health informatics lecture 4 understanding clinical processes. protocols, care pathways and...
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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
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.
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
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 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.
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
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
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.
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”
• 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
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