Detailed Profile Proposal for 2015/16presented to theCardiology Technical Committee
Cardiology consultation and patology board – Workflow Definition
Elena Vio, Mauro Zanardini, Claudio Saccavini, Glauco Brandolino (Arsenàl.IT)
28 October, 2015
General problem
•We need to guarantee an optimal cardiac treatment strategy inwhole territory with limited health resources.
•Limited highly specialized hospitals centralized in cardiac diseases have tosupport peripheral hospitals without cathlab or cardiac surgeon, in efficiencyway, but it is difficult to manage the sharing of knowledge
•Example of specific problematic disease for peripheral hospital :
–coronary artery disease
–cardiac valvular disease
–aortic disease
–advanced heart failure
–cardiogenic shock
–…
3
A.O. VR
A.O. PD
Highly specialized centerswith cardiac surgeon
Peripheral Hospital withambulatory and Cath lab
Peripheral Hospitalwith only cardiacambulatory
Italian regional example:
Local Health Authorities
distribution
5 highly specializedhospital on cardiology
18 peripheral hospital withambulatory and/orwithout cath lab
5 millions of citizens
Dynamic Heart team
PeripheralHospital
PeripheralHospital
Cardiologist
Cardiologist
Cardiologist
Patient
Cardiacsurgeon
Cardiacsurgeon
Cardiacsurgeon
Highly specialized
Center A
Highly specialized
Center A
Clinicaldata
Clinicaldata
Clinicaldata
Clinicaldata
Clinicaldata
Clinicaldata
interventionalcardiologist
Cardiologist
Clinicaldata
Clinicaldata
interventionalcardiologist
PeripheralHospital
PeripheralHospital
PeripheralHospital
PeripheralHospital
PeripheralHospital
PeripheralHospital
Highly specialized
Center B
Highly specialized
Center B
Highly specialized
Center B
Highly specialized
Center B
interventionalcardiologist
Patient
Patient
Patient
Support
Support
Support
Support
Support
Support
Support
Support
Hub network
Hub network
Dynamic HT: Chairperson, professionals, needed clinical documents, priority
Specific problems
•The professionals can be geographically distant because they maybelong to different hospitals
Difficult to communicate and share information
•Team’s members can be enrolled in the “Heart Team” dynamically
Difficult to manage attending to the meeting and preparation of pre-meeting
•Clinical protocols are different on base of the disease
Difficult to manage the sharing of documents when HT is numerous
We need a specific Workflow management engine able to defineparticipant tasks, tasks transitions, and useful clinical information thathave to be exchange
State of art
•A Document sharing infrastructure is not enough to create the WF managementinfrastructure
what documents have to be shared for this task? who can see documents? Whohave to produce documents?
•WF management for Heart team must be specific for cardiac field, we need tostandardize the Heart Team activities
What is the next task? Who the task has to do? When the task has to be done?What is the input for this task? What is the output of the task?
Aim of proposal
•To define a standardized workflow to manageand coordinate remote interaction betweenmultidisciplinary and dynamic team ofhealthcare professionals (HT composed ofnetwork of hubs), with not only a simplesharing of information and digital documents.
•The workflow will support and manage theactivation of the dynamic HT that allows us toadapt the team to simple or complex cases.
Impact
•Example of specific problematic disease for pheriperal hospital
–coronary artery disease
–cardiac valvular disease
–aortic disease
–advanced heart failure
–cardiogenic shock
–…
•Coronary heart disease:
–Every year, 3.8 millions of man and 3.4 millions of female die (WHO)
•Coronary artery disease:
–CAD is the most common type of heart disease.
–In 2008, 405,309 individuals died in the U.S.
–In 2010, $108.9 billion including the cost of health care services, medications,and lost productivity.
•First heart attack
–Every year, 785,000 suffer a first heart attack
–Every year, 470,000 suffer an additional myocardial infarction.
