Scheduled Workflow II - Detailed Proposal

1. Proposed Profile: Scheduled Workflow II

• Proposal Editor: Chris Lindop/Ruth Berge/Tony Palmer/Doug Castle
• Date: N/A (Wiki keeps history)
• Version: N/A (Wiki keeps history)
• Domain: Radiology

Summary

The Scheduled Workflow Integration Profile pioneered the use cases for interoperability of Healthcare systems for Radiology Imaging. It is not current with the existing standards. It has gaps that do not cover the interoperability workflow of today's system needs. This integration profile addresses the usage of current standards and the interoperability gaps.

The Problem

It is based on HL-7 v2.3.1. The current balloted version is HL-7 V 2.5.1. Some new systems in development are using the current version and not the version profiled in Scheduled workflow. This impedes new adoption of this profile. Conversely, adopting the existing profile is impeding the adoption of the current HL7 version.

The original scheduled workflow has interoperability gaps since it was originally published.

• Additional granularity in defining the procedure is required. For is an order for a 2-view chest but you want to specify the view to include decubitis.
• Lack workflow triggers for review or display of images.

Many of interoperability concerns are published as options. An option review is required. Options which are needed for interoperability need to be folded into the text.

New integration profile, Patient Administration Management, addresses a common approach for all domains for patient management. SWF needs to address the adoption of this profile. Additionally an open issue is with adoption of full fidelity PAM transactions with unscheduled use cases with the order filler and Image Manager.

PIR needs to be analyzed and potentially folded into SWF 2 or create a PIR 2.

A risk that there may be items which PAM may have open issue the existing HL& v2.3.1 requirements.

The original scheduled workflow has interoperability gaps with the order placer. The order granularity and feedback from the order filler is not sufficiently designed to profile the expectations of the clinical environment when placing orders.

The original scheduled workflow does not address specific interoperability requirements of the order filler. Many of the options do address the order filler interoperability. However specific clinical data and human intervention to confirm that an imaging ack is completed is missing.

Japan and Spain have provided National Extensions which have specified usage of HL7 V2.5. The changes proposed need to be analyzed.

It should be noted that MPPS is not profiled apropriately. MPPS is identified by SWF as the trigger for end of exam. MPPS only indicates that a procedure step is complete and not the end of exam. The new Scheduled workflow needs a trigger to indicate that the exam is complete. This is needed for available for viewing. An open issue is to define when is the exam, study or order is complete. Would be good to define what a study and and exam is.

Wet read workflow needs to be analyzed. There may be a need for the ordering provider to request wet reads and a trigger for when a wet read available.

SWF does not address who authorized an order change. This is important with cancelling an order or modify an order. HL7 v2.5 addresses this with a signature mode to indicate how it was approved. This needs to be analyzed.

Current SWF has identified the gap where the Study UID is not included in the ORR. This is now included in the OMI specified in HL7 v2.5.

Current SWF incorporates an implicit content profile with workflow. We need to address whether or not to factor out the image content profile.

Gap Analysis

Technical Committee has requested a new Section to perform a gap analysis with the current SWF.

DICOM needs to be evaluated for the ability to meet the needs for the new transactions listed.

Other DOMAINS need to be notified of the changes we are considering for their feedback. Currently 4 domains are using SWF.

The International Committees need to be invited to review the proposal and provide feedback and support.

Key Use Case

This Integration profile leverages the same use cases as scheduled workflow.

• Simple Case - A patient is registered, an imaging order is placed, a procedure is scheduled, and images are acquired.
• UnScheduled Case - Images are acquired for an unscheduled procedure.
• Patient Update Case - Any update to patient information.
• Appointment Update Case - Any update to the patient's appointment.
• Order Change Case - Any update to the order where the order is changed except for status change.
• Abandon Case - Where an order is started, but discontinued. Valid images may have been acquired and work may be billable.
• Append Case - Additional acquisition procedures steps are performed that were not part of the original order.
• Group Case - A single procedure performed at the modality for multiple procedures scheduled for the patient.
• Implicit Post Processing - Post processing on an imaging set implied by the acquisition worklist. Images may be transferred to a seperate workstation for postprocessing task completion.
• Relevant Clinical Information Distribution - Critical relevant patient information provided from other EMR systems distributed to every system, including the acquisition modality through Modality Worklist.
• Results Distribution - Information provided by the Order Placer to the Order Filler for Results Distribution.
• Multimodality Acquisition - Where an order contains procedure steps for multi-modalites.
• Intermittently Connected Devices - Where a modality may not be continuously connected to the department information system.
• Raw Data Management - Image Management, including retention and distribution of raw images.

Most of these use cases are documented to some level throughout the Current Integration Profile.

Technical Committee would like to see definition of each of these workflow Use Cases and recommendations if they should be moved forward to SWFII. Additionally, are there options which should be required or removed.

Results Distribution should be removed from SWFII. However, there needs to be information about the Distribution List and Methods of Distribution.

Consideration should be given to Use Cases required by National Extensions such as Spain and Japan.

