Reporting Whitepaper - Section 3

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The Reporting Process

Identify the "process nodes" that surround reporting.

• what input data is required
• what controls/constrains/triggers the activity
• what data is produced
• what is the nature of the activity
• what exceptions/variations exist

<<Consider notation to show which inputs/outputs/controls are critical vs which are supplemental>>

<<Should we differentiate between nodes that add information vs ones that just transcode it vs ones that just move it?>>

<<Insert Diagram of nodes and the data flow>>

<<In different architectures, different nodes are located/connected differently>>

<<Need to map inpatient/outpatient, Dept vs Clinic vs …, Intra-Enterprise vs Inter-Enterprise>>

<<This exercise has not, but probably should, try to benefit from current workflow tools. BPMN, XPDL and BPEL are described and related here: [1]

• BPMN (Business Process Modeling Notation) is a standardized graphical notation for drawing business processes in a workflow. BPMN’s primary goal is to be readily understandable by all business stakeholders and thus serve as common language to bridge the communication gap that frequently occurs between business process design and subsequent implementation.
• XPDL is effectively the file format or "serialization" of BPMN. It offers a one-for-one representation of the original BPMN process diagram. Its primary goal is to store and exchange the process diagrams, or specifically to allow one tool to model a process diagram, and another to read the diagram and edit, another to "run" the process model on an XPDL-compliant BPM engine, and so on.
• BPEL is an "execution language" the goal of which is to provide a definition of web service orchestration, the underlying sequence of interactions and the flow of data from point to point. You can take a BPMN diagram and produce BPEL, but it is difficult or impossible to recover the original BPMN diagram from the BPEL. This is not surprising since BPEL was not designed for process design interchange.

Keep in mind the needs of each of the large process(es) to which reporting contributes:

• Clinical
• Research
• Education
• Administration (operational)
• Management (planning)

Order Phase

Order Phase activities lead up to the Reporting work.

Registration

In:

Out: Patient Account

Ordering

In: Patient Account

Out: Order

Scheduling

In: Order

Out: Worklist(item)

Activity: (Clarify as specifically assigning a time slot or just putting it on the Dept Worklist)

Exceptions: the appointment may be set before the order is created.

Data Acquisition

In: Worklist

Out: Acquired Data (Images/Radiology Data); Performed Procedure Details (Radiation Dose, Contrast administered/lot number, Description of Performed Procedure, Procedure Log, Tech Comments, Checklist completion (check consent, check pregnancy, etc.), Billable Materials Usage, Billable Tasks Performed)

Activity: Perform the requested scan, etc.

Exceptions: Handling repeats? Aborted procedures? Additional Consents?

Data Processing

In: Current Radiology Data, [Worklist]

Out: Additional Radiology Data

Activity: Perform requested 3D Reconstructions, CAD, etc.

Data Marshalling - Initial

In: Radiology Data (Current, Additional, Analysis/Measurements, Priors, Prior Reports), Order (Reason for Study), Other Orders (Recent & Prior), History/Allergies/Problems/Medications, Lab Data (Current, Prior), Pathology Data (Current, Prior), Patient History Sheet, Tech Interview Sheet

Out: Notification of Readiness

Activity: Collecting together the necessary inputs for the Reading node and deciding "readiness".

Creation Phase

Creation Phase activities involve generation of the report.

Review/Reading/Interpretation/Dictation

In: Worklist, Marshalled Data, [Notification of Readiness]

Out: Voice Audio, [Proto Report], [References to Images?] Delay Flags, Followup Flags (e.g. Mammo), Critical Results Flags

Activity: The radiologist may set several “delay flags” (see IHE Teaching Files and Clinical Trials) indicating that the interpretation activities are complete, but the report should be considered incomplete until the associated lab/pathology/etc data has been marshaled for inclusion.

In common cases the reading may be performed in parallel by two different resources (blind overread, QC, resident/attending)

Transcription/Authoring

In: Worklist, Voice Audio, [Proto Report], [References to Images?]

Out: Draft Report

This step will have several different flavors.

Traditionally it is performed by a transcription service located somewhere else with a human listening to the audio and entering simple electronic report text. The text may be a single “block” or may be separated into several sections with titles.

Some transcription services are using voice-recognition systems and a human “correctionist”. A few sites put the voice-recognition on the “dictation” system itself in an attempt to compress most of the activities from Review to Signature into a single step.

Data Marshalling – Final

In: Delay Flags, Draft Report, Referenced Additional Data (see Delay Flags)

Out: Draft Report (Updated with delayed data)

<Are there other kinds of “follow-up flags?”>

Verification/Correction/Confirmation/Over-read

In: Draft Report, Voice Audio?

Out: Final Report

Signature/Finalization

Out: Signed Report

<Consider reworking this and the above to be one node which is "Verify with intent to Sign" and another with is "Verify for some other purpose" e.g. QC overread, etc.>

Distribution Phase

Distribution Phase activities involve getting the report to the consumers. Note that this grouping means a couple steps are listed out of sequence. Preliminary Access could happen after initial Transcription/Authoring was complete.

Preliminary Access

Out: Draft Report

Exceptions: Is this where we handle "recalled" reports, when there is an overread exception?

Urgent/Critical Results Notification

In: Order (Referring), PWP Contact Info, [Critical Results Flags], Signed Report

Out: Signed Report, Notification

Note this could also happen at prelim.

Receipt of Report? of Notification?

In: Signed Report

Out: Confirmation?

<Should we be thinking about receipt of the notification (in which case this node might be part of the previous node), or receipt of the report?>

Typical Notification

Should Order Placer get a reference to the report in the status msg so to help the ordering physician who checks status be able to retrieve the report from the Enterprise Report Repository (HIS, EMR, etc) more easily? And do we differentiate between the Report Completion defining the end point, or do we need to receive completion of each of the composite steps? <<dar: I'd vote for 'yes' and 'completion of each of the composite steps')

Distribution

In: Prelim or Signed Report, recipients, distribution method for each recipient (e.g. fax, email with link, page, etc.)

Out: Report and/or notification, audit trail

Consumption Phase

Consumption Phase activities involve using the contents of the report or output of the reporting process.

Order Closure

Activity: Feedback to Order Placer that it has been filled.

Note that this step might actually happen immediately after signature/finalization and the notification steps happen in parallel.

Procedure Coding/Findings Coding

In: Order, Performed Procedure Details, Signed Report, Procedure Codes (what's been assigned so far)

Out: Procedure Codes

Activity:

Even rule-based coding will involve constant maintenance as new billing codes appear and payor policies and hospital policies change and department procedures change.

Natural Language Processing (NLP) can help transform inputs to outputs.

Billing

In: Order, Performed Procedure Details, Procedure Codes

Out: Bill

Activity:

Archiving Phase

Archival – Operation & Legal

In: Current Report

Out:

Recording the test and findings in the patients EHR, incorporating the report into the medical record.

Who will archive copies of the report (for what scope/timeframe/purpose)?

Who retrieves reports and where do they want to get them from?

Next Step

Now all we have to do is connect the nodes according to the inputs/outputs, assign transaction numbers, choose a preferred encoding (and one or two transports) for each transaction, and consolidate any identical transactions.