PeripheralHospital
PeripheralHospital
Cardiologist
Cardiologist
Cardiologist
Cardiacsurgeon
Cardiacsurgeon
Cardiacsurgeon
Highlyspecialized
Center A
Highlyspecialized
Center A
Clinicaldata
Clinicaldata
Clinicaldata
Clinicaldata
Clinicaldata
Clinicaldata
interventionalcardiologist
interventionalcardiologist
Current Use Case
Cardiologist
Clinicaldata
Clinicaldata
interventionalcardiologist
PeripheralHospital
PeripheralHospital
PeripheralHospital
PeripheralHospital
PeripheralHospital
PeripheralHospital
Highly specialized
Center B
Highly specialized
Center B
Highlyspecialized
Center B
Highlyspecialized
Center B
interventionalcardiologist
Heartteam
Heartteam
Cardiologist
Patient
Cardiacsurgeon
Cardiacsurgeon
Cardiacsurgeon
Heartteam
Heartteam
Clinicaldata
Clinicaldata
Current Use Case
interventionalcardiologist
PeripheralHospital
PeripheralHospital
Cardiologist
Cardiologist
Clinicaldata
Clinicaldata
Clinicaldata
Clinicaldata
interventionalcardiologist
interventionalcardiologist
Cardiologist
Clinicaldata
Clinicaldata
interventionalcardiologist
PeripheralHospital
PeripheralHospital
PeripheralHospital
PeripheralHospital
Highlyspecialized
Center A
Highlyspecialized
Center A
Highly specialized
Center B
Highly specialized
Center B
Highlyspecialized
Center B
Highlyspecialized
Center B
PeripheralHospital
PeripheralHospital
Cardiologist
Patient
Cardiacsurgeon
Cardiacsurgeon
Cardiacsurgeon
Heartteam
Heartteam
Clinicaldata
Clinicaldata
Current Use Case
interventionalcardiologist
PeripheralHospital
PeripheralHospital
Cardiologist
Cardiologist
Clinicaldata
Clinicaldata
Clinicaldata
Clinicaldata
interventionalcardiologist
interventionalcardiologist
Cardiologist
Clinicaldata
Clinicaldata
interventionalcardiologist
PeripheralHospital
PeripheralHospital
PeripheralHospital
PeripheralHospital
Highlyspecialized
Center A
Highlyspecialized
Center A
Highly specialized
Center B
Highly specialized
Center B
Highlyspecialized
Center B
Highlyspecialized
Center B
PeripheralHospital
PeripheralHospital
Cardiologist
Patient
Cardiacsurgeon
Cardiacsurgeon
Heartteam
Heartteam
Clinicaldata
Clinicaldata
Current Use Case
interventionalcardiologist
PeripheralHospital
PeripheralHospital
Cardiologist
Cardiologist
Clinicaldata
Clinicaldata
Clinicaldata
Clinicaldata
interventionalcardiologist
interventionalcardiologist
Cardiologist
Clinicaldata
Clinicaldata
interventionalcardiologist
PeripheralHospital
PeripheralHospital
PeripheralHospital
PeripheralHospital
Highlyspecialized
Center A
Highlyspecialized
Center A
Highlyspecialized
Center B
Highlyspecialized
Center B
PeripheralHospital
PeripheralHospital
Document sharing by XDS profile, phone interaction to coordinate activities
Cardiacsurgeon
Highly specialized
Center B
Highly specialized
Center B
Cardiologist
Patient
Cardiacsurgeon
Clinicaldata
Clinicaldata
Current Use Case
Hearth teammeeting
Hearth teammeeting
Cardiacsurgeon
Cardiacsurgeon
Document sharing by XDS profile, phone interaction to coordinate activities
interventionalcardiologist
Heartteam
Heartteam
PeripheralHospital
PeripheralHospital
Cardiologist
Cardiologist
Clinicaldata
Clinicaldata
Clinicaldata
Clinicaldata
interventionalcardiologist
interventionalcardiologist
Cardiologist
Clinicaldata
Clinicaldata
interventionalcardiologist
PeripheralHospital
PeripheralHospital
PeripheralHospital
PeripheralHospital
Highlyspecialized
Center A
Highlyspecialized
Center A
Highly specialized
Center B
Highly specialized
Center B
Highlyspecialized
Center B
Highlyspecialized
Center B
PeripheralHospital
PeripheralHospital
Current Use Case - Obstacles
Difficulty:
•sharing of documents, in particular if theheart team is extended and if new documentsare added
•to manage involvement of professionals andattending to meeting
•notify all members of HT on the state of tasks:new members, new documents, new date ofmeeting etc.
Cardiologist
Patient
Cardiacsurgeon
Clinicaldata
Clinicaldata
interventionalcardiologist
Proposed Use Case
Virtual Heartteam meeting
Virtual Heartteam meeting
Cardiacsurgeon
Cardiacsurgeon
Workflow document forheart team
Task1
•In: link document 1
•Out: link document 2
Task2
•In: link document 2
•Out: link document 3
Task3
•In: link document 4
•Out: link document 5
interventionalcardiologist
Heartteam
Heartteam
Cardiologist
Clinicaldata
Clinicaldata
PeripheralHospital
PeripheralHospital
Highlyspecialized
Center A
Highlyspecialized
Center A
Highly specialized
Center B
Highly specialized
Center B
Highlyspecialized
Center B
Highlyspecialized
Center B
PeripheralHospital
PeripheralHospital
Proposed Use Case
•Benefit:
–immediate sharing between all actors on what happens in the process:all professionals are notified on new clinical documents, otherprofessionals involved, new meetings etc.
