1. Health informatics Lecture 4 Understanding clinical processes. Protocols, care pathways and workflow. Messaging and communication. Traditional process management tools, workflow technology, task network models, Medical research to clinical practice – closing the loop.

2. Medical research  Clinical practice Understanding diseases and their treatment Understanding diseases and their treatment Ensure right Patients receive right intervention Ensure right Patients receive right intervention Service delivery, performance assessment Service delivery, performance assessment Develop and test treatments Develop and test treatments Health Records

3. Clinical process management Understanding diseases and their treatment Understanding diseases and their treatment Ensure right Patients receive right intervention Ensure right Patients receive right intervention Service delivery, performance assessment Service delivery, performance assessment Develop and test treatments Develop and test treatments Health Records Manage safe workflow, professional communication, security

4. Informatics in the process of care

5. Clinical organisations and processes

6. Most health care processes involve exchanging information Within the work-group, to record and manage the care of individual patients Between specialised diagnostic and treatment departments, to request services and to report results Across organisation boundaries between hospital doctors GPs and community staff, to ensure continuity of care From the care provider to payers and regulatory agencies, for revenue and accountability.

7. Growth of communication traffic (Danish data)

8. HL7 Interoperability protocol Functional interoperability: e.g. send and receive documents and data files, share data and information. Semantic interoperability: common vocabulary and concepts to “understand” complex medical conditions and processes. HL7 interoperability protocol is an internationally accepted and accredited standard for –inter-system and inter-organisation messaging, –clinical document structure –a health data model (RIM)

9. Health Level 7 messaging model “HL7 messages are in human-readable (ASCII) format, though they may require some effort to interpret” ! MSH|^~\&|EPIC|EPICADT|SMS|SMSADT|199912271408|CHARRIS|ADT^A04|1817457|D|2.5| PID||0493575^^^2^ID1|454721||DOE^JOHN^^^^|DOE^JOHN^^^^|19480203|M||B|254E238ST^^EUCLID^OH^ NK1||CONROY^MARI^^^^|SPO||(216)731-4359||EC||||||||||||||||||||||||||| PV1||O|168 ~219~C~PMA^^^^^^^^^||||277^ALLEN FADZL^BONNIE^^^^||||||||||||2688684|||||||||| 199912271408

10. HL7 Message segments Each message consists of one or more segments, one per line of text. Each segment contains one specific category of information, such as patient information or patient visit data. Name of each message segment specified by the first field, always 3 characters long.

11. Message segments MSH (Message Header) segment contains information about the message itself (sender/receiver of the message, type of message, date and time it was sent. Every HL7 message specifies MSH as its first segment. The PID (Patient Information) segment contains demographic data, such as patient name, ID, address. The PV1 (Patient Visit) segment contains information about the patient's hospital stay, such as the assigned location and the referring doctor. Over 120 different segments are available for use

12. System interoperability

13. HL7 Reference Information Model The purpose of the RIM is to share consistent meaning to permit interoperation –connect systems operated in different clinical settings, –across many types of healthcare organizations –potentially across political jurisdictions/countries, RIM needs to be flexible enough to express a diverse range of information content while maintaining a unified framework.

14. HL7 Reference Information Model The Version 3 RIM defines all the things of interest referenced in HL7 messages, –structured documents or any future HL7 "information packages" (e.g. decision support applications) –definitions of the characteristics of all entities of interest and the relationships between them. RIM is expressed using entity-relation diagrams; network of classes containing their attributes and connected by their associations.

15. HL7 Reference information model

16. RIM general classes

17. RIM Role classes

18. RIM Act classes

19. State transition diagram for the HL7 act class

20. HL7 structured document standard An XML markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. Consists of a mandatory textual part (which ensures human interpretation of the document contents) and optional structured parts (for software processing). The structured part relies on coding systems (such as from SNOMED and LOINC) to represent concepts (lecture 2).SNOMEDLOINC

21. HL7 structured document standard E.g. Patient summary document –a means for one healthcare practitioner or system to forward data to another practitioner or system to support continuity of care. –a core data set most relevant administrative, demographic, and clinical facts about a patient's healthcare, covering one or more healthcare encounters.

