1. Detailed Profile Proposal for 2015/16 presented 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

2. 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. 3 A.O. VR A.O. PD Highly specialized centers with cardiac surgeon Peripheral Hospital with ambulatory and Cath lab Peripheral 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

4. Dynamic Heart team Peripheral Hospital Cardiologist Patient Cardiac surgeon Highly specialized Center A Highly specialized Center A Clinical data ‪ interventional cardiologist ‬ Cardiologist Clinical data ‪ interventional cardiologist ‬ Peripheral Hospital Highly specialized Center B Highly specialized Center B Highly specialized Center B Highly specialized Center B ‪ interventional cardiologist ‬ Patient Support Hub network Dynamic HT: Chairperson, professionals, needed clinical documents, priority

5. 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” dynamically  Difficult 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

6. State of art A Document sharing infrastructure is not enough to create the WF management infrastructure  what 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 activities  What 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?

7. 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.

8. 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.

9. Peripheral Hospital Cardiologist Cardiac surgeon Highly specialized Center A Highly specialized Center A Clinical data ‪ interventional cardiologist ‬ Current Use Case Cardiologist Clinical data ‪ interventional cardiologist ‬ Peripheral Hospital Highly specialized Center B Highly specialized Center B Highly specialized Center B Highly specialized Center B ‪ interventional cardiologist ‬ Heart team

10. Cardiologist Patient Cardiac surgeon Heart team Clinical data Current Use Case ‪ interventional cardiologist ‬ Peripheral Hospital Cardiologist Clinical data ‪ interventional cardiologist ‬ Cardiologist Clinical data ‪ interventional cardiologist ‬ Peripheral Hospital Highly specialized Center A Highly specialized Center A Highly specialized Center B Highly specialized Center B Highly specialized Center B Highly specialized Center B Peripheral Hospital

11. Cardiologist Patient Cardiac surgeon Heart team Clinical data Current Use Case ‪ interventional cardiologist ‬ Peripheral Hospital Cardiologist Clinical data ‪ interventional cardiologist ‬ Cardiologist Clinical data ‪ interventional cardiologist ‬ Peripheral Hospital Highly specialized Center A Highly specialized Center A Highly specialized Center B Highly specialized Center B Highly specialized Center B Highly specialized Center B Peripheral Hospital

12. Cardiologist Patient Cardiac surgeon Heart team Clinical data Current Use Case ‪ interventional cardiologist ‬ Peripheral Hospital Cardiologist Clinical data ‪ interventional cardiologist ‬ Cardiologist Clinical data ‪ interventional cardiologist ‬ Peripheral Hospital Highly specialized Center A Highly specialized Center A Highly specialized Center B Highly specialized Center B Peripheral Hospital Document sharing by XDS profile, phone interaction to coordinate activities Cardiac surgeon Highly specialized Center B Highly specialized Center B

13. Cardiologist Patient Cardiac surgeon Clinical data Current Use Case Hearth team meeting Cardiac surgeon Document sharing by XDS profile, phone interaction to coordinate activities ‪ interventional cardiologist ‬ Heart team Peripheral Hospital Cardiologist Clinical data ‪ interventional cardiologist ‬ Cardiologist Clinical data ‪ interventional cardiologist ‬ Peripheral Hospital Highly specialized Center A Highly specialized Center A Highly specialized Center B Highly specialized Center B Highly specialized Center B Highly specialized Center B Peripheral Hospital

14. 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.

15. Cardiologist Patient Cardiac surgeon Clinical data ‪ interventional cardiologist ‬ Proposed Use Case Virtual Heart team meeting Cardiac surgeon Workflow document for heart team Task1 In: link document 1 Out: link document 2 Task2 In: link document 2 Out: link document 3 Task3 In: link document 4 Out: link document 5 ‪ interventional cardiologist ‬ Heart team Cardiologist Clinical data Peripheral Hospital Highly specialized Center A Highly specialized Center A Highly specialized Center B Highly specialized Center B Highly specialized Center B Highly specialized Center B Peripheral Hospital

