November, 2012What IHE Delivers XDW (Cross-Enterprise Document Workflow) & XBeR-WD (Cross-Enterprise Basic eReferral Workflow Definition) Workflow Management for a Referral Process XDW (Cross-Enterprise Document Workflow) & XBeR-WD (Cross-Enterprise Basic eReferral Workflow Definition) ftp://ftp.ihe.net/IT_Infrastructure/iheitiyr /Planning_Cmte/EducMaterial/ IT Infrastructure Planning Committee Charles Parisot (GE) Mauro Zanardini (Arsenàl.IT)

BACKGROUND ON INTEGRATING THE HEALTHCARE ENTERPRISE 2

IHE International  Over 500 Member Organizations world-wide  Effective multi-stakeholder, multi-country balance  You may join today ! Free.  Even better, organize an IHE initiative in your country and join IHE International ! 3

Interoperability: From a problem to a solution 4 Profile Development & testing eHealth Projects 4 Project Specific Extensions IHTSDO IETF Profiling Organizations are well established IHE has a Liaison A with ISO, recognized as SDO by JIC Base Standards

5 IHE: Connecting Standards to Care  Healthcare professionals work with industry  Coordinate implementation of standards to meet clinical and administrative needs  Clinicians and HIT professionals identify the key interoperability problems they face  Providers and industry work together to develop and make available standards-based and tested specifications  Implementers follow common guidelines in purchasing and integrating effective systems IHE: A forum for agreeing on how to implement standards and processes for making it happen

6 IHE vs. alternative approaches If your health IT project selects independently its standards:  The same requirement addressed with a different mix of standards in different projects  Large effort & time needed for detailed project interoperability specifications (12 to 24 months, several man years)  Even larger effort to develop custom conformance test tools, and organize own testing efforts (many man years).  Initial implementation cost are very high, and on-going costs only increase. No reuse benefit from other eHealth projects. eHealth Projects shall drive their own requirements but address them by reusing as much as possible robust standards-based profiles or implementation specifications

Over the past 13 years, IHE has analyzed hundreds of such “use cases” across 11 domains and responded with over 120 Profile Specifications: 7 Work done by IHE  Anatomic Pathology  Cardiology  Eye Care  IT Infrastructure  Laboratory  Patient Care Coordination  Patient Care Device  Pharmacy  Quality Research and Public Health  Radiatoion Oncology  Radiology

IHE Region & IHE National IHE Region & IHE National IHE International 8 Standards Adoption Process Document Use Case Requirements Identify available standards ( e.g. HL7, DICOM, IETF, OASIS) Develop technical specifications Testing at Connectathons IHE Demonstrations Products with IHE Profiles Timely access to information Easy to integrate products

REQUIREMENTS AND STATE OF THE ART FOR CROSS-ORGANIZATION WORKFLOWS IN EHEALTH 9

Multi-organization Workflows in eHealth (1) Business Use Case: Coordinate the activities and associated tasks related to patient-centric workflows in a multi-organizational environment. Business Actors: Health Professionals/GPs, various specialized clinics, diagnosis/pharmacies/care support organizations, acute care hospitals, etc. Key Requirements:  Focus should be “workflows” between the participating organizations  Keep workflows within the organizations unconstrained  Decentralize workflow decisions to be largely made by the health professionals within each collaborating organizations  Workflow to be patient centric, influence how workflows unfold  Support decentralized workflow control  Ensure flexible workflow deployment, with participating organizations joining and leaving (clinically and technically)  The definition of specific workflows need to scale to 1000’s of workflows & workflow variants

Multi-organization Workflows in eHealth (2) Current State of the Art: Mostly failures. Heavy deployment, one workflow at a time (e.g. lab orders to a specific lab, ePrescription). Typical Approach: Creates a central workflow hub, where the workflow is defined and managed. Participating organizations manage their participation either manually (e.g. web browser) or through scripted messages (e.g. HL7 V2). Key Issues:  Requires co-deployment of central hub and custom interfacing of each participating organizations  Challenged by health professionals in the collaborating organizations, where exceptions are difficult to address  Patients influence is generally excluded  Centralized workflow control, creates complex consensus  Workflow deployment is one workflow at a time and very slow (5-15 years). Silo approach. No scaling to other workflows.

INTRODUCING IHE PROFILES FOR CROSS-ENTERPRISE WORKFLOWS IN EHEALTH 12

Outline:  High level description of a clinical process that can be tracked and managed using XDW approach.  Use of an instrument (Workflow Document) in a common scenario such as Referral Process  Overview on a Workflow Definition profile and explanation of its relationship with XDW  Definition of simple guidelines to fit process rules into a Workflow Definition profile. 13

Use-case: 14 Un-targeted eReferral process:  a physician requests a specialist’s consultation for the patient;  the Health Care Provider (HCP), from the Hospital Information System, schedules the visit;  the HIS admits the patient in hospital and the specialist can start the consultation which may span one or more visits;  the specialist completes the consultation and produces a report.

