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.

{D1} is used to show specific instances of data for reference later to match specific inputs to specific outputs.

Consider if we want to use them to make "equations", e.g. D4 = W1 + D1 + D2

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. The early steps have less to do with reporting and are only sketched in.

Registration

In:

• [Existing Account]

Out:

• Patient Account {D1} (new or updated)

Activity: Create/Update the patient demographics

Exceptions: May be backfilled afterwards in case of emergency.

Ordering

In:

• Patient Account {D1}

Out:

• Order {D2}
  • Order Placed Date/Time
  • Reason for Study
  • Admitting Diagnosis

Activity: Place an order for Radiology services, providing clinical context/need.

Exceptions: May be backfilled afterwards in case of emergency.

Scheduling

In:

• Order {D2}

Out:

• Acquisition Worklist {W1}

Activity: Put item on acquisition worklist, possibly specifying timeslot and/or equipment

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

Data Acquisition

Control:

• [Acquisition Worklist {W1}]
• [Unscheduled case]

In:

• [Acquisition Worklist {W1}]
• [Manually entered order & demographics]

Out:

• Acquired Data {D3}
  • Images/Radiology Data
• Performed Procedure Details
  • Acq. Start/Stop Date/Time
  • Description of Performed Procedure
  • Radiation Dose
  • Contrast administered/lot number
  • Procedure Log
  • Checklist completion (check consent, check pregnancy, etc.)
  • Billable Materials Usage
  • Billable Tasks Performed
  • Tech Comments

Activity: Perform the requested scan, etc.

Exceptions: Unscheduled acquisitions. Handling repeats. Aborted procedures. Additional Consents?

Data Processing

Control:

• [Processing Worklist]
• [Input Availability]

In:

• Acquired Data {D3}

Out:

• Processed Data {D4} <split up later>

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

Creation Phase

Creation Phase activities involve generation of the report.

Reporting Workflow Management

In:

• Reading Requests/Orders
• [Time/Date of Request]
• Staff Schedule
• Staff "Certifications" (What/Where they can read)

Out:

• Reading Worklist {W4}

Activity: Coordinate/distribute the work for reporting.

For Reading Service this would be an internal activity, with external inputs.

Data Marshalling - Initial

In:

• Radiology Data (Current, Additional, Analysis/Measurements, Priors, Prior Reports)
• Order (Reason for Study) {D2}
• Other Orders (Recent & Prior)
• History/Allergies/Problems/Medications
• Lab Data (Current, Prior)
• Pathology Data (Current, Prior)
• Patient History Sheet
• Tech Interview Sheet
• Contact Information (for performer of acquisition, physician(s) responsible for patient)

Out:

• "Ready to Read" Notification {W3}
• [Time/Date of Availability]
• Count of Images to Read (for legal reasons)
• Completeness of Data (what is missing, how many priors are there, etc)

Activity: Collect the necessary inputs for the Reading node and decide "readiness".

Exceptions:

• "Wet Reads" do minimal marshalling (just the current data).
• For Reading Service the order and other data may be coming from another organization

Interpretation/Dictation

<figure how to show this as two steps (to see what we learn) because of box separation, but reflect that to the user it is really one task>

Control:

• Reading Worklist {W4} <Workflow management (Overdue? Exception Mgt?)? Worklist partitioning?>
• ["Ready to Read" Notification {W3}]

In:

• "Marshalled Data"
• Reference materials (Teaching Files, "StatDX", etc.)

Out:

• Findings/Conclusions as Voice Audio?
• [Proto Report]
• [References to Images?]
• [Report Start/Stop Date/Time]
• Delay Flags
• Followup Flags (e.g. Mammo)
• Critical Results Flags
• Image QC Comments
• Flag for Teaching File
• Flag for Clinical Trial Candidacy

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.

<<Provide explanation of Proto Report>>

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

Exceptions: Should we come back to template based/checklists/selection/typed entry reports? <Some places may use them for normals but devolve to dictation if something seen>

Transcription/Authoring

Control:

• Transcription Worklist

In:

• Voice Audio
• [Proto Report]
• [References to Images?]

Out:

• Draft Report

Activity: 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.

<Add something about feedback, e.g. a note to the Rad from the Transcriptionist, phone calls, IM, etc.>

Data Marshalling – Final

Control:

• Delay Flags
• Input Availability

In:

• Draft Report
• Referenced Additional Data (see Delay Flags)

Out:

• Draft Report (Updated with delayed data)

Activity:

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

Over-read

In:

Out:

Activity

Exceptions:

• For Reading Service reports, Overread by the requesting organization is often mandatory. The overread may also require changing the report format to local standard.

Differential Reconciliation

In:

Out:

• Discrepancies Report <<COMPILED OR CASE BY CASE?>>
  • (Often distributed back to the Reading Service, often used to "rate" them)

Activity:

Verification/Correction/Confirmation

Control:

• Verification/Over-read Worklist

In:

• Draft Report
• [Voice Audio]

Out:

• Final Report

Activity: (Two kinds of verify, 1 to verify transcription, 1 to overread). In both cases they want access to the images.

Exceptions: wouldn't listen to the audio.

Signature/Finalization

Control:

• Signature Worklist

In:

• Final Report

Out:

• Signed Report

Activity: <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.>

Really verify always involves a signature (if you won't sign it, why do we trust you to verify), but signature does not always result in finalization.

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

<<Also add the voice audio of the dictation available over the phone>>

Activity: Making the draft report available to interested parties (usually those treating the patient).

May be distributed to multiple destinations.

Preliminary distribution is particularly important for Reading Services since it's the reason for doing it. If they could wait for the local final report, there's no need for the reading service.

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

Urgent/Critical Results Notification

Control:

• Critical Results Flags

In:

• Order (Referring)
• PWP Contact Info
• On-call/work schedule
• Prelim Report or Signed Report

Out:

• Signed Report
• Notification

Activity: Notify referring or other relevant physician that the report contains urgent/critical findings.

Exceptions: Note there are levels of urgency which dictate different notification strategies.

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 w 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

Control:

Out:

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: Ideally this would happen during performance of the procedure and authoring of the findings. Typically it happens separately later for a number of reasons.

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

Control:

In:

• Order
• Performed Procedure Details
• Procedure Codes

Out: Bill

Activity:

Archiving Phase

Archival – Operation & Legal

In:

• Signed Report

Out:

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

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

Recording the test and findings in the patients EHR, incorporating the report into the medical record. Consumption or Archival?

Do we document the various cases here? E.g. Reporting Service keeps studies online for a week for distribution availability, but archiving is considered the responsibility of the requesting institution.

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.