common data (patient data, author data, institution General and common data (patient data, author data, institution data, etc)data, etc)

Section 2…nSection 2…n

One section for any performed Workflow Step (e.g. ePrescription, One section for any performed Workflow Step (e.g. ePrescription, eReferral) which contains:eReferral) which contains:

• Internal management properties about workflow step (status, Internal management properties about workflow step (status, author, date/time of the change, relationship with previous author, date/time of the change, relationship with previous workflow step, expected upcoming workflow steps..)workflow step, expected upcoming workflow steps..)

• Reference to the shared documents that were used as input to Reference to the shared documents that were used as input to the workflow step (if any)the workflow step (if any)

• Reference to the documents that were shared as a result of the Reference to the documents that were shared as a result of the workflow stepworkflow step

Section 1Section 1

General and common data (patient data, author data, institution General and common data (patient data, author data, institution data, etc)data, etc)

Section 2…nSection 2…n

One section for any performed Workflow Step (e.g. ePrescription, One section for any performed Workflow Step (e.g. ePrescription, eReferral) which contains:eReferral) which contains:

• Internal management properties about workflow step (status, Internal management properties about workflow step (status, author, date/time of the change, relationship with previous author, date/time of the change, relationship with previous workflow step, expected upcoming workflow steps..)workflow step, expected upcoming workflow steps..)

• Reference to the shared documents that were used as input to Reference to the shared documents that were used as input to the workflow step (if any)the workflow step (if any)

• Reference to the documents that were shared as a result of the Reference to the documents that were shared as a result of the workflow stepworkflow step


Proposed Standards & Systems

• ITI Afferent IHE ProfilesITI Afferent IHE Profiles: : – XDS.b, DSUB, NAV, XCA, BPPC, ATNA, XDRXDS.b, DSUB, NAV, XCA, BPPC, ATNA, XDR

• Afferent IHE Profiles:Afferent IHE Profiles: – Pharmacy - CMPD, PCC - PCCP, XDS-MS, RAD, LABs, Cardiology, Pharmacy - CMPD, PCC - PCCP, XDS-MS, RAD, LABs, Cardiology,

Ophthalmology, Mammo CAD, etc.Ophthalmology, Mammo CAD, etc.

• Other standards itemsOther standards items: : – HL7 CDAHL7 CDA

• Stability and robustnessStability and robustness: : – No new transaction are introducedNo new transaction are introduced– The only new actor introduced is Workflow Document Consumer but it The only new actor introduced is Workflow Document Consumer but it

is an XDS Doc Consumer and Source grouped togetheris an XDS Doc Consumer and Source grouped together– 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


Discussion

• This proposal arises from the necessity to manage the This proposal arises from the necessity to manage the documents in pharmacy area but it also answers to the documents in pharmacy area but it also answers to the infrastructure requires from other profiles and domains, for infrastructure requires from other profiles and domains, for ex. PCCP (Patient Centered Coordination Plan), Pharmacy ex. PCCP (Patient Centered Coordination Plan), Pharmacy Domain (Extension to Community Medication Prescription Domain (Extension to Community Medication Prescription and Dispense)and Dispense)

• It proposes a more general approach which allows to It proposes a more general approach which allows to extend the management of workflow that rely on the clinical extend the management of workflow that rely on the clinical documents in many different care areas. documents in many different care areas.


Discussion

The value statement of this proposal is:The value statement of this proposal is:• The standardization of the workflows’ management The standardization of the workflows’ management

transactions and the associated workflow tracking structure transactions and the associated workflow tracking structure linked with clinical eventslinked with clinical events

• The creation of a document structure able to respond at The creation of a document structure able to respond at the present and possibly to extend to future requirementsthe present and possibly to extend to future requirements

• This profile proposal benefits many domains. So it This profile proposal benefits many domains. So it increases the consistency of workflow interoperability and increases the consistency of workflow interoperability and the skill to solve the requests of the various care areas. It the skill to solve the requests of the various care areas. It will avoid that different competing solutions are developed will avoid that different competing solutions are developed in the different domains. It is necessary to create an IT in the different domains. It is necessary to create an IT Infrastructure Profile in this field.Infrastructure Profile in this field.


Effort Estimates

• The work effort (in term of documentation) for profiling the XDW The work effort (in term of documentation) for profiling the XDW is low because there aren’t new transactions and the new is low because there aren’t new transactions and the new actor, the Workflow Doc Consumer, is only assemblage of two actor, the Workflow Doc Consumer, is only assemblage of two already existing actors. already existing actors.

• The work will be focused on the definition of a basic workflow The work will be focused on the definition of a basic workflow document structure, its document entry metadata rules and the document structure, its document entry metadata rules and the principles to define “workflow content” profiles by ITI and other principles to define “workflow content” profiles by ITI and other IHE Domains (e.g. definition of the possible status in the IHE Domains (e.g. definition of the possible status in the specific) clinical process specific) clinical process

• Profile editors:Profile editors:– Luca Zalunardo, Arsenàl.IT, Luca Zalunardo, Arsenàl.IT, [email protected]– Arianna Cocchiglia, Arsenàl.IT, Arianna Cocchiglia, Arsenàl.IT, [email protected]– Organization: Arsenàl.IT, Organization: Arsenàl.IT, www.consorzioarsenal.it

Documents

Cross-enterprise Document Workflow (XDW) Brief Profile Proposal for 2009/10 presented to the IT Infrastructure Planning Committee Charles Parisot, Claudio