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Feb 2009: my University of Wisconsin colloquim presentation


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Feb 2009: my University of Wisconsin colloquim presentation

  1. 1. Use of Workflow Technology to Model Clinical Processes Vojtech Huser MD PhD RetroGuide
  2. 2. Agenda <ul><li>Workflow Technology (WT) overview </li></ul><ul><li>Executable clinical guidelines </li></ul><ul><li>Application of WT (my research) </li></ul>http://
  3. 3. General research interest <ul><li>Research in: Clinical Informatics </li></ul><ul><ul><ul><li>Biomedical informatics (Medical Informatics) </li></ul></ul></ul><ul><ul><li>Lifetime Electronic Health Record (EHR) </li></ul></ul><ul><ul><li>Computable knowledge representation </li></ul></ul><ul><ul><ul><li>Clinical Decision Support systems </li></ul></ul></ul><ul><ul><ul><li>Quality improvement </li></ul></ul></ul><ul><ul><ul><li>Medical research using retrospective data </li></ul></ul></ul>
  4. 4. 1/3: Workflow Technology (WT) overview
  5. 5. Automating Workflow <ul><li>Defined by Workflow Management Coalition (WfMC) </li></ul><ul><ul><li> </li></ul></ul><ul><li>Terminology and Glossary </li></ul><ul><ul><li> </li></ul></ul>
  6. 6. Terms <ul><li>Workflow </li></ul><ul><ul><li>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. </li></ul></ul><ul><ul><ul><ul><ul><li>WfMS = Workflow Management System </li></ul></ul></ul></ul></ul><ul><li>BPM = Business Process Management </li></ul><ul><ul><ul><ul><ul><li>BPMS = Business Process Management System </li></ul></ul></ul></ul></ul>
  7. 9. Humans & machines working together
  8. 11. eComm (worklist handler)
  9. 12. XPDL schema
  10. 13. Minimum components language editor execution engine
  11. 14. WT development <ul><li>1960s </li></ul><ul><ul><ul><ul><li>Petri Nets (Carl A. Petri PhD work) </li></ul></ul></ul></ul><ul><li>1960s-present </li></ul><ul><ul><ul><ul><li>Workflow components of various systems </li></ul></ul></ul></ul><ul><li>1999 </li></ul><ul><ul><ul><ul><li>WfMC: terminology </li></ul></ul></ul></ul><ul><li>2000s </li></ul><ul><ul><ul><ul><li>2002: XPDL 1.0 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>2005 XPDL 2.0 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>2008 XPDL 2.1 </li></ul></ul></ul></ul>
  12. 18. Standards
  13. 19. Standards <ul><li>Key standards </li></ul><ul><ul><li>XPDL = XML Process Definition Language </li></ul></ul><ul><ul><ul><ul><ul><li>Delivered as: XSD file </li></ul></ul></ul></ul></ul><ul><ul><li>BPMN = Business Process Modeling Notation </li></ul></ul><ul><ul><ul><ul><ul><li>Delivered as: PDF file </li></ul></ul></ul></ul></ul><ul><li>Key organizations </li></ul><ul><ul><li>Workflow Management Coalition </li></ul></ul><ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul></ul><ul><ul><li>Object Management Group </li></ul></ul><ul><ul><ul><ul><ul><li> ( ) </li></ul></ul></ul></ul></ul>
  14. 20. Other standards <ul><li>BPEL </li></ul><ul><ul><ul><li>Business process execution language </li></ul></ul></ul><ul><ul><ul><li>Origins: XLANG (Microsoft) + WSFL (IBM) = BPEL4WS </li></ul></ul></ul><ul><ul><ul><li>Also known as WS-BPEL </li></ul></ul></ul><ul><ul><ul><li>Efforts to link BPEL to BPMN </li></ul></ul></ul><ul><li>YAWL </li></ul><ul><ul><ul><li>Yet another workflow language </li></ul></ul></ul><ul><ul><ul><li>Research project </li></ul></ul></ul>
  15. 21. Use of workflow engines
  16. 22. Use of WT <ul><li>Pioneer domains </li></ul><ul><ul><li>Banking </li></ul></ul><ul><ul><li>Manufacturing </li></ul></ul><ul><ul><li>Shipping </li></ul></ul><ul><ul><li>Government authorities </li></ul></ul><ul><ul><li>Pharmaceutical </li></ul></ul><ul><li>Healthcare </li></ul><ul><ul><li>Gartner 2008 report: <5% use </li></ul></ul>
  17. 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.
