Detailed Profile Proposal for 2015/16 presented to the Cardiology Technical Committee Cardiology consultation and patology board – Workflow Definition

Detailed Profile Proposal for 2015/16presented to the

Cardiology Technical Committee

Cardiology consultation and patology board – Workflow Definition

Elena Vio, Mauro Zanardini, Claudio Saccavini, Glauco Brandolino (Arsenàl.IT)

28 October, 2015

General problem• We need to guarantee an optimal cardiac treatment strategy in

whole territory with limited health resources.

• Limited highly specialized hospitals centralized in cardiac diseases have to support peripheral hospitals without cathlab or cardiac surgeon, in efficiency way, but it is difficult to manage the sharing of knowledge

• Example of specific problematic disease for peripheral hospital :– coronary artery disease– cardiac valvular disease– aortic disease– advanced heart failure– cardiogenic shock– …

3

A.O. VR A.O. PD

Highly specialized centers with cardiac surgeonPeripheral Hospital with ambulatory and Cath labPeripheral Hospital with only cardiac ambulatory

Italian regional example:Local Health Authorities

distribution

5 highly specialized hospital on cardiology

18 peripheral hospital with ambulatory and/or without cath lab

5 millions of citizens

Dynamic Heart team

Peripheral Hospital

Cardiologist

CardiologistCardiologist

Patient

Cardiac surgeon

Cardiac surgeon

Cardiac surgeon

Highly specializedCenter A

Clinical data

Clinical data

Clinical data

interventional cardiologist

Cardiologist

Clinical data


Peripheral HospitalPeripheral

Hospital

Peripheral Hospital

Highly specializedCenter B



Patient

Patient

Patient

Support

Support

Support

Support

Hub network

Dynamic HT: Chairperson, professionals, needed clinical documents, priority

Specific problems• The professionals can be geographically distant because they may belong

to different hospitals Difficult to communicate and share information

• Team’s members can be enrolled in the “Heart Team” dynamicallyDifficult to manage attending to the meeting and preparation of pre-meeting

• Clinical protocols are different on base of the disease Difficult to manage the sharing of documents when HT is numerous

We need a specific Workflow management engine able to define participant tasks, tasks transitions, and useful clinical information that have to be exchange

State of art

• A Document sharing infrastructure is not enough to create the WF management infrastructurewhat documents have to be shared for this task? who can see documents? Who have to produce documents?

• WF management for Heart team must be specific for cardiac field, we need to standardize the Heart Team activitiesWhat is the next task? Who the task has to do? When the task has to be done? What is the input for this task? What is the output of the task?

Aim of proposal

• To define a standardized workflow to manage and coordinate remote interaction between multidisciplinary and dynamic team of healthcare professionals (HT composed of network of hubs), with not only a simple sharing of information and digital documents.

• The workflow will support and manage the activation of the dynamic HT that allows us to adapt the team to simple or complex cases.

Impact• Example of specific problematic disease for pheriperal hospital

– coronary artery disease– cardiac valvular disease– aortic disease– advanced heart failure– cardiogenic shock– …

• Coronary heart disease: – Every year, 3.8 millions of man and 3.4 millions of female die (WHO)

• Coronary artery disease: – CAD is the most common type of heart disease. – In 2008, 405,309 individuals died in the U.S. – In 2010, $108.9 billion including the cost of health care services, medications, and

lost productivity.• First heart attack

– Every year, 785,000 suffer a first heart attack – Every year, 470,000 suffer an additional myocardial infarction.

Peripheral Hospital

Cardiologist


Cardiac surgeon

Cardiac surgeon

Cardiac surgeon

Highly specialized

Center A

Clinical data

Clinical data

Clinical data



Current Use Case

Cardiologist

Clinical data


Peripheral Hospital

Peripheral Hospital

Peripheral Hospital

Highly specializedCenter B Highly

specializedCenter B


Heart team

CardiologistPatient

Cardiac surgeon

Cardiac surgeon

Cardiac surgeon

Heart team

Clinical data

Current Use Case


Peripheral Hospital


Clinical data

Clinical data



Cardiologist

Clinical data


Peripheral Hospital

Peripheral Hospital

Highly specialized

Center A


specializedCenter B

Peripheral Hospital

CardiologistPatient

Cardiac surgeon

Cardiac surgeon

Cardiac surgeon

Heart team

Clinical data

Current Use Case


Peripheral Hospital


Clinical data

Clinical data



Cardiologist

Clinical data


Peripheral Hospital

Peripheral Hospital

Highly specialized

Center A


specializedCenter B

Peripheral Hospital

CardiologistPatient

Cardiac surgeon

Cardiac surgeon

Heart team

Clinical data

Current Use Case


Peripheral Hospital


Clinical data

Clinical data



Cardiologist

Clinical data


Peripheral Hospital

Peripheral Hospital

Highly specialized

Center A

Highly specialized

Center B

Peripheral Hospital

Document sharing by XDS profile, phone interaction to coordinate activities

Cardiac surgeon


CardiologistPatient

Cardiac surgeon

Clinical data

Current Use Case

Hearth team meeting

Cardiac surgeon

Cardiac surgeon

Document sharing by XDS profile, phone interaction to coordinate activities


Heart team

Peripheral Hospital


Clinical data

Clinical data



Cardiologist

Clinical data


Peripheral Hospital

Peripheral Hospital

Highly specialized

Center A


specializedCenter B

Peripheral Hospital

Current Use Case - Obstacles

Difficulty:• sharing of documents, in particular if the heart

team is extended and if new documents are added

• to manage involvement of professionals and attending to meeting

• notify all members of HT on the state of tasks: new members, new documents, new date of meeting etc.

