Healthcare decision support ideally takes place within the clinician’s workflow with access to all of the patient’s healthcare data and preferences. As patients move around the healthcare ecosystem, their electronic health records must be ubiquitously available and discoverable. FHIR® can serve as a lingua franca for this data. For decision support to be embraced by physicians, it needs to be timely, based on best practices, simple to understand and easy to adopt. BPM+ workflow and decision software provide a visual representation of evidence-based best practices with the potential for automation.

1. Trisotech.com
Automatable Healthcare
Decisions and Workflows
Using FHIR®
Ken Stevens
Director of Enterprise Solutions
ken@smilecdr.com
Denis Gagne
Chief Executive Officer (CEO),
dgagne@Trisotech.com

2. Trisotech.com
Using FHIR®
Ken Stevens
Director of Enterprise Solutions
ken@smilecdr.com

3. What is FHIR
Fast
Healthcare
Interoperability
Resources

4. The Problem
Lab
Meds
Appts
Claims
Lab
Meds
Appts
Claims
Site 1 Site 2

5. 1989: HL7v2
Lab
Meds
Appts
Claims
Lab
Meds
Appts
Claims
Site 1 Site 2
OBX|2|NM|^Body Weight||79|kg^Kilogram^ISO+|||||F

6. HL7v2 Limitations
Lab
Meds
Appts
Claims
Lab
Meds
Appts
Claims
Site 1 Site 2
Limitations:
✖ Point to point
✖ Limited interoperability
✖ Expensive
OBX|2|NM|^Body Weight||79|kg^Kilogram^ISO+|||||F

7. 2009 Meaningful Use: CDA HIE
Lab
Meds
Appts
Claims
Lab
Meds
Appts
Claims
Site 1 Site 2
CDA
HIE

8. CDA HIE Limitations
Lab
Meds
Appts
Claims
Lab
Meds
Appts
Claims
Site 1 Site 2
CDA
Limitations:
✔ Central Repository
✖ Document oriented
✖ No structured search
✖ Not interoperable
✖ Cumbersome format
HIE

9. Solution 3: FHIR
Lab
Meds
Appts
Claims
Lab
Meds
Appts
Claims
Site 1 Site 2
FHIR

10. 2015: FHIR
Lab
Meds
Appts
Claims
Lab
Meds
Appts
Claims
Site 1 Site 2
FHIR
Benefits:
✔ Central Repository
✔ Interoperable
✔ Structured data
✔ Rich query language
✔ Easy to implement

11. Solution 3: FHIR
Lab
Meds
Appts
Claims
Lab
Meds
Appts
Claims
Site 1 Site 2
FHIR

12. FHIR is a free and open standard for health interoperability, based on modern approaches. It consists of:
1. A robust data model for describing health and administrative data
2. A RESTful API for interacting with that data using either JSON or XML
3. A set of open source tools to implement and test FHIR applications
4. A collection of FHIR Servers around the world that you can interact with
5. A community of implementers working together
What is FHIR
Five Things

13. FHIR places a heavy emphasis on the 80:20 rule
● 80% - Specification covers only what is needed by 80% of systems worldwide
● 20% - FHIR is easy to extend for your use cases
The FHIR Manifesto
Common Scenarios

14. FHIR is free to use and free to contribute to
● Specification is licensed under Creative Commons CC0
● Many tools are open source (MIT / Apache license)
The FHIR Manifesto
Be Open

15. ● Being easy to learn is critical to the success of FHIR
● Many organizations have adopted FHIR in weeks
The FHIR Manifesto
Be Easy to Adopt

16. The Data Model
These are the building blocks of the specification, examples include:
● Patient (the person who receives healthcare)
● Encounter (a doctor’s appointment or hospital stay)
● Observation (e.g. a device reading, or lab value)
● DiagnosticReport (e.g. a whole lab or Xray report)
● MedicationPrescription (Rx for meds)
FHIR defines a set of roughly 150 resources

18. The Data Model
The FHIR data model is freely available online

19. {
"resourceType":"Observation",
"id":"287",
"meta":{
"versionId":"2"
},
"extension":[{
"url":"http://uhn.ca/fhir/readings#context",
"valueCode":"BREAKFAST"
}],
"text":{
"div":"<div>Fasting glucose of <b>11.2 mg/dl</b></div>"
},
"status":"final",
"code":{
"coding":[{
"system":"http://loinc.org",
"code":"41604-0",
"display":"Fasting glucose [Mass/​volume] in Capillary blood by Glucometer"
}]
},
"subject":{
"reference":"Patient/1"
JSON
Metadata
Extensions
Narrative
Structured
Data