16. 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

17. Proposed Standards & Systems Systems that can be involved in the process described above are: CIS system Hospital EHR system HIS IHE 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

18. Infrastructure: XDW with a XDS/DSUB Profile based on the Workflow Definition Template

19. 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 owner Cardiac surgeon opens the request eReferral workflow Concluded IN PROGRESS Cardiac surgeon requires new clinical reports in order to prepare intervention Owner: Participant (Hub) IN: Clinical report, imaging, request OUT: Preliminary evaluation Workflow Document for HT management 0…n 1….1

20. REQUEST COMPLETED Cardiologist produces request of HT activation START Owner: Requester IN: Clinical report, imaging OUT: Request Workflow Document for HT management 1….1

21. REQUEST COMPLETED Cardiologist produces request of HT activation PERFORM IN PROGRESS COMPLETED START Owner: Requester IN: Clinical report, imaging OUT: Request Cardiac surgeon opens the request Workflow Document for HT management 1….1 Owner: Performer (Hub) IN: Clinical report, imaging, request

22. REQUEST COMPLETED Cardiologist produces request of HT activation PERFORM IN PROGRESS COMPLETED START Owner: Requester IN: Clinical report, imaging OUT: Request Cardiac surgeon opens the request Workflow Document for HT management 1….1 Change of owner Owner: Performer (Hub) IN: Clinical report, imaging, request

23. REQUEST COMPLETED Cardiologist produces request of HT activation PERFORM IN PROGRESS COMPLETED START Owner: Requester IN: Clinical report, imaging OUT: Request Cardiac surgeon opens the request Workflow Document for HT management 1….1 Change of owner Owner: Performer (Hub) IN: Clinical report, imaging, request eReferral workflow HT INVOLVEMENT COMPLETED IN PROGRESS Surgeon involves an other professional, for videoconference or asynchrony discussion eReferral workflow Concluded Owner: Participant (Hub) IN: Clinical report, imaging, request OUT: Preliminary evaluation 0…n

24. REQUEST COMPLETED Cardiologist produces request of HT activation PERFORM IN PROGRESS Discussion is concluded; Surgeon produce a preliminary report HT INVOLVEMENT COMPLETED START 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 Change of owner Cardiac surgeon opens the request eReferral workflow Concluded Owner: Participant (Hub) IN: Clinical report, imaging, request OUT: Preliminary evaluation Workflow Document for HT management 0…n 1….1

25. REQUEST COMPLETED Cardiologist produces request of HT activation PERFORM IN PROGRESS Discussion is concluded; Surgeon produce a preliminary report HT INVOLVEMENT COMPLETED FINALIZATION 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 eReferral workflow Change of owner Cardiac surgeon opens the request eReferral workflow Concluded IN PROGRESS Cardiac surgeon requires new clinical reports in order to prepare intervention Owner: Participant (Hub) IN: Clinical report, imaging, request OUT: Preliminary evaluation Workflow Document for HT management 0…n 1….1

26. 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 owner Cardiac surgeon opens the request eReferral workflow Concluded IN PROGRESS Cardiac surgeon requires new clinical reports in order to prepare intervention Owner: Participant (Hub) IN: Clinical report, imaging, request OUT: Preliminary evaluation Workflow Document for HT management 0…n 1….1

27. 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

28. Discussion Profile Editor: Mauro Zanardini, mzanardini@consorzioarsenal.it, Arsenàl.ITmzanardini@consorzioarsenal.it Elena Vio, evio@consorzioarzioarsenal.it, Arsenàl.ITevio@consorzioarzioarsenal.it Claudio Saccavini, csaccavini@consorzioarsenal.it, Arsenàl.ITcsaccavini@consorzioarsenal.it Glauco Brandolino, gbrandolino@consorzioarsenal.it, Arsenàl.ITgbrandolino@consorzioarsenal.it Supporting Resources Charles Parisot, charles.parisot@med.ge.com, GEcharles.parisot@med.ge.com Harry Solomon, Harry.Solomon@med.ge.com, GEHarry.Solomon@med.ge.com IHE Cardiology Domain