1. Cross-enterprise Document Workflow (XDW) Brief Profile Proposal for 2009/10 presented to the IT Infrastructure Planning Committee Charles Parisot, Claudio Saccavini, Luca Zalunardo, Arianna Cocchiglia October, 18 th 2010

2. IT Infrastructure Planning Committee XDW - Key Elements This proposal focuses on the Cross-Enterprise Workflow for Document Sharing in support of workflow document and status management. Key elements: Managing workflow specific status with relationship to one or more documentsManaging workflow specific status with relationship to one or more documents Tracking the health care entity that change a status associated to a workflow stepTracking the health care entity that change a status associated to a workflow step Tracking the past steps of the workflow related to specific clinical eventTracking the past steps of the workflow related to specific clinical event

3. IT Infrastructure Planning Committee Necessity: it is now becoming essential by the increase of the use by different sectors of these document sharing related IHE profiles with their different types of documents and information.it is now becoming essential by the increase of the use by different sectors of these document sharing related IHE profiles with their different types of documents and information. Many different worldwide projects have as goals to paperless of documents and digitalization of clinical processes. At the bases of all these projects there is the management of ePrescription and eReferral for theirMany different worldwide projects have as goals to paperless of documents and digitalization of clinical processes. At the bases of all these projects there is the management of ePrescription and eReferral for their –Variuos and structures workflow –Clinical, economic, social and organizational impact values XDW - Necessity

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

5. IT Infrastructure Planning Committee Algnment with governaments/national programs Austria Veneto Region Italy France DMP InFSE Italy Electronic Transfer of ePrescription Australia European Project 12 Coutries Projects of the Department of Health and Human Services

6. IT Infrastructure Planning Committee 2-Booking the visit Use Case: an example of eReferral workflow Ordered Placed Placed In Progress In Progress Completed Ordered 3-ADT Admission of the patient 4- RX Exam 5- Production of the Clinical Report 6- Publication of RX report 7-Notification to the GP 1-Visit and production of eReferral

7. IT Infrastructure Planning Committee 2-Booking the visit Use Case: an example of eReferral workflow Ordered Placed Placed In Progress In Progress Completed Ordered 3-ADT Admission of the patient 4- RX Exam 5- Production of the clinical report 6- Pubication of RX report 7-Notification to the GP 1-Visit and production of eReferral Clinical steps: A patient attends a consultation with his GPA patient attends a consultation with his GP The GP examines him and generates an eReferralThe GP examines him and generates an eReferral 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 XDSFolder mechanism)Provide a Document Folder (the 2 objects are grouped using XDSFolder mechanism) Provide the eReferral Doc and WDProvide the eReferral Doc and WD

8. IT Infrastructure Planning Committee 2-Booking the visit Use Case: an example of eReferral workflow Ordered Placed Placed In Progress In Progress Completed Ordered 3-ADT Admission of the patient 4- RX Exam 5- Production of the clinical report 6- Pubication of RX report 7-Notification to the GP 1-Visit and production of eReferral 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 and books the visitThe HCP cunsults the eReferral Doc and WD associeted and books the visit 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 Workflow Document (WD)Modify the status associated whit eRefferral inside the Workflow Document (WD) Replace the WDReplace the WD

9. IT Infrastructure Planning Committee 2-Booking the visit Use Case: an example of eReferral workflow Ordered Placed Placed In Progress In Progress Completed Ordered 3-ADT Admission of the patient 4- RX Exam 5- Production of the clinical report 6- Pubication of RX report 7-Notification to the GP 1-Visit and production of eReferral Clinical steps: The patient is admitted at the hospitalThe patient is admitted at the hospital The HCP cunsults the eReferral Doc and WD associetedThe HCP cunsults the eReferral Doc and WD associeted The visit takes placeThe visit takes place Technical steps: Query and Retrieve of the eReferral Doc and WDQuery and Retrieve of the eReferral Doc and WD Modify the status associated with eRefferral inside the Workflow Document (WD)Modify the status associated with eRefferral inside the Workflow Document (WD) Replace the WDReplace the WD

10. IT Infrastructure Planning Committee 2-Booking the visit Use Case: an example of eReferral workflow Ordered Placed Placed In Progress In Progress Completed Ordered 3-ADT Admission of the patient 4- RX Exam 5- Production of the clinical report 6- Pubication of RX report 7-Notification to the GP 1-Visit and production of eReferral Clinical steps: The doctor generates the clinical report of the examThe doctor generates the clinical report of the exam Technical steps: Creation of the Clinicl Report DocCreation of the Clinicl Report Doc Modify the status associated with eRefferral inside the Workflow Document (WD)Modify the status associated with eRefferral inside the Workflow Document (WD) Replace the WDReplace the WD Provide the Clinical Report Doc associated with eReferral in the same FolderProvide the Clinical Report Doc associated with eReferral in the same Folder

11. IT Infrastructure Planning Committee 2-Booking the visit Use Case: an example of eReferral workflow Ordered Placed Placed In Progress In Progress Completed Ordered 3-ADT Admission of the patient 4- RX Exam 5- Production of the clinical report 6- Pubication of RX report 7-Notification to the GP 1-Visit and production of eReferral Clinical steps: There is the possibility to send a notification about the pubblication of the Report associeted with the eReferral that he has produced beforeThere is the possibility to send a notification about the pubblication of the Report associeted with the eReferral that he has produced before However at anytime during this process, the GP may consult the WD and access related new documents producedHowever at anytime during this process, the GP may consult the WD and access related new documents produced