  18. 24. Stroke guideline (WfMS) Quaglini, Panzarasa, et al. (2000,2001,2003,2007)
  19. 25. GLIF guideline (task-network model) Wang, (1999, 2004) Boxwala, (2004)
  20. 26. Examples of workflow editors and engines
  21. 32. WT software components <ul><li>Core components </li></ul><ul><ul><li>Editor </li></ul></ul><ul><ul><li>Engine </li></ul></ul><ul><li>Additional components </li></ul><ul><ul><li>Administration application (deplay, terminate, versioning) </li></ul></ul><ul><ul><li>Worklist handler </li></ul></ul><ul><ul><li>User management (LDAP, MS, other) </li></ul></ul><ul><ul><li>Organizational roles </li></ul></ul><ul><ul><li>Monitoring/Analytical application </li></ul></ul><ul><ul><li>Simulation tools </li></ul></ul><ul><ul><li>Worfkflow mining </li></ul></ul>
  22. 33. Interesting analyses <ul><li>Improving processes </li></ul><ul><ul><li>Allocation of tasks </li></ul></ul><ul><ul><ul><li>Push (human decides) /pull (machine) strategy </li></ul></ul></ul><ul><ul><ul><ul><ul><li>(push to all or to one and then escalate) </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Earliest due date, first-in first-out </li></ul></ul></ul><ul><ul><ul><li>Rules: (1)let a resource practice its specialty; (2) do similar task in succession; (3) flexibility of staff (“save the generalist”) </li></ul></ul></ul><ul><ul><li>Bottlenecks </li></ul></ul><ul><ul><ul><li>Number of cases in progress </li></ul></ul></ul><ul><ul><ul><li>Case completion time </li></ul></ul></ul><ul><ul><ul><li>Level of service (customers) </li></ul></ul></ul><ul><ul><ul><li>Resource based indicators </li></ul></ul></ul><ul><li>BPR = business process re-engineering </li></ul>
  23. 34. Workflow patterns Prof. van der Aalst’s Lab (Netherlands) Van der Aalst (2003) Russel (2006) Peleg (2008) Wf Patterns and Clinical Guidelines format
  24. 35. Adaptive workflow
  25. 36. Computer Supported Collaborative Work
  26. 37. Workflow mining <ul><li>Traditional approach </li></ul><ul><ul><li>model your process, pilot, deploy </li></ul></ul><ul><li>Alternative </li></ul><ul><ul><li>Take existing event data </li></ul></ul><ul><ul><li>Mine process definition </li></ul></ul><ul><ul><li>Delta analysis </li></ul></ul><ul><ul><ul><li>Discovered process (current) vs. Human modelled process (goal, dream design) </li></ul></ul></ul><ul><ul><ul><li>Migration strategy </li></ul></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><ul><li> ProM (SourceForge) </li></ul></ul></ul>
  27. 38. Summary <ul><li>Workflow technology </li></ul><ul><ul><li>Terms </li></ul></ul><ul><ul><li>History </li></ul></ul><ul><ul><li>Software components </li></ul></ul><ul><ul><li>Research </li></ul></ul><ul><li>Future of WT </li></ul><ul><ul><li>Bright (IT users will require it, ipod generation) </li></ul></ul><ul><ul><li>Gradual adoption </li></ul></ul><ul><ul><li>Maturation of standards, software </li></ul></ul>
  28. 39. 2/3: Executable clinical guidelines
  29. 40. Executable Clinical Guidelines <ul><li>Why? </li></ul><ul><ul><li>Physician’s mind capacity is limited </li></ul></ul><ul><li>What is it? </li></ul><ul><ul><li>Executable representation format which is managed/authored by physicians </li></ul></ul><ul><li>Challenge: </li></ul><ul><ul><li>Fact representation </li></ul></ul><ul><ul><li>Knowledge representation </li></ul></ul>
  30. 41. Examples <ul><li>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. </li></ul><ul><li>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. </li></ul>
  31. 42. Executable Guidelines <ul><li>Clinician’s decisions (goal, alternatives) </li></ul><ul><li>Temporal dimensions of actions and data </li></ul><ul><li>Abstractions (granulocytopenia) </li></ul><ul><li>Degree of uncertainty </li></ul><ul><li>Targeted recipient (MD, RN, patient) </li></ul><ul><li>Normal case and exceptions </li></ul><ul><li>Medical knowledge vs. events/actions (+participant) </li></ul>Tu (1999)
