The document discusses workflow technology and its applications in healthcare. It provides an overview of workflow technology, including key terms and standards. It also discusses how workflow technology can be used to create executable clinical guidelines and analyze retrospective patient data to identify opportunities for quality improvement. The author's research uses workflow technology to model clinical processes and apply it to retrospective data from an electronic health record system.

1. Use of Workflow Technology to Model Clinical Processes Vojtech Huser MD PhD RetroGuide

2. Agenda Workflow Technology (WT) overview Executable clinical guidelines Application of WT (my research) http:// www.linkedin.com/in/vojtechhuser

3. General research interest Research in: Clinical Informatics Biomedical informatics (Medical Informatics) Lifetime Electronic Health Record (EHR) Computable knowledge representation Clinical Decision Support systems Quality improvement Medical research using retrospective data http://clinicalinformatics.stanford.edu/scci_seminars http://en.wikipedia.org/wiki/Clinical_informatics

4. 1/3: Workflow Technology (WT) overview

5. Automating Workflow Defined by Workflow Management Coalition (WfMC) www.wfmc.org Terminology and Glossary http://www.wfmc.org/standards/docs/TC-1011_term_glossary_v3.pdf

6. Terms Workflow The automation of a business process, in whole or part, during which documents, information or tasks are passed from one participant to another for action, according to a set of procedural rules. WfMS = Workflow Management System BPM = Business Process Management BPMS = Business Process Management System

9. Humans & machines working together

11. eComm (worklist handler)

12. XPDL schema http://wfmc.org/standards/docs/bpmnxpdl_31.xsd http://healthcareworkflow.wordpress.com/2008/11/04/xpdl-21-technical-specifications

13. Minimum components language editor execution engine

14. WT development 1960s Petri Nets (Carl A. Petri PhD work) 1960s-present Workflow components of various systems 1999 WfMC: terminology 2000s 2002: XPDL 1.0 2005 XPDL 2.0 2008 XPDL 2.1

18. Standards

19. Standards Key standards XPDL = XML Process Definition Language Delivered as: XSD file BPMN = Business Process Modeling Notation Delivered as: PDF file Key organizations Workflow Management Coalition www.wfmc.org Object Management Group www.omg.org ( www.bpmn.org )

20. Other standards BPEL Business process execution language Origins: XLANG (Microsoft) + WSFL (IBM) = BPEL4WS Also known as WS-BPEL Efforts to link BPEL to BPMN YAWL Yet another workflow language Research project

21. Use of workflow engines

22. Use of WT Pioneer domains Banking Manufacturing Shipping Government authorities Pharmaceutical Healthcare Gartner 2008 report: <5% use

23. Examples of WT use in healthcare Bed management Infections control (MRSA) J. Emanuele and L. Koetter, &quot; Workflow Opportunities and Challenges in Healthcare ,&quot; in 2007 BPM & Workflow Handbook, 2007. L. Koetter, &quot; MRSA infection control with workflow technology ,&quot; Spring AMIA Conference, Orlando, FL, 2007. R. Hess, &quot; The Chester County Hospital: Case Study ,&quot; in 2007 Excellence in Practice: Moving the Goalposts., 2007.

24. Stroke guideline (WfMS) Quaglini, Panzarasa, et al. (2000,2001,2003,2007)

25. GLIF guideline (task-network model) Wang, (1999, 2004) Boxwala, (2004)

26. Examples of workflow editors and engines

32. WT software components Core components Editor Engine Additional components Administration application (deplay, terminate, versioning) Worklist handler User management (LDAP, MS, other) Organizational roles Monitoring/Analytical application Simulation tools Worfkflow mining

33. Interesting analyses Improving processes Allocation of tasks Push (human decides) /pull (machine) strategy (push to all or to one and then escalate) Earliest due date, first-in first-out Rules: (1)let a resource practice its specialty; (2) do similar task in succession; (3) flexibility of staff (“save the generalist”) Bottlenecks Number of cases in progress Case completion time Level of service (customers) Resource based indicators BPR = business process re-engineering