CardiologistPatient

Cardiac surgeon

Clinical data


Proposed Use Case

Virtual Heart team meeting

Cardiac surgeon

Cardiac surgeon Workflow document for

heart team

Task1• In: link document 1• Out: link document 2




Heart team

Cardiologist

Clinical data Peripheral

HospitalHighly

specializedCenter A


specializedCenter B

Peripheral Hospital

Proposed Use Case• Benefit:

– immediate sharing between all actors on what happens in the process: all professionals are notified on new clinical documents, other professionals involved, new meetings etc.

– Immediate sharing of clinical documents for all professionals involved in the workflow

– dynamic enrolment of clinicians in a HT: clinicians are involved in process in relation of their skills and availabilities so that they can be activated promptly

– clear process for the highly specialized center to address heart team activation request: on the basis of the heart team activation request, the guidelines of the process identifies specific physicians of the HT to activate, the time of the response, which patient’s clinical exams have to be exchange, how to reach an agreement between HT members and which data should be reported to the requester

Proposed Standards & SystemsSystems that can be involved in the process described above are:• CIS system• Hospital EHR system• HISIHE profiles: • XDS.b-I (Cross-Enterprise Document Sharing) for Imaging, • XDS.b (Cross-Enterprise Document Sharing)• DSUB (Document Metadata Subscription): this profile allows to create a notification

infrastructure based the XDS.b Infrastructure• XDW (Cross-Enterprise Document Workflow): this profile allows the creation of a

Workflow management Infrastructure based on a XDS.b Environment. XDW guidelines provide a flexible tool that can be further profiled (defining a Workflow Definition profile) to manage specific clinical workflows.

• Example of CDA that could be used: • [DRPT] - Displayable Reports manages creation and distribution of “display ready” (PDF or CDA) clinical

reports from the creating application, to the department, and to the enterprise• [CIRC] - Cardiac Imaging Report Content format for a CDA report of a cardiac diagnostic imaging procedure,

including discrete data elements• [CRC] - Cath Report Content format for a CDA report of a cardiac Cath/PCI procedure, including discrete data

elements Imagining, radiolog

Infrastructure: XDW with a XDS/DSUB

Profile based on the Workflow Definition Template

REQUEST

COMPLETED

Cardiologist produces request of HT activation

PERFORM

IN PROGRESS

Discussion is concluded; Surgeon produce a preliminary report

HT INVOLVEMENT

COMPLETED

FINALIZATION

COMPLETED

Cardiac surgeon link new clinical reports and final report

COMPLETED

START

END

IN PROGRESS

Surgeon decides activate videoconference

Surgeon involves an other professional, for videoconference or asynchrony discussion• Owner: Performer

(Hub)

• IN: Clinical report, imaging, request

• OUT: Preliminary Report

• Owner: Requester

• IN: Clinical report, imaging

• OUT: Request

• Owner: Performer (Hub)

• IN: Preliminary report

• OUT: Final Report, new clinical reports

eReferral workflow

Change of ownerCardiac surgeon opens the request

eReferral workfloweReferral workflow

Concluded

IN PROGRESS

Cardiac surgeon requires new clinical reports in order to prepare intervention

• Owner: Participant (Hub)


• OUT: Preliminary evaluation

Workflow Document for HT management

0…n

1….1

1….1

1….1

REQUEST

COMPLETED


START



• OUT: Request


1….1

REQUEST

COMPLETED


PERFORM

IN PROGRESS

COMPLETED

START



• OUT: Request

Cardiac surgeon opens the request


1….1

1….1



REQUEST

COMPLETED


PERFORM

IN PROGRESS

COMPLETED

START



• OUT: Request



1….1

1….1

Change of owner• Owner: Performer (Hub)


REQUEST

COMPLETED


PERFORM

IN PROGRESS

COMPLETED

START



• OUT: Request



1….1

1….1

Change of owner• Owner: Performer (Hub)


eReferral workflow

HT INVOLVEMENT

COMPLETED

IN PROGRESS

Surgeon involves an other professional, for videoconference or asynchrony discussion

eReferral workflow

Concluded



• OUT: Preliminary evaluation0…n

REQUEST

COMPLETED


PERFORM

IN PROGRESS


HT INVOLVEMENT

COMPLETED

COMPLETED

START

IN PROGRESS



(Hub)





• OUT: Request



Concluded





0…n

1….1

1….1

REQUEST

COMPLETED


PERFORM

IN PROGRESS


HT INVOLVEMENT

COMPLETED

FINALIZATION

COMPLETED

COMPLETED

START

END

IN PROGRESS



(Hub)





• OUT: Request



eReferral workflow



Concluded

IN PROGRESS






0…n

1….1

1….1

1….1

REQUEST

COMPLETED


PERFORM

IN PROGRESS


HT INVOLVEMENT

COMPLETED

FINALIZATION

COMPLETED

Cardiac surgeon link new clinical reports and final report

COMPLETED

START

END

IN PROGRESS



(Hub)





• OUT: Request



• OUT: Final Report, new clinical reports

eReferral workflow



Concluded

IN PROGRESS






0…n

1….1

1….1

1….1

New actors

– HT Requester actor that requires the activation of HT for a clinical support

– HT Performer actor that manages the HT and concludes it with a final report and exame for the operation

– HT Participant actor that participates to the HT

Discussion

Profile Editor:Mauro Zanardini, [email protected], Arsenàl.IT Elena Vio, [email protected], Arsenàl.ITClaudio Saccavini, [email protected], Arsenàl.ITGlauco Brandolino, [email protected], Arsenàl.IT

Supporting Resources Charles Parisot, [email protected], GEHarry Solomon, [email protected], GEIHE Cardiology Domain

mailto:[email protected]










Documents

Detailed Profile Proposal for 2015/16 presented to the Cardiology Technical Committee Cardiology consultation and patology board – Workflow Definition