  32. 43. Arden Syntax <ul><li>Text based format </li></ul><ul><ul><ul><li>Clinician-friendly syntax </li></ul></ul></ul><ul><li>ANSI approved standard </li></ul><ul><li>Several versions </li></ul><ul><li>Existing vendor implementations </li></ul><ul><li>Columbia repository </li></ul><ul><ul><li>283 DSS modules </li></ul></ul>
  33. 44. browse MLM file
  34. 45. GLIF <ul><li>Developed by InferMed collaboration </li></ul><ul><li>Task-network model </li></ul><ul><li>Protégé as the guideline editor </li></ul><ul><li>2 types of graph </li></ul><ul><ul><li>Action map </li></ul></ul><ul><ul><li>Decision map </li></ul></ul><ul><li>Rule-in, rule-out criteria </li></ul><ul><li>Has important similarities with EON, SAGE </li></ul><ul><li>Engine component (experimental vs. actual use) </li></ul>Wang, (1999, 2004) Boxwala, (2004)
  35. 46. GLIF guideline (task-network model) Wang, (1999, 2004) Boxwala, (2004)
  36. 48. Current status and future of DSS <ul><li>Active vs. historical standards </li></ul><ul><li>Vendor based communities </li></ul><ul><ul><ul><ul><li>Emergence of a major player? </li></ul></ul></ul></ul><ul><li>Sharing problem (business model) </li></ul><ul><li>DSS as a service </li></ul><ul><ul><li>SEBASTIAN, HL7 DSS specification, SANDS </li></ul></ul><ul><li>Future </li></ul><ul><ul><li>Market solution vs. authoritative solution (government) </li></ul></ul><ul><ul><li>“ YAGL” = Yet another guideline language </li></ul></ul>
  37. 49. 3/3: Application of WT (my research)
  38. 50. HL Scenario
  39. 56. Clinical Guidelines Quality Improvement measures
  40. 57. RetroGuide (RG): key concepts <ul><li>Works with retrospective data </li></ul><ul><li>Flowchart layer + code layer (applications) </li></ul><ul><li>Set of RG external applications (RGEAs) </li></ul><ul><li>Single patient execution model (DSS) </li></ul><ul><li>Works with time ordered chart </li></ul><ul><ul><li>Concept of current position in EHR </li></ul></ul><ul><li>Resembles manual chart review </li></ul><ul><li>Use of variables to remember data </li></ul><ul><li>Procedural modeling approach (rather then declarative) </li></ul>
  41. 58. WT, guidelines, RetroGuide <ul><li>Goal: Use of WT within an EHR system </li></ul><ul><li>Why? </li></ul><ul><ul><li>Clinicians are willing to review a flowchart </li></ul></ul><ul><ul><li>Knowledge management should by done by clinicians </li></ul></ul><ul><li>Retrospective mode </li></ul><ul><ul><li>Search EHR data without any intervention </li></ul></ul><ul><ul><li>Identifying opportunities </li></ul></ul><ul><ul><li>Refining the logic </li></ul></ul><ul><ul><li>Demonstrating the potential value to consumers, administrators, physicians </li></ul></ul><ul><li>Prospective mode </li></ul><ul><ul><li>Intervention at the point of care </li></ul></ul>
  42. 59. RetroGuide
  43. 62.
  44. 63. Reports generated by RetroGuide
  45. 64. 1. Summary report (population)
  46. 65. 2. Detailed report (execution trace)
  47. 66. 3. Individual patient view
  48. 67. Publications
  49. 68. Examples using Marshfield Clinic Data
  50. 69. FILE-BASED DEMO HERE 10 minutes
  51. 70. Process Mining
  52. 73. Conclusion <ul><li>Summary </li></ul><ul><ul><li>Workflow Technology (WT) </li></ul></ul><ul><ul><ul><ul><ul><li>New emerging technology </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Standards </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Possibilities </li></ul></ul></ul></ul></ul><ul><ul><li>Executable Clinical Guidelines </li></ul></ul><ul><ul><ul><ul><ul><li>Basic Introduction </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Arden </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>GLIF </li></ul></ul></ul></ul></ul><ul><ul><li>Use of WT </li></ul></ul><ul><ul><ul><ul><ul><li>Retrospective analysis of data </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Plans for prospective implementation </li></ul></ul></ul></ul></ul><ul><li>Questions ? </li></ul>