34. Workflow patterns http://workflowpatterns.com Prof. van der Aalst’s Lab (Netherlands) Van der Aalst (2003) Russel (2006) Peleg (2008) Wf Patterns and Clinical Guidelines format

35. Adaptive workflow

36. Computer Supported Collaborative Work

37. Workflow mining Traditional approach model your process, pilot, deploy Alternative Take existing event data Mine process definition Delta analysis Discovered process (current) vs. Human modelled process (goal, dream design) Migration strategy www.processmining.org ProM (SourceForge)

38. Summary Workflow technology Terms History Software components Research Future of WT Bright (IT users will require it, ipod generation) Gradual adoption Maturation of standards, software

39. 2/3: Executable clinical guidelines

40. Executable Clinical Guidelines Why? Physician’s mind capacity is limited What is it? Executable representation format which is managed/authored by physicians Challenge: Fact representation Knowledge representation

41. Examples On each encounter, check compliance with medications, take asthma history, record peak flow, look at asthma diary, check inhaler technique, and assess asthma state. For patients taking short-acting β2 agonists and low-dose steroid inhalers, if asthma is not under control, consider stepping up to a medium-dose of steroid or adding a long-acting β2 agonist. Patients in the alternative regimen group should receive Adriamycin 60mg/m2 IV every 21 days for 4 cycles, along with Cytoxan 600mg/m2 IV every 21 days for 4 cycles. Patients who are estrogen-receptor positive will receive tamoxifen PO for 5 years. Delay administration of Adriamycin and Cytoxan if there exists > grade 1 granulocytopenia on day 1.

42. Executable Guidelines Clinician’s decisions (goal, alternatives) Temporal dimensions of actions and data Abstractions (granulocytopenia) Degree of uncertainty Targeted recipient (MD, RN, patient) Normal case and exceptions Medical knowledge vs. events/actions (+participant) Tu (1999)

43. Arden Syntax Text based format Clinician-friendly syntax ANSI approved standard Several versions Existing vendor implementations Columbia repository 283 DSS modules

44. browse MLM file

45. GLIF Developed by InferMed collaboration Task-network model Protégé as the guideline editor 2 types of graph Action map Decision map Rule-in, rule-out criteria Has important similarities with EON, SAGE Engine component (experimental vs. actual use) Wang, (1999, 2004) Boxwala, (2004)

46. GLIF guideline (task-network model) Wang, (1999, 2004) Boxwala, (2004)

48. Current status and future of DSS Active vs. historical standards Vendor based communities Emergence of a major player? Sharing problem (business model) DSS as a service SEBASTIAN, HL7 DSS specification, SANDS Future Market solution vs. authoritative solution (government) “ YAGL” = Yet another guideline language

49. 3/3: Application of WT (my research)

50. HL Scenario

56. Clinical Guidelines Quality Improvement measures

57. RetroGuide (RG): key concepts Works with retrospective data Flowchart layer + code layer (applications) Set of RG external applications (RGEAs) Single patient execution model (DSS) Works with time ordered chart Concept of current position in EHR Resembles manual chart review Use of variables to remember data Procedural modeling approach (rather then declarative)

58. WT, guidelines, RetroGuide Goal: Use of WT within an EHR system Why? Clinicians are willing to review a flowchart Knowledge management should by done by clinicians Retrospective mode Search EHR data without any intervention Identifying opportunities Refining the logic Demonstrating the potential value to consumers, administrators, physicians Prospective mode Intervention at the point of care

59. RetroGuide

62. http://healthcareworkflow.wordpress.com

63. Reports generated by RetroGuide

64. 1. Summary report (population)

65. 2. Detailed report (execution trace)

66. 3. Individual patient view

67. Publications

68. Examples using Marshfield Clinic Data

69. FILE-BASED DEMO HERE 10 minutes

70. Process Mining

73. Conclusion Summary Workflow Technology (WT) New emerging technology Standards Possibilities Executable Clinical Guidelines Basic Introduction Arden GLIF Use of WT Retrospective analysis of data Plans for prospective implementation Questions ?