Scheduled Workflow II Phase 2 - Brief Proposal

Proposed Profile: Scheduled Workflow II

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

Summary

The Scheduled Workflow Integration Profile for the Radiology Domain was first introduced in the IHE Technical Framework Version 1 over 8 years ago. Since the introduction, IHE Radiology has added several options to make it more operable. Additionally, some of the early technology did not address all of the interoperability needs due to limitations of the technology. As such, the level of uptake is not consistent with all actors.

The Problem

SWF is based on HL7 v2.3.1. The current balloted version is HL7 v2.5.1. SWF is the most widely deployed IHE Integration Profile. For health care providers who have already deployed systems based on IHE SWF, SWF is a roadblock for deployment of the current HL7 version.

IHE National Committees have identified their deployment need to use HL7 v2.5.1.

IHE-Spain has submitted a National Extension which makes use of the PID definition provided in the HL7 v2.5 definition. This version of HL7 v2.5 better meets the requirements for dealing with Names (multiple surnames) and Identifiers associated with Patients, Physicians, etc.

IHE-Japan has submitted a National Extension which makes extensive use of the new Order Segments (including: OMG, ORG and TQ1). Japan would prefer to make use of the latest HL7 v2.5 as it provides better organization for the information they require.

As part of the United States standards harmonization initiative, HHS plans to require that all Government contracts use HL7 v2.5 or higher.

SWF is a roadblock for regions to deploy version 2.5.1.

Some new systems in development are utilizing HL-7 v2.5.1.

• Some may choose to still support SWF. This provides compatibility with the installed base and gives them a profile to claim, but requires implementing v2.3.1 messaging and if they want to support equivalent capability in the HL7 2.3.1 version it requires extensive remapping of the unprofiled v2.5.1 features.
• For others, compatibility with the installed base may be less of an issue and the dual development costs are significant, but without SWF II they have no profile to serve as a basis for claiming compatibility.

Some specific features relevant to SWF that are lacking in 2.3.1 include:

• Order Granularity: the ability to specify procedure details is limited
  • e.g. in an order for a 2-view chest, it is not possible to specify the view to include decubitus
  • ORC segment may include the JJ1017 Code (Japanese master code for Radiology)
  • V2.5.1 provides increased Order Granularity in the fields added to the OBR in v2.4

• Authorization Mode: there is no way to indicate how an order change/cancellation was approved.
  • Hospital policy may require the signing provider to approve it when Imaging department needs to change ordered procedure
  • V2.5 added a field to specify the entering users authorization mode in the ORC

• Result Study UID: ORR can't normally provide the Study UID to reference.
  • SWF added a custom ZDS Segment to handle Study Instance UID in Transactions RAD-4 and RAD-13 v2.5 formally defines it in the OMI

SWF also has a number of interoperability gaps that need addressing, including:

• Implicit post processing Workflow: No explicit workflow trigger is identified for an evidence creator to initiate their post-processing of an image set that is implicitly required in the worklist item selected on the modality.
• Wetread Workflow: Ordering provider can't request wet reads and set a trigger for when a wet read result is available
• Change Authority: SWF does not address the authority of the person cancelling or modifying an order (either at the HL7 level or the DICOM level)
• Study Complete: MPPS is identified by SWF as meaning end of exam or study complete. MPPS only indicates that a procedure step is complete, not the exam or study. There is a need for knowing when the complete is study and available for viewing or reading.
• Intermittently Connected Devices: IHE Cardiology supplemented Scheduled Workflow to address ultrasound systems that disconnect from the network while moving around the hospital but need to remain "integrated". Radiology needs to address the same issue.

The number of options in SWF makes it unnecessarily complex for users trying to order it in products or review Integration Statements. The options include useful SWF features, but because they were added later it was necessary to document them as options. It would simplify things if an updated profile folded in existing options. Likely examples include:

• Exception Management Option
• Assisted Protocol Option

Patient Administration Management provides a common approach for all domains for patient management. SWF had to include patient management because it wasn't' profiled at the time. The PAM specification differs and improves on the SWF specification. SWF II could reduce variation by factoring out patient management and referencing PAM instead.

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.
• Un-Scheduled 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 separate workstation for post-processing 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-modalities.
• Intermittently Connected Devices - Where a modality may not be continuously connected to the department information system.