–Immediate sharing of clinical documents for all professionals involvedin the workflow
–dynamic enrolment of clinicians in a HT: clinicians are involved inprocess in relation of their skills and availabilities so that they can beactivated promptly
–clear process for the highly specialized center to address heart teamactivation request: on the basis of the heart team activation request,the guidelines of the process identifies specific physicians of the HT toactivate, the time of the response, which patient’s clinical exams haveto be exchange, how to reach an agreement between HT membersand which data should be reported to the requester
Proposed Standards & Systems
Systems that can be involved in the process described above are:
•CIS system
•Hospital EHR system
•HIS
IHE profiles:
•XDS.b-I (Cross-Enterprise Document Sharing) for Imaging,
•XDS.b (Cross-Enterprise Document Sharing)
•DSUB (Document Metadata Subscription): this profile allows to create a notificationinfrastructure based the XDS.b Infrastructure
•XDW (Cross-Enterprise Document Workflow): this profile allows the creation of a Workflowmanagement Infrastructure based on a XDS.b Environment. XDW guidelines provide a flexibletool that can be further profiled (defining a Workflow Definition profile) to manage specificclinical workflows.
•Example of CDA that could be used:
•[DRPT] - Displayable Reports manages creation and distribution of “display ready” (PDF or CDA) clinical reports fromthe creating application, to the department, and to the enterprise
•[CIRC] - Cardiac Imaging Report Content format for a CDA report of a cardiac diagnostic imaging procedure, includingdiscrete data elements
•[CRC] - Cath Report Content format for a CDA report of a cardiac Cath/PCI procedure, including discrete data elementsImagining, radiolog
Infrastructure: XDW with a XDS/DSUB
Profile based on the Workflow Definition Template
REQUEST
COMPLETED
COMPLETED
Cardiologist producesrequest of HT activation
PERFORM
IN PROGRESS
IN PROGRESS
Discussion is concluded; Surgeonproduce a preliminary report
HT INVOLVEMENT
COMPLETED
COMPLETED
FINALIZATION
COMPLETED
COMPLETED
Cardiac surgeon link new clinical reportsand final report
COMPLETED
COMPLETED
START
END
IN PROGRESS
IN PROGRESS
Surgeon decidesactivatevideoconference
Surgeon involves an otherprofessional, for videoconferenceor asynchrony discussion
•Owner: Performer(Hub)
•IN: Clinical report,imaging, request
•OUT: PreliminaryReport
•Owner: Requester
•IN: Clinical report,imaging
•OUT: Request
•Owner: Performer(Hub)
•IN: Preliminary report
•OUT: Final Report,new clinical reports
eReferral workflow
Change of owner
Cardiac surgeon opensthe request
eReferralworkflow
eReferral workflow
Concluded
IN PROGRESS
IN PROGRESS
Cardiac surgeon requires new clinicalreports in order to prepare intervention
•Owner:Participant(Hub)
•IN: Clinicalreport,imaging,request
•OUT:Preliminaryevaluation
Workflow Documentfor HT management
0…n
1….1
1….1
1….1
REQUEST
COMPLETED
COMPLETED
Cardiologist producesrequest of HT activation
START
•Owner: Requester
•IN: Clinical report,imaging
•OUT: Request
Workflow Documentfor HT management
1….1
REQUEST
COMPLETED
COMPLETED
Cardiologist producesrequest of HT activation
PERFORM
IN PROGRESS
IN PROGRESS
COMPLETED
COMPLETED
START
•Owner: Requester
•IN: Clinical report,imaging
•OUT: Request
Cardiac surgeon opensthe request
Workflow Documentfor HT management
1….1
1….1
•Owner: Performer(Hub)
•IN: Clinical report,imaging, request
REQUEST
COMPLETED
COMPLETED
Cardiologist producesrequest of HT activation
PERFORM
IN PROGRESS
IN PROGRESS
COMPLETED
COMPLETED
START
•Owner: Requester
•IN: Clinical report,imaging
•OUT: Request
Cardiac surgeon opensthe request
Workflow Documentfor HT management
1….1
1….1
Change of owner