22. State transition diagram for the document class

23. Formalising clinical processes and workflows

24. PERT charts are for managing large projects to simplify planning and scheduling, is commonly used in R&D-type projects where time, rather than cost, is the major factor.

25. Gantt Charts. illustrate a project schedule, showing the start/finish dates of the component tasks of a project aligned on a timeline and showing the status of planned and active tasks

26. Limitations Designed primarily for managing one-off projects Typically used for analysing dependencies in a process e.g. detecting overruns Not developed for –actively executing or supporting the management of a business or other process in real time. –initiating or changing activities

27. Business process modelling and “workflow”

28. Workflow management systems “A system that completely defines, manages, and executes workflows through the execution of software whose order of execution is driven by a computer representation of the workflow logic.” Workflow Management Coalition

29. Business process modelling & workflow Source: Workflow management coalition

30. BPM for part of breast cancer pathway

31. A workflow modelling language: BPMN Flow objects; –Activity: any kind of work: –Gateways control branching and merging of flows, can be points where decisions are taken. –Events: anything that can “happen” which is not under the control of the process Connecting objects; –Sequence Flow order in which activities are to be performed. –Message Flow flow of information between businesses or individuals. –Associations typically used to represent the inputs and outputs of activities. Swimlanes; –BPMN supports two main constructs: pools and lanes –show independent services or processes.

32. BPM for part of breast cancer pathway

33. Workflow platform

34. Clinical services ancillary to the general workflow Messaging Data capture Decision making Appointments Reminders Alerts Clinical orders (e.g. tests and investigations) …

35. Clinical task networks ASBRU GLIF PROforma Peleg et al JAMIA 2003 … www.openclinical.orgwww.openclinical.org

36. Clinical goals Clinical options Commitments Patient data Protocols & pathways Actions & orders Plans and pathways Pain, discharge, nodule Ultrasound Mammogram CT etc. Age, nodule, Family history … (lots) Mammogram, ultrasound Mammogram Ultrasound Registration Report Investigate symptoms for possible Ca Order Mammogram & ultrasound

37. Clinical goals Clinical options Commitments Patient data Protocols & pathways Actions & orders Plans and pathways Plans Decisions Enquiries Actions

38. decision :: 'WhichRadiologyDecision' ; caption :: "Which radiology?"; choice_mode :: multiple ; support_mode :: symbolic candidate :: 'mammogram' ; caption :: "Do a mammogram of both breasts"; argument :: -, patientAge < 35 ' ; caption :: "The patient is younger than 35yrs"; argument :: +, patient_latestHistory_priorThoracicRT = "yes" and patient_latestHistory_priorThoracicRT_timing > 8 and patientAge >= 30 caption ::"Patient is over 30 years of age and has received chest radiotherapy … argument :: +, (patient_historyPreviousMalignancyType includes "breast in situ" or patient_historyPreviousMalignancyType includes "breast invasive") caption :: "The patient has had a previous breast malignancy"; argument :: +, patient_latestHistory_pain = "yes" and patient_latestHistory_pain_cyclicity = "non cyclical" ; caption ::"The patient has non-cyclical breast pain recommendation ::netsupport( WhichRadiologyDecision, mammogramCandidate) >= 1; candidate :: 'ultrasound' ; caption :: "Do an ultrasound of the affected area"; argument :: +, patient_latestMammography_appearance includes "mass lesion" or patient_latestMammography_appearance includes "asymmetric density“ recommendation :: netsupport(WhichRadiologyDecision, ultrasoundCandidate) >= 1; candidate :: 'neither' ; caption :: "No imaging is necessary"; recommendation :: netsupport(WhichRadiologyDecision, ultrasoundCandidate) < 1 AND netsupport( WhichRadiologyDecision, mammogramCandidate) < 1 ; end decision. Task network modelling

