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

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.

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

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

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 

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

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

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

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

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

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

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.)

Use Case: Neurosurgical Teleconselling Workflow Step view Workflow Document view

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

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

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

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

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?

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?

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

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.

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