•Owner: Performer(Hub)
•IN: Clinical report,imaging, request
REQUEST
COMPLETED
COMPLETED
Cardiologist producesrequest of HT activation
PERFORM
IN PROGRESS
IN PROGRESS
COMPLETED
COMPLETED
START
•Owner: Requester
•IN: Clinical report,imaging
•OUT: Request
Cardiac surgeon opensthe request
Workflow Documentfor HT management
1….1
1….1
Change of owner
•Owner: Performer(Hub)
•IN: Clinical report,imaging, request
eReferral workflow
HT INVOLVEMENT
COMPLETED
COMPLETED
IN PROGRESS
IN PROGRESS
Surgeon involves an otherprofessional, for videoconferenceor asynchrony discussion
eReferralworkflow
Concluded
•Owner:Participant(Hub)
•IN: Clinicalreport,imaging,request
•OUT:Preliminaryevaluation
0…n
REQUEST
COMPLETED
COMPLETED
Cardiologist producesrequest of HT activation
PERFORM
IN PROGRESS
IN PROGRESS
Discussion is concluded; Surgeonproduce a preliminary report
HT INVOLVEMENT
COMPLETED
COMPLETED
COMPLETED
COMPLETED
START
IN PROGRESS
IN PROGRESS
Surgeon decidesactivatevideoconference
Surgeon involves an otherprofessional, for videoconferenceor asynchrony discussion
•Owner: Performer(Hub)
•IN: Clinical report,imaging, request
•OUT: PreliminaryReport
•Owner: Requester
•IN: Clinical report,imaging
•OUT: Request
Change of owner
Cardiac surgeon opensthe request
eReferralworkflow
eReferral workflow
Concluded
•Owner:Participant(Hub)
•IN: Clinicalreport,imaging,request
•OUT:Preliminaryevaluation
Workflow Documentfor HT management
0…n
1….1
1….1
REQUEST
COMPLETED
COMPLETED
Cardiologist producesrequest of HT activation
PERFORM
IN PROGRESS
IN PROGRESS
Discussion is concluded; Surgeonproduce a preliminary report
HT INVOLVEMENT
COMPLETED
COMPLETED
FINALIZATION
COMPLETED
COMPLETED
COMPLETED
COMPLETED
START
END
IN PROGRESS
IN PROGRESS
Surgeon decidesactivatevideoconference
Surgeon involves an otherprofessional, for videoconferenceor asynchrony discussion
•Owner: Performer(Hub)
•IN: Clinical report,imaging, request
•OUT: PreliminaryReport
•Owner: Requester
•IN: Clinical report,imaging
•OUT: Request
•Owner: Performer(Hub)
•IN: Preliminary report
eReferral workflow
Change of owner
Cardiac surgeon opensthe request
eReferralworkflow
eReferral workflow
Concluded
IN PROGRESS
IN PROGRESS
Cardiac surgeon requires new clinicalreports in order to prepare intervention
•Owner:Participant(Hub)
•IN: Clinicalreport,imaging,request
•OUT:Preliminaryevaluation
Workflow Documentfor HT management
0…n
1….1
1….1
1….1
REQUEST
COMPLETED
COMPLETED
Cardiologist producesrequest of HT activation
PERFORM
IN PROGRESS
IN PROGRESS
Discussion is concluded; Surgeonproduce a preliminary report
HT INVOLVEMENT
COMPLETED
COMPLETED
FINALIZATION
COMPLETED
COMPLETED
Cardiac surgeon link new clinical reportsand final report
COMPLETED
COMPLETED
START
END
IN PROGRESS
IN PROGRESS
Surgeon decidesactivatevideoconference
Surgeon involves an otherprofessional, for videoconferenceor asynchrony discussion
•Owner: Performer(Hub)
•IN: Clinical report,imaging, request
•OUT: PreliminaryReport
•Owner: Requester
•IN: Clinical report,imaging
•OUT: Request
•Owner: Performer(Hub)
•IN: Preliminary report
•OUT: Final Report,new clinical reports
eReferral workflow
Change of owner
Cardiac surgeon opensthe request
eReferralworkflow
eReferral workflow
Concluded
IN PROGRESS
IN PROGRESS
Cardiac surgeon requires new clinicalreports in order to prepare intervention
•Owner:Participant(Hub)
•IN: Clinicalreport,imaging,request
•OUT:Preliminaryevaluation
Workflow Documentfor HT management
0…n
1….1
1….1
1….1
New actors
–HT Requester actor that requires the activationof HT for a clinical support
–HT Performer actor that manages the HT andconcludes it with a final report and exame for theoperation
–HT Participant actor that participates to the HT
Discussion
Profile Editor:
Supporting Resources
IHE Cardiology Domain