39. Triple assessment of women with suspected breast cancer V Patkar, C Hurt, …, J Fox (Brit J Cancer 2006) Triple assessment of women with suspected breast cancer V Patkar, C Hurt, … (Brit J Cancer 2006)

40. A plan model plan :: HL7_example' ; caption ::"Example for presentation in HL7"; component :: 'Diagnosis decision' ; schedule_constraint :: completed('Patient_history') ; number_of_cycles :: 1; component :: 'Patient_history' ; number_of_cycles :: 1; component :: 'Pathway_1' ; schedule_constraint :: completed('Diagnosis_decision') ; number_of_cycles :: 1; component :: 'Pathway_2' ; schedule_constraint :: completed('Diagnosis_decision') ; number_of_cycles :: 1; abort ::patient_discharged = yes; terminate ::patient_recovered = yes; end plan.

41. Comparisons (1): Theory Workflow –Petri nets provide formal foundation –Can be combined with other standard frameworks e.g. decision theoretic methods (lecture 2) Task network models –Emphasise scenarios (triggers) and natural tasks –Classical logic (FOPC) and non-classical logics for inference & decision –Description logics for knowledge representation

42. Comparisons (2): Technologies Workflow –Variety of workflow design tools available –Scalable workflow management engines –Standard benchmarks are key (e.g. control patterns) Task Network Models –Several languages proposed (www.openclinical.org)www.openclinical.org –Authoring tools and scalable execution engines –Interoperability in semantic web

43. Petri nets For “concurrent, asynchronous, distributed, parallel, nondeterministic and/or stochastic” systems. –Can formalise a process as a directed graph with annotations –Can be interpreted dynamically to simulate or “enact” that process. There are two kinds of nodes in a Petri net: places and transitions. –Places represent conditions and transitions represent events. –A transition node has a certain number of input and output places representing the preconditions and post-conditions of the event.

44. Petri nets Gantt charts Petri nets

45. Formal definition of PNs P is a finite set of places T is a finite set of transitions (P ∩ T = Ø) F  (P X T)  (T X P) is a flow relation Common extensions –Time (model durations and delays) –Colour (e.g. resources, goods, humans) –Hierarchy (subnets)

46. Some virtues of PNs Very general Graphical language: intuitive and easy to learn Well understood mathematical foundations, clear and precise semantics Analysis tools for –Proving properties like invariance, network deadlocks, safety … –Simulation –Calculating performance measures like response times, waiting times, occupation rates

47. Example PN (A Grando) Patient free Radiographer free Take X-ray Patient in X-ray dept. Radiographer taking X-ray Developing X-ray Hand-over X-ray Patient leaves

48. Medical research  Clinical practice Understanding diseases and their treatment Understanding diseases and their treatment Ensure right Patients receive right intervention Ensure right Patients receive right intervention Service delivery, performance assessment Service delivery, performance assessment Develop and test treatments Develop and test treatments Health Records

49. Closing the loop Understanding diseases and their treatment Understanding diseases and their treatment Ensure right Patients receive right intervention Ensure right Patients receive right intervention Service delivery, performance assessment Service delivery, performance assessment Develop and test treatments Develop and test treatments Health Records Clinical engagement, post- marketing surveillance, data mining

50. Closing the loop: Researchers engage with clinicians

51. “Closing the loop” Record clinical decisions and reasons –Why is guideline or research recommendation not followed? –Why are argument or supporting evidence rejected? –Why is apparently eligible patient not recruited into trial? Customise decision services to reflect local circumstances –Record and adapt to local practice –Document “work arounds”

52. Medical research  Clinical practice Understanding diseases and their treatment Understanding diseases and their treatment Ensure right Patients receive right intervention Ensure right Patients receive right intervention Service delivery, performance assessment Service delivery, performance assessment Develop and test treatments Develop and test treatments Health Records