XDW Workflow Encapsulates Organization 2 - Schedule Appointment 3- Start of the Consultation 4 – End of the consultation and creation of the clinical report 5 – Possible notification to the GP 1-Visit and production of eReferral The workflow within the organization is encapsulated into a few selected XDW steps

Approach of the XDW Profile The Cross-Enterprise Document Workflow (XDW) profile enables participants in a multi-organizational environment to manage and track the tasks related to patient-centric workflows as organizations coordinate their activities:  No central controller (reduce deployment costs)  No central scheduler (the Referral Scheduler is not known at the start of the process)  Decisions are made by the “edges” (each actor involved can influence the evolution of the workflow)  Information related to the workflow, and document produced (eReferral document, Clinical Input, Report) are shared between all actors involved

XDW Workflow management infrastructure Workflow Document in XDW:  Specified by XDW is generic across specific workflow content  Manages workflow specific status with relationship to input/output documents  Tracking the current/past steps of the workflow and engaged health care entities

XDW profile and Workflow Definition profile  Cross Enterprise Document Workflow is:  a framework to manage workflows  a platform upon which a wide range of specific workflows can be defined with minimal specification and implementation efforts  workflow definitions independent  Focused on document-based workflow: applicable on different document sharing infrastructures already deployed.  Content shared between workflow’s participants has to be wrapped into a document object  Documents objects are exchanged using the same infrastructure used for the Workflow Document  Workflow Definition Profile is:  the definition of a specific clinical process  a set of rules and task definition which characterize the process  the definition of the actors involved in the process and their roles

XDW technical approach  The detailed description of the technical approach used by XDW: Educational material: ftp://ftp.ihe.net/IT_Infrastructure/ITI_EducationalMaterials/CurrentPublished/I HE-XDW_ ppt XDW Content Profile: 19

OVERVIEW OF THE BASIC REFERRAL WORKFLOW DEFINITION PROFILE 20

XBeR-WD potentialities: 21 Flexibility for a wide variety of use-cases:  Any health professional involved in the Referral process can contribute adding information to the clinical process identifying other actors involved in subsequent steps (e.g. Targeted Referral process)  Referring to a Health Service Queue and not to a clinician is allowed  Selfdetermination of the patient that is the only OWNER for the clinical process: the patient can affect the evolution of clinical workflow in accordance with domain policies.

From the use-case to a Workflow Definition profile 22 To define for a Workflow Definition profile:  Actors involved: any participant with specific role that can condition the evolution of the process changing the status of the workflow:  Participant: an health professional that adds information to the clinical process  Actor: an health professional that can complete clinical tasks  Workflow tasks: a structured action that describes process steps in a simple and standardized way  Allowed evolutions of the process: any workflow path that can be followed in response to specific triggers.  Documents produced during the process: clinical information shared between actors involved

eReferral Workflow Actors 23 Referral Requested (COMPLETED) (COMPLETED) Referral Referred (COMPLETED) (COMPLETED) Referral Scheduled (COMPLETED) (COMPLETED) Referral Referred (IN_PROGRESS) (IN_PROGRESS) Referral Requester Referral Performer Referral Scheduler WorkflowMonitorWorkflowMonitorStartStartStopStop The Workflow Monitor can read the status of the task at any time Any participant that affects the evolution of the process:  GP: acts as Referral Requester, starting the process with a referral request  HCP : acts as Referral Scheduler, scheduling the visit  Specialist : acts as Referral Performer, starting and completing the visit  Process Oversight : acts as Workflow Monitor, managing exceptions eReferral Process Flow between Workflow Actors

eReferral workflow Tasks 24 Any simple/complex action performed by an enterprise that needs to be externally “visible”:  Referral Requested: a type of task that tracks the request for a referral process.  Referral Scheduled: a task type that tracks the taking in charge of the eReferral by an HCP.  Referral Referred: a task type that tracks the progress and the completion of the referral.

eReferral process evolution 25 Identify events that affects the evolution of the process as triggers:  Completion of Request (Task “Referral Requested” in status COMPLETED)  Completion of Scheduling (Task “Referral Scheduled” in status COMPLETED)  Start of the consultation (Task “Referral Referred” in status IN_PROGRESS)  Completion of the Referral (Task “Referral Referred” in status COMPLETED)

Documents Referenced 26 Any clinical or administrative information conveyed between actors involved:  eReferral: document that describe the referral requested and probably the reason for the request  Clinical Input: clinical information tracked to justify the request  Exception Report: document produced in case of exception situation  Reminder Note: document that tracks information reated to the scheduling of the visit  Clinical Report of the visit: document that tracks results of the specialist's consultation Label used in XDW Workflow Document Example of content profile eReferralXDS-SD Clinical Report of the Visit XDS-SD EDR PPOC XD-LAB ECDR CIRC DRPT APSR Exception ReportXDS-SD Clinical Input XDS-SD PPOC XD-LAB ECDR CIRC DRPT APSR Reminder NoteXDS-SD

