Health informaticsLecture 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.

Medical research Clinical practice

Understanding

diseases and their

treatment

Understanding

diseases and their

treatment

Ensure rightPatients receiveright

intervention

Ensure rightPatients receiveright

intervention

Service delivery,

performance

assessment

Service delivery,

performance

assessment

Develop and test

treatments

Develop and test

treatments

HealthRecords

Clinical process management

Understanding

diseases and their

treatment

Understanding

diseases and their

treatment

Ensure rightPatients receiveright

intervention

Ensure rightPatients receiveright

intervention

Service delivery,

performance

assessment

Service delivery,

performance

assessment

Develop and test

treatments

Develop and test

treatments

HealthRecords

Manage safe workflow, professional

communication, security

Informatics in the process of care

Clinical organisations and processes

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.

Growth of communication traffic(Danish data)

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)

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

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.

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

System interoperability

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.

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.

HL7 Reference information model

RIM general classes

RIM Role classes

RIM Act classes

State transition diagram for the

HL7 act class

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).

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.

State transition diagram for the document class

Formalising clinical processes and workflows

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.

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

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

Business process modelling and “workflow”

Workflow management systems

“A system that completely defines, manages, and executesworkflows through the execution of software whose order of

execution is driven by a computer representation of the workflow logic.”

Workflow Management Coalition

Business process modelling & workflow

Source: Workflow management coalition

BPM for part of breast cancer pathway

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.

BPM for part of breast cancer pathway

Workflow platform

Clinical services ancillary to the general workflow

• Messaging• Data capture• Decision making• Appointments• Reminders• Alerts• Clinical orders (e.g. tests and

investigations)• …

Clinical task networks

• ASBRU• GLIF• PROforma

• Peleg et al JAMIA 2003• … www.openclinical.org

Clinicalgoals

Clinical options

Commitments

Patient data

Protocols & pathways

Actions & orders

Plans and pathways

Pain, discharge, nodule

UltrasoundMammogramCT etc.

Age, nodule, Family history … (lots)

Mammogram, ultrasound

MammogramUltrasoundRegistrationReport

Report

Investigate symptoms for possible Ca

Order Mammogram &ultrasound

Clinicalgoals

Clinical options

Commitments

Patient data

Protocols & pathways

Actions & orders

Plans and pathways

PlansDecisions

Enquiries Actions

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

Define problem requirements

Model plans, decisions, processes

Verify knowledge

content

Test

Deploy

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 cancerV Patkar, C Hurt, … (Brit J Cancer 2006)

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.

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.

Petri nets

Gantt charts

Petri nets

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)

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

Example PN (A Grando)

Patient free

Radiographer free

Take X-ray

Patient inX-ray dept.

Radiographer taking X-ray

DevelopingX-ray

Hand-over X-ray

Patient leaves

Medical research Clinical practice

Understanding

diseases and their

treatment

Understanding

diseases and their

treatment

Ensure rightPatients receiveright

intervention

Ensure rightPatients receiveright

intervention

Service delivery,

performance

assessment

Service delivery,

performance

assessment

Develop and test

treatments

Develop and test

treatments

HealthRecords

Closing the loop

Understanding

diseases and their

treatment

Understanding

diseases and their

treatment

Ensure rightPatients receiveright

intervention

Ensure rightPatients receiveright

intervention

Service delivery,

performance

assessment

Service delivery,

performance

assessment

Develop and test

treatments

Develop and test

treatments

HealthRecords

Clinical engagement, post-

marketing surveillance, data

mining

Closing the loop: Researchers engage with clinicians

“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”

Medical research Clinical practice

Understanding

diseases and their

treatment

Understanding

diseases and their

treatment

Ensure rightPatients receiveright

intervention

Ensure rightPatients receiveright

intervention

Service delivery,

performance

assessment

Service delivery,

performance

assessment

Develop and test

treatments

Develop and test

treatments

HealthRecords