ftp://ftp.ihe/IT_Infrastructure/iheitiyr11-2013-2014/Planning_Cmte/EducMaterial/

1. Workflow Management for a Referral ProcessXDW (Cross-Enterprise Document Workflow)&XBeR-WD (Cross-Enterprise Basic eReferral Workflow Definition) ftp://ftp.ihe.net/IT_Infrastructure/iheitiyr11-2013-2014/Planning_Cmte/EducMaterial/ IT Infrastructure Planning Committee Charles Parisot (GE) Mauro Zanardini, Claudio Saccavini (Arsenàl.IT)

2. Background onIntegrating the HEALTHCARE ENTERPRISE

3. IHE International • Over 500 Member Organizations world-wide • Effective multi-stakeholder, multi-country balance www.ihe.net/governance/member_organizations.cfm • You may join today ! Free. • Even better, organize an IHE initiative in your country and join IHE International !

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

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 6

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

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

9. Requirements andState of the ART forCross-Organization Workflows in eHealth

10. 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

11. 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 definedand 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.

12. Introducing IHE Profiles For Cross-Enterprise Workflows in EHealth

13. 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.

14. Use-case: • 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.

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

16. Approach of the XDW Profile The Cross-Enterprise Document Workflow (XDW) profile enables participants in a multi-organizationalenvironment to manage and track the tasks related to patient-centric workflowsas 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

17. 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

18. 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

19. XDW technicalapproach • The detaileddescription of the technicalapproachused by XDW: Educational material: ftp://ftp.ihe.net/IT_Infrastructure/ITI_EducationalMaterials/CurrentPublished/IHE-XDW_2012-03-06.ppt XDW Content Profile: http://www.ihe.net/Technical_Framework/upload/IHE_ITI_Suppl_XDW.pdf

20. Overview of TheBasic Referral Workflow Definition Profile

21. From the use-case to a Workflow Definition profile To define for a Workflow Definition profile: • Actors involved: anyparticipant with specific role that can condition the evolution of the process changing the status of the workflow. • 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

22. eReferralWorkflowParticipants 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 Start Referral Requester Referral Requested (COMPLETED) Workflow Monitor Referral Scheduler eReferral Process Flows Between Workflow Participants ReferralReferred (COMPLETED) Referral Scheduled (COMPLETED) The Workflow Monitor can read the status of the task at any time Referral Referred (IN_PROGRESS) Stop Referral Performer

23. eReferralworkflowTasks 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: atask type that tracks the progress and the completion of the referral.

24. eReferralprocessevolution • Identify events that affect 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)

25. DocumentsReferenced 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

26. 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. ReferralRequest (1) The GP’s software, as Referral Requester, produces the eReferral Document and the related Workflow Document characterized by: • WorkflowDefinitionReference= 1.3.6.1.4.1.19376.1.5.3.1.5.1 • WorkflowStatus=OPEN • Only one task “Referral Referred” in status COMPLETED • This “eReferral” document is attached to the Workflow Document XDS infrastructure Workflow Document Ver.1 APPROVED eReferral document Documentsproduced 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

28. Scheduling the Referral (2) 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 • Add a new task “Referral Scheduled” in status COMPLETED • Updates the Workflow Document Workflow Document Ver.2 APPROVED eReferral document Workflow Document Ver.1 DEPRECATED • 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 28

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

30. End of the consultation 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 Workflow Document Ver.4 APPROVED eReferral document Workflow Document Ver.3 DEPRECATED Workflow Document Ver.2 DEPRECATED Workflow Document Ver.1 DEPRECATED Clinical Report of the Visit The Referral process is completed

31. 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