Workflow Definition profiles specific features: Define alternative paths and rules, and suggest the use of other profiles to define sharing infrastructure and content of shared documents:  Workflow Options: can be selected by a specific project implementation, and allows the profile to be more flexible through different local scenarios. (e.g. the Referral process in a specific implementation can evolve without the scheduling phase. In this case a specific option is selected and rules for transition between tasks are changed. Options selected is not an information conveyed between actors but a “foundation” upon which any actor is created inside the specific project implementation)  Grouping of actors: used to require:  Specific document sharing infrastructures (e.g. XDW, XDS, XDM, XDR)  Including referenced content in standardized way (e.g. XDS-SD, XD-LAB, XDS-I, XPHR, XDS-MS) 27

1) Referral Request (1/2) 28 The GP’s software, as Referral Requester, produces the eReferral Document and the related Workflow Document characterized by:  WorkflowDefinitionReference=  WorkflowStatus=OPEN  Only one task “Referral Referred” in status COMPLETED  This “eReferral” document is attached to the Workflow Document eReferral Doc Workflow Document Referral Requested Input: -- Output: eReferral doc Referral Requested Input: -- Output: eReferral doc COMPLETED

1) Referral Request (2/2) 29 eReferral document Workflow Document Ver.1APPROVED Ver.1APPROVED XDS infrastructure Documents produced are submitted to the XDS Infrastructure The eReferral document is now available, along with its related status tracked by the Workflow Document, to all organizations

2) Scheduling the Referral (1/2) 30 The patient calls for appointment. Administrative person on Hospital System, as Referral Scheduler, checks the status of the eReferral workflow by consuming the Workflow Document :  Visit needs to be scheduled (task “Referral Requested” status COMPLETED)  Use the “eReferral” document as input  Set appointment (producing “Reminder Note” for patient)  Add a new task “Referral Scheduled” in status COMPLETED  Updates the Workflow Document Workflow Document Referral Requested COMPLETED Referral Scheduled Input: eReferral doc Output: Reminder Note Referral Scheduled Input: eReferral doc Output: Reminder Note COMPLETED Reminder Note

31 eReferral document Workflow Document Ver.1 DEPRECATE D Workflow Document Ver.1 DEPRECATE D Workflow Document Ver.2APPROVED Ver.2APPROVED The visit can be cancelled by an administrative person, changing the status of the task “Referral Scheduled” to:  IN_PROGRESS: needs to re-schedule the visit (same Provider)  FAILED: eReferral is released by the Health Care Provider Reminder Note 2) Scheduling the Referral (2/2)

3) Start of the consultation (1/2) 32 The patient visits the specialist. The specialist’s software, as Referral Performer, checks the status of the workflow.   By consuming the Workflow Document   Sees that the visit has been scheduled (task “Referral Scheduled” in status COMPLETED)   Reviews the eReferral document related.   Referral Performer starts the visit process updating the Workflow Document   Adding a new task “Referral Referred” in status IN_PROGRESS 32 Workflow Document Referral Requested COMPLETED Referral Scheduled COMPLETED Referral Referred Input: eReferral doc Output: -- Referral Referred Input: eReferral doc Output: -- IN_PROGRESSIN_PROGRESS

The visit process is in execution. eReferral document Workflow Document Ver.1 DEPRECATE D Workflow Document Ver.1 DEPRECATE D Workflow Document Ver.2 DEPRECATE D Workflow Document Ver.2 DEPRECATE D Workflow Document Ver.3APPROVED Ver.3APPROVED 3) Start of the consultation (2/2)

Workflow Document 4) End of the consultation (1/2) 34 The specialist’s software, as Referral Performer, completes the visit process producing the “Clinical Report Of The Visit” and closes the Referral process completing the Referral Referred task:  Set the task “Referral Referred” status to COMPLETED  Close the workflow by setting the WorkflowStatus to CLOSED  Reference the “Clinical Report of the Visit” document as output of the Referral Referred task 34 Referral Requested COMPLETED Referral Scheduled COMPLETED Referral Referred Input: eReferral doc Output: Clinical Report of the visit Referral Referred Input: eReferral doc Output: Clinical Report of the visit IN_PROGRESSIN_PROGRESSCOMPLETED

35 eReferral document Workflow Document Ver.1 DEPRECATE D Workflow Document Ver.1 DEPRECATE D Workflow Document Ver.2 DEPRECATE D Workflow Document Ver.2 DEPRECATE D Clinical Report of the Visit Workflow Document Ver.3 DEPRECATE D Workflow Document Ver.3 DEPRECATE D Workflow Document Ver.4APPROVED Ver.4APPROVED The Referral process is completed The Referral Requester actor can be notified for the publication of the Report (e.g. using a DSUB notification system) 4) End of the consultation (2/2)

XDW e XBeR-WD references XDW supplement:  Trial Implementation status  Good feedbacks for the first testing session in EU Connectathon  First testing planned for US Connectathon - Jan 2013 XBeR-WD supplement:  Trial Implementation status  First product announced at RSNA December 2012  Adoption is strictly related to XDW dissemination

37