Standards & Systems

Relevant standards:

HL-7 v2.5.1

IHE SWF needs to use the most currently balloted version of HL-7. Moving to the current balloted version is an essential component of this proposal. HL-7 v 2.5 was identified as a critical need by the Japan National Committee and the Spain National Committee. Version 3 has not currently passed ballot. The current balloted version is HL7 v2.5.1.

HL-7 v2.6

Technical Committee would like to understand when HL7 v2.6 is going to be released and determine if this version should be used rather than v2.5.1. Additionally, it would be nice to see a consideration of the 2.x migration plan.

HL-7 v3.x

Technical Committee would like to see a discussion on why HL7 v3.x should or should not be considered so that this can be reviewed.

Regional HL-7 Version Requirements

Technical Committee would like to ensure that the requirements from other Regions (e.g. Spain and Japan) are taken into consideration.

DICOM

Technical Committee would like to see a discussion on the consideration of the DICOM UPS as opposed to MWL. It is understood that MWL is well accepted by the Modalities/DSS/OF, and unless there is a compeling reason, there is no reason to change to UPS.

Technical Approach

Existing Actors

All existing actors in the Current Scheduled Workflow Integration Profile will be included in this effort.

ADT - Remove from SWF II The transactions are currently up to HL-7 v 2.5 in PAM. WIll include PAM Actors to replace.

DSS/Order Filler - no change or combine to be referred as DSS or Imaging Department Scheduler only

Order Placer - no change

PPS Mgr - Remove with direct from the modality or Leave but require that it must be grouped with either Image Mgr/Image Archive of DSS/Order Filler

Image Display - no change

Evidence Creator - no change

Acquisition Modality - no change

Image Manager/Image Archive - Combine to be referred to as Image Manager only

Technical Committee would like to have you consider if any of the existing Actors should be removed (e.g. PPS Manager), Permanently Grouped (e.g. Image Manager/Image Archived), renamed; or whether Actors from other Domains should be considered (e.g. Actors from the PAM Profile)

New Actors

Enterprise System Scheduler - Add to assume the scheduled Item Updates, grouped with Patient Demographics Consumer and grouped with Patient Encounter Consumer.

Patient Demographics Consumer - Add as requirement to be grouped with Order Placer and Department System Scheduler

Patient Encounter Consumer - Add as requirement to be grouped with Order Placer and Department System Scheduler

Existing Transactions

Transactions with HL-7 messaging will need to be re-written. Regional requirements/differences will need to be considered.

RAD-1 Patient Registration - Remove, replace with Pateint Identity Feed[ITI-030] and Patient Encounter Feed[ITI-031]

RAD-2 Orders Management - Remove, replace with new RAD-62 Orders Management V2.5 using the specific OMI message.

RAD-3 Order Filler Management - Remove, replace with new RAD-63 Order Filler Management using the specific V2.5 OMI message.

RAD-4 Procedure Scheduled - Remove, replace with new RAD-64. Procedure Schedule using the specific V2.5 OMI message.

RAD-5 Query Modality Worklist - Remove and replace with RAD 65. Need to make the Scheduled and Requested Procedure code sequence required. Relavent Clinical Information needs to be required.

RAD-6 Modality Performed Procedure Step in-Progress and RAD-7 Modality Performed Procedure Step Complete/Discontinued Remove and replace with RAD-66 and RAD-67 to include the assisted protocol option. Technlogist performer/provider name and person identifier/s needs to be provided for RAD-67. Discontinuation reason codes must be required for RAD-67.

RAD-8 no change

RAD-9 no change

RAD-10 no change

RAD-11 remove. It is permenantly replaced with RAD-49

RAD-12 remove and replace with the the RAD-68 using HL7 v2.5.

RAD-13 procedure update, remove and replace with the RAD-69 using HL-7 V2.5 OMI

RAD-14, RAD 15, RAD 16 and RAD 17 have no workflow trigger for initiating either query. These could be removed and addressed in Reporting workflow. A realisitc option is to provide a study complete message, indicating that images are available. A new transaction is proposed; RAD-X1 Work Item Complete.

RAD-20 and RAD 21 change to required for evidence creator.

RAD-18, RAD-20. RAD-21 and RAD-10 from evidence Creator have no workflow trigger for creasting the evidence documents. Currently the workitem is considered implied. This has not been an effective or realistic model. These could be removed and addressed in Post-Processing workflow. A realisitc option is to provide a study complete message, indicating that images are available. A new transaction is proposed; RAD-X2 Assign Work Item.

RAD- 48 change optionality to required. Change destination actor to Enterprise System Scheduler.

RAD-49 change optionality to required.

New Transactions

New transaction/s identified:

• Work Item Complete - from the Acquisition Modality to the Order filler. Indicates all work by Technologist with patient is complete. The expectation is that the Technologist has completed all tasks associated with this patient. This will provide the workflow trigger for RAD-14, RAD 15, RAD 16 and RAD 17.

• Assign Work Item - Work Item pushed to Evidence creator for completion. Workitem is an implicit workitem to be performed as part of the modality procidure step. This will provide for the workflow trigger for the evidence creator to initiate RAD-18, RAD-20. RAD-21 and RAD-10.