20. Trisotech.com
Automatable Healthcare
Decisions and Workflows
Denis Gagne
Chief Executive Officer (CEO),
dgagne@Trisotech.com

21. © 2020 Object Management Group
Established to foster the sharing and
promulgation of best-practices around
modeling and sharing:
• shareable pathways,
• clinical pathways,
• automatable clinical guidelines, and
• other healthcare knowledge
A robust and thriving community-of-
practice of healthcare institutions,
professional societies, and vendors
www.BPM-Plus.org

22. Trisotech.com
Setting some Basic Terminology
Workflow
Automation
Decision
Automation
Open Standards
DMN
(DECISION MODEL AND NOTATION)
Decision tables and logical expressions
BPMN
(BUSINESS PROCESS MODEL AND NOTATION)
Prescriptive sequence of activities
CMMN
(CASE MANAGEMENT MODEL AND NOTATION)
Declarative unstructured event-condition-action
Technology enabled
orchestration of activities, able
to react to business events.
Both may have humans in the loop or not.
(Referred to as Knowledge Workers.)
Technology enabled decisions,
returning answers given some
inputs.

23. Trisotech.com
Answering the Healthcare call to action
Empowering
Patients
01
Moving to
Value-Based
Care
02
Ensuring and
Advancing
Interoperability
03
Promoting Use
of New
Technology
04
Reducing
Clinical and
Administrative
Burden
05

24. Trisotech.com
Benefits of BPM+ Health
Automatable Clinical Decisions and Workflows
Rapid access
to evidence-
based best
practices
Standardized
clinical
pathways
Better
coordination
of patient
care
Visual story
of the
patient's
progress
Better
decisions at
point of care
Provides
data in
context
Better
clinical and
financial
outcomes
Improved
organizational
and
operational
efficiency

25. Trisotech.com
Visual Story of what needs to be done

26. Trisotech.com
Created by
clinicians for
clinicians
 The model is the guideline narrative documentation
 The model is the guideline behavior specification
 The model is the guideline logic
 The model is the guideline automation code
BPM+ Guideline Models
www.Trisotech.com

27. Trisotech.com
COPD Initial Assessment

28. Trisotech.com
Human in the loop or not
Unattended
(Straight Through Process)
 The sequence of activities is “orchestrated” by the
automation engine. It does not involve humans in loop.
Examples include:
o medical calculators,
o Scoring,
o Categorization, etc.
 Allows elimination of mundane tasks and decisions.
Attended
(Human Centric Process)
 The sequence of activities is “orchestrated” by the
automation engine. Humans can be involved to:
o confirm or provide inputs,
o confirm or provide outputs,
o make decisions, or
o carry out tasks.
 Allows humans to have veto power.

29. Trisotech.com
Human in the loop or not
Unattended
(Straight Through Process)
Attended
(Human Centric Process)

30. Trisotech.com
Modeling Best Practices
Computational
Independent Model
(CIM)
Platform Independent
Model
(PIM)
Platform Specific
Model
(PSM)
SEPARATION OF CONCERNS
Narrative
FHIR enabled
BPMN, CMMN, DMN
Services
Add data types and
logical expressions
Add bindings to
specific data source

31. Trisotech.com

32. Trisotech.com
Models
Unattended and Attended
Services
CDS Hooks Card
Pre-fetch
FHIR enabled
Services
Emulates an eHR or eMR
Subject Matter Expert Healthcare Professional

33. Trisotech.com
COPD
Demo

34. Trisotech.com
Conclusion
• Visual story of the patient's progress
• Standardized clinical pathways
• Provides data in context
• Improved organizational and operational efficiency
• Better coordination of patient care
• Rapid access to evidence-based best practices
• Better decisions at point of care
• Better clinical and financial outcomes
Automatable Healthcare Decisions and Workflows
Using FHIR®
Ken Stevens
Director of Enterprise Solutions
ken@smilecdr.com
Denis Gagne
Chief Executive Officer (CEO),
dgagne@Trisotech.com