12. IT Infrastructure Planning Committee Analysis of different solutions Alternative SolutionsWhy 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 MachineThis 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 WorkflowThis 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 its correct to structure it as a CDA

13. IT Infrastructure Planning Committee The structure of the Workflow Document Section 1 General and common data (patient data, author data, institution data, etc) Section 2…n One section for any performed Workflow Step (e.g. ePrescription, eReferral) which contains: Internal management properties about workflow step (status, author, date/time of the change, relationship with previous workflow step, expected upcoming workflow steps..)Internal management properties about workflow step (status, author, date/time of the change, relationship with previous workflow step, expected upcoming workflow steps..) Reference to the shared documents that were used as input to the workflow step (if any)Reference to the shared documents that were used as input to the workflow step (if any) Reference to the documents that were shared as a result of the workflow stepReference to the documents that were shared as a result of the workflow step Section 1 General and common data (patient data, author data, institution data, etc) Section 2…n One section for any performed Workflow Step (e.g. ePrescription, eReferral) which contains: Internal management properties about workflow step (status, author, date/time of the change, relationship with previous workflow step, expected upcoming workflow steps..)Internal management properties about workflow step (status, author, date/time of the change, relationship with previous workflow step, expected upcoming workflow steps..) Reference to the shared documents that were used as input to the workflow step (if any)Reference to the shared documents that were used as input to the workflow step (if any) Reference to the documents that were shared as a result of the workflow stepReference to the documents that were shared as a result of the workflow step

14. IT Infrastructure Planning Committee Proposed Standards & Systems ITI Afferent IHE Profiles:ITI Afferent IHE Profiles: –XDS.b, DSUB, NAV, XCA, BPPC, ATNA, XDR Afferent IHE Profiles:Afferent IHE Profiles: –Pharmacy - CMPD, PCC - PCCP, XDS-MS, RAD, LABs, Cardiology, Ophthalmology, Mammo CAD, etc. Other standards items:Other standards items: –HL7 CDA Stability and robustness:Stability and robustness: –No new transaction are introduced –The only new actor introduced is Workflow Document Consumer but it is an XDS Doc Consumer and Source grouped together –No XDS Metadata extension expected, but specific rules about Metadata content for the workflow Document

15. IT Infrastructure Planning Committee Discussion This proposal arises from the necessity to manage the documents in pharmacy area but it also answers to the infrastructure requires from other profiles and domains, for ex. PCCP (Patient Centered Coordination Plan), Pharmacy Domain (Extension to Community Medication Prescription and Dispense)This proposal arises from the necessity to manage the documents in pharmacy area but it also answers to the infrastructure requires from other profiles and domains, for ex. PCCP (Patient Centered Coordination Plan), Pharmacy Domain (Extension to Community Medication Prescription and Dispense) It proposes a more general approach which allows to extend the management of workflow that rely on the clinical documents in many different care areas.It proposes a more general approach which allows to extend the management of workflow that rely on the clinical documents in many different care areas.

16. IT Infrastructure Planning Committee Discussion The value statement of this proposal is: The standardization of the workflows management transactions and the associated workflow tracking structure linked with clinical eventsThe standardization of the workflows management transactions and the associated workflow tracking structure linked with clinical events The creation of a document structure able to respond at the present and possibly to extend to future requirementsThe creation of a document structure able to respond at the present and possibly to extend to future requirements This profile proposal benefits many domains. So it increases the consistency of workflow interoperability and the skill to solve the requests of the various care areas. It will avoid that different competing solutions are developed in the different domains. It is necessary to create an IT Infrastructure Profile in this field.This profile proposal benefits many domains. So it increases the consistency of workflow interoperability and the skill to solve the requests of the various care areas. It will avoid that different competing solutions are developed in the different domains. It is necessary to create an IT Infrastructure Profile in this field.

17. IT Infrastructure Planning Committee Effort Estimates The work effort (in term of documentation) for profiling the XDW is low because there arent new transactions and the new actor, the Workflow Doc Consumer, is only assemblage of two already existing actors.The work effort (in term of documentation) for profiling the XDW is low because there arent new transactions and the new actor, the Workflow Doc Consumer, is only assemblage of two already existing actors. The work will be focused on the definition of a basic workflow document structure, its document entry metadata rules and the principles to define workflow content profiles by ITI and other IHE Domains (e.g. definition of the possible status in the specific) clinical processThe work will be focused on the definition of a basic workflow document structure, its document entry metadata rules and the principles to define workflow content profiles by ITI and other IHE Domains (e.g. definition of the possible status in the specific) clinical process Profile editors:Profile editors: –Luca Zalunardo, Arsenàl.IT, lzalunardo@consorzioarsenal.it lzalunardo@consorzioarsenal.it –Arianna Cocchiglia, Arsenàl.IT, acocchiglia@consorzioarsenal.it acocchiglia@consorzioarsenal.it –Organization: Arsenàl.IT, www.consorzioarsenal.it www.consorzioarsenal.it