1. Cross-enterprise Document Workflow (XDW)
First Tcon
Charles Parisot, Claudio Saccavini, Luca Zalunardo, Arianna Cocchiglia
December, 20th 2010

2. Introduction
The Cross-Enterprise Document Workflow profile handles the difficult to manage the status of documents involved in a clinical workflow. The metadata “availabilityStatus”, in fact, allows to specify only two status (approved or deprecated) but this doesn’t allow to manage the different steps in a clinical workflow. This profile resolves the problem through the use of a specific document, the Workflow Document, where we track the different steps of all documents related to a same clinical event and all specific properties (who, when) connected to the change of a status by an healthcare professional; it defines also a set of rules to manage this particular document in an XDS scenario.

3. Actors/Transactions diagram
Document SOURCE
Workflow Document Consumer
[ITI – 41]
Provide and Register Document Set-b
[ITI – 41]
Provide and Register Document Set-b
Document SOURCE
Document REPOSITORY
[ITI – 43]
Retrieve Document Set-b
Document CONSUMER
[ITI – 42]
Register Document Set-b
XDS
Registry
[ITI – 18]
Registry Stored Query

4. Actor/Transaction Table
Actors
Transactions
Optionality
Section
Document Source
[ITI-41] R
ITI TF -2b: 3.41
Document Repository
[ITI-42]
[ITI-43]
ITI TF -2b: 3.42
ITI TF -2b: 3.43
Document Registry
[ITI-18]
ITI TF -2a: 3.18
Document Consumer

5. Integration Profile Options
Actors
Options
Vol&Sections
Workflow Document Consumer
XDS Doc Source and Consumer embedded
XDS Doc Source
Management Docs life cycle required (RPLC)
ITI TF-2b: 3.41
Grouped Actors 

6. Process Flow – Use cases
Possible Use Cases:
ePrescription
eReferral
Mobility/disability/healthcare aids
Healthcare professional monitoring
Neurosurgical Teleconselling …
Oncological scenario

7. Use Case ePrescription workflow
Ordered
2-Pharmacy partialy dispenses drugs
1-Visit and production of ePrescription
PlacedIn Progress
3-Publication of dispensed document related to the dispensed drug
5-Publication of dispensed document related to the dispensed drug
Redthe changes of the status about eReferral
White the clinical steps of an eReferral workflow event
4-Pharmacy dispenses all drugs
In ProgressCompleted

8. Use Case ePrescription
Workflow Document Consumer
Document
Source
Document Repository
Document Registry
Document Consumer
Document
Source
[ITI – 41] Provide & Register Document Set-b
Create a folder
[ITI – 42] Register
Document Set-b
[ITI – 41] Provide & Register Document Set-b
Pubblishing of ePrescription
[ITI – 42] Register
Document Set-b
[ITI – 41] Provide & Register Document Set-b
Pubblishing of WD
[ITI – 42] Register
Document Set-b
[ITI – 18] Registry Stored Query
Query and Retieve WD
[ITI - 43] Retrieve Document Set
[ITI – 18] Registry Stored Query
Query and Retrieve ePrescription
[ITI - 43] Retrieve Document Set
[ITI – 41] Provide & Register
Document Set-b_RPLC
Replace of WD
[ITI – 42] Register
Document Set-b
[ITI – 41] Provide & Register Document Set-b
Pubblishing of Dispensed Document
[ITI – 42] Register
Document Set-b

9. Use Case eReferral workflow
2-Booking the visit
Ordered  Placed
Ordered
1-Visit and production of eReferral
3-ADT
Admission of
the patient
PlacedIn Progress
7-Notification to the GP
4- RX Exam
Redthe changes of the status about eReferral
White the clinical steps of an eReferral workflow event
6- Publication of RX report
5- Production of the Clinical Report
In ProgressCompleted

10. Use Case eReferral Workflow Document Consumer Document Source
Document Repository
Document Registry
Document Consumer
Document
Source
[ITI – 41] Provide & Register Document Set-b
Create a folder
[ITI – 42] Register
Document Set-b
[ITI – 41] Provide & Register Document Set-b
Pubblishing of eRefeeral
[ITI – 42] Register
Document Set-b
[ITI – 41] Provide & Register Document Set-b
Pubblishing of WD
[ITI – 42] Register
Document Set-b
[ITI – 18] Registry Stored Query
Query and Retieve WD
[ITI - 43] Retrieve Document Set
[ITI – 18] Registry Stored Query
Query and Retrieve eRefeeral
[ITI - 43] Retrieve Document Set
[ITI – 41] Provide & Register
Document Set-b_RPLC
Replace of WD
[ITI – 42] Register
Document Set-b