New Integration Profiles Needed

Partition Scheduled Workflow (SWF) to remove the ADT transactions and add:

• Patient Account Management (PAM) - Use existing ITI profile

Other Domains will need to consider which version/s to use.

Breakdown of Tasks that need to be acomplished

Technical Committee discussed the possibility of using the Mammography as the test case for the first year implementation of SWFII. This would give an opportunity to see if the implementation will work on a speciality area which has high Clinical Input and determine where to go from there.

1. Use Case Review

The Use Case Descriptions need to be restructured and reviewed for completeness. In their current state, they are not explicitly described in any single section.

2. Profile Options Review

There are a total of 16 options specified in Scheduled Workflow. Each of the options specified must be reviewed against the Use Cases. If the options are necessary to meet the use cases, then the optional usage must be changed to required. If not, they need to be removed.

3. Transaction Data Elements Options Review.

Each Transaction within Scheduled Workflow has optional data elements specified. Each optional data element needs to be reviewed against the Use Cases. They are to be removed if not necessary or changed to required if they do contribute to the use case. Elements marked as required but are not clearly mapped to a use case or are not clearly testable against a use case need to be evaluated as well.

3.1. MWL Clinical Information Option

MWL has inclusion of clinically relevant data in the worklist as an option today. This is in conflict with the Order Filler requirement to provide this information to the modality.

3.2. Mandatory Usage of Exception Codes in MPPS

The usage of exception codes needs to be mandatory for Order Fillers to accept and modalities to provide.

3.3. Mandatory Usage of Protocol Codes in MPPS

The usage of protocol codes is necessary for true interoperability with RIS systems. Clearly defining what was ordered versus what was performed. This is essential for re-takes appends, and other, well documented, use cases which impede the effective interoperability of SWF.

4. Enhanced Interoperabiilty with HL-7 v2.5.1

4.1. Enhanced OBR Segment

The transaction RAD-2 created by the order placer contains the OBR segment. The OBR segment is enhanced in version 2.5.1. The additional information in the OBR segments enables finer grain order definition with the placer and filler supplemental service information.

The segment is bi directional. The supplemental service information fields provide supplemental service information for procedure information when the order from the master file is not sufficient. A placed order needs to provide additional specificity beyond the master file. Conversely, the feedback with supplemental service information fields is necessary when the order is not sufficient for proper billing and reporting.

OBR includes additional fields for results distribution. Additional information includes “who” to send the report to and how.

OBR segment introduces the parent universal service identifier for identifying the parent order. This would be very useful in appends and duplicate procedure uses cases. There is also the duplicate procedures field to provide additional rationale for procedure duplication.

4.2. Imaging Procedure Control Inclusion of the OMI Message

Version 2.5 introduces the OMI message, specific to imaging orders.

It includes the IPC segment, designed to provide a direct mapping with DICOM Imaging Procedure Control attributes. The IPC includes modality, protocol, procedure step and other acquisition information that is not available in version 2.3.1.

It also introduces the TQ1 and TQ2 timing and quantity segments, enabling you to specify specific timing requirements also not possible in 2.3.1.

4.3 ORC Segment

The ORC Segment includes the inter-authorization mode needed to identify the filler’s-authorization for use case events such as append or unscheduled events.

The ORC includes an Order Confidentiality field to provide confidentiality handling of the order being placed.

4.4. CTD Contact Data Segment

CTD Contact data segment provides additional types of contact information for report distribution.

5. SWF Order Modify

Clean up the Order Modification workflow (as it is an inefficient process today). For an order modification, the order is cancelled and then a new order is placed. HL-7 allows for the order to be modified without cancelling first. This practice was adopted in the original version of SWF. It is not a constraint of HL-7 v2.3.1. Reason or usage for cancel/new order workflow is not captured. This workflow would be inconsistent with other workflows such as a modality changing an order with the DICOM MPPS changing what was requested with what was performed using procedure codes.

6. Add, Work Item Complete Transaction

Add a “Work Item Complete Transaction” from the Modality to the Order Filler with additional fields necessary for Workflow Management by the Order Filler to properly close the completion of an exam procedure. The additional attributes need to include the clinical elements of the image acquisition.

Note that the current MPPS is not sufficient to support closing an exam. Without the additional clinical information, MPPS can not be used to close an exam by an Order Filler.

7. PAM Transactions

Replace the ADT transactions currently specified with the IHE ITI Patient Demographics Management (PAM) transaction.

8. Precautions and Allergies

Precautions and Allergies and other comment fields need to be reviewed and potentially remapped to alternate segments in v.2.5 that are currently relevant.

Tech Cmte Evaluation

Effort Evaluation (as a % of Tech Cmte Bandwidth):

Technical Committee has requested additional information be added before it is able to provide a final effort evaluation. Next review to occur on September 26, 2007.

Responses to Issues:

See italics in Risk and Open Issue sections

Candidate Editor:

Chris Lindop/Ruth Berge/Tony Palmer <List a lead editor and if appropriate, a couple co-editors>

Other Contributors? <should be listed in the resources section>