11. Use Case Mobility/Disability/Healthcare Aids
2-The hospital decide if autorize the prescription and produce an advise document
Ordered  Authorized
1-Visit and production of Request for healthcare aids
3-The hospital dispenses the health aid and produce a document of dispensation
Ordered
Authorized Dispensed
6-The patient returns the ait to the hospital
4-The doctor tests the health aid dispensed and produces a report of the test
Tested and Dispensed  Returned
Dispensed Tested and Dispensed
5 – Notification to the GP

12. Use Case Healthcare professional Monitoring
Tracking of the follow up
Follow up of the conselling requests
Grouping of all reports related at the same workflow
Notification to the GP of the proceeding of the follow uo with the reports of the visits
Follow up at patient’s home or in structures dedicated (elderly home, health districts, etc.)

13. Use Case: Neurosurgical Teleconselling
Workflow Step view
Workflow Document view

14. Use Case 2: Workflow Document Content
Status
Teleconselling Request Document
In progress - Requested - Completed
CT Image KOS (1)
In progress - Completed …
CT Image KOS (n)
CT Report (1)
Preliminary – Completed - Signed
CT Report (n)
Preliminary - Signed
Teleconselling Response Document

15. Use Case - Neurosurgical Teleconselling
Workflow Document Consumer
Document
Source
Document Repository
Document Registry
Document Consumer
Document
Source
[ITI – 41] Provide & Register Document Set-b
Create a folder
[ITI – 42] Register
Document Set-b
Pubblishing of Teleconselling request Document
[ITI – 41] Provide & Register Document Set-b
[ITI – 42] Register
Document Set-b
Pubblishing of WD
[ITI – 41] Provide & Register Document Set-b
[ITI – 42] Register
Document Set-b
[ITI – 18] Registry Stored Query
Query and Retieve WD
[ITI - 43] Retrieve Document Set
Query and Retrieve Teleconselling request Document
[ITI – 18] Registry Stored Query
[ITI - 43] Retrieve Document Set
[ITI – 41] Provide & Register
Document Set-b_RPLC
Replace of WD
[ITI – 42] Register
Document Set-b
Pubblishing of Neurosurgeon Response Document
[ITI – 41] Provide & Register Document Set-b
[ITI – 42] Register
Document Set-b

16. Security Considerations
No new security problems are introduced by XDW
Security XDS  ATNA and CT Time Client actor, EUA, PWP
Time window = Retrieve modify and replace
XDS rules of replacement
Use steps to have a time window as close as possible

17. Proposed Standards & Systems
ITI Afferent IHE Profiles:
XDS.b, DSUB, NAV, XCA, BPPC, ATNA, XDR
Afferent IHE Profiles:
Pharmacy - CMPD, PCC - PCCP, XDS-MS, RAD, LABs, Cardiology, Ophthalmology, Mammo CAD, etc.
Other standards items:
HL7 CDA
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
Radiology, Cardiology, Ophthalmology, Radiation Oncology, Reporting Workflow, Mammo CAD, Labs, and Pharma all fit this structure

18. OPEN ISSUES AND QUESTIONS
CDA2 structure/Flux Schema
Document oriented or step oriented
Pharmacy profile and use cases (In Appendice or as an use case?)
Level of the use cases: technical or like a scenario discussion?
Integration with XCA profile:
Provide and register document set-b cross-community
Management of Workflow Document(RPLC and Life cycle)
Folder cross community?

19. 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..)
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 step
Dove metterlo?

20. The structure of the Workflow Document
Header
Body
Workflow Step Level Section
- General data about the document
- Link at the document
- orderStatus and related data
Second Level Section
- general data about the item
- status of the item and related data
- the link to possible documents generated by this item

21. Discussion The value statement of this proposal is:
The 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 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.

22. Next Steps Teleconference: January 14th ? US connectathon
may be the 21th or 25th could be better
F2F meeting: February 7th – 10th
May 2nd – 6th
July 18th – 22nd
Publish Trial Implementation August 2011