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

Standards & Systems

HL-7 v2.3.1 (Released)

This is the version currently profiled in Scheduled Workflow and implemented by compliant systems.

HL-7 v2.5.1 (Released)

HL-7 v 2.5.1 is the most currently balloted and relevant version of HL-7 to SWF II. HL-7 v 2.5.1 is identified as a critical need by the Japan National Committee and the Spain National Committee.

HL-7 v2.6 (In Ballot)

The initial assessment by the Rad TC is that v2.6 has no additional features useful or relevant to SWF II.

HL-7 v2.7 (In Development)

The initial assessment by the Rad TC is that v2.7 has no additional features useful or relevant to SWF II.

The initial assessment by the Rad TC is that SWF II will not define any additional requirements relevant to v2.7 development.

HL-7 v3.x (In Development)

The initial assessment by the Rad TC is that the impact of HL-7 v3.x is so significant that it warrants a separate profile.

Regional HL-7 Version Requirements

see strawman process described in open issues section

DICOM

Modality Worklist (MWL) and Unified Procedure Step (UPS)

MWL is well accepted and broadly implemented by the Modalities/DSS/OF. Unless a compelling advantage is found, there is no reason to change to UPS. It might be worth considering if any problems would be created by some niche systems using UPS in addition to MWL.

Technical Approach

Existing Actors

All existing actors in the Current Scheduled Workflow Integration Profile will be included in this effort with the exception of:

Remove from SWF II

DSS ADT Image Archive MPPS Manager Image Display Remove the following option:

Remove the following option:

• Departmental Appointment Notification

Evidence Creator

Change Optionality to Manadatory the following Option:

• Creator Performed Procedure Step
• PPS Exception Management

Acquisition Modality

Change Optionality to Manadatory the following Option:

• Assisted Acquisition Protocol Setting
• PPS Exception Management

No Change to the following Options:

• Patient Based Worklist Query
• Broad Worklist Query
• Modality Group Case

Image Manager/Image Archive

Permantly combine Image Manager and Image Archive, propose to be referred to as Image Manager only

Change Optionality to Manadatory the following Option:

• Availability of PPS-Referenced Instances
• PPS Exception Management
• Performed Work Status Update - Receive

Existing Transactions

The following changes are proposed for each tranaction:

RAD-1 Patient Registration - Remove RAD-2 Orders Management - Remove, replace with new RAD-x+1 Orders Management V2.5 using the specific OMG message. Note that this message complies with the IHE-Japan request to include the ORC segment to include the JJ1017 Code (Japanese master code for Radiology)

RAD-3 Order Filler Management - Remove, replace with new RAD-X+2 Order Filler Management using the specific V2.5 OMI message.

RAD-4 Procedure Scheduled - Remove, replace with new RAD-x+3. Procedure Schedule using the specific V2.5 OMI message.

New Transactions

New transaction/s identified:

New Integration Profiles Needed

Create Scheduled Workflow II.

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

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

Domains outside of Radiology will need to consider which version/s of SWF to use.

Breakdown of Tasks that need to be accomplished

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.

Rad TC 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.

2. 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.

2.1. 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.

2.2. 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.

2.3. Mandatory Usage of Protocol Codes in MWL & MPPS

The usage of protocol codes is necessary for robust interoperability. 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.

3. Enhanced Interoperability with HL-7 v2.5.1

3.1. 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.

3.2. 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.

3.3 Enhanced ability to specify timing for an order

HL-7 v2.5 introduces the TQ1 and TQ2 timing and quantity segments, enabling you to specify specific timing requirements also not possible in 2.3.1.

3.4 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.

3.5 CTD Contact Data Segment

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

3.6 PID Segment The identification data of a patient specified in the PID segment with the HL7 v2.5 version is neccessary for support of the IHE Spain National requirements for Patient Identification. Included in this requiremnt is the need for specifying the ID number, Assigning Authority, Identifier Type Code, Expiration Date, and Assigning Authority Jurisiction.

4. 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.

5. 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.

6. PAM Transactions

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

7. 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.

Support & Resources

The resource needs for this profile are high. It is important to obtain commitment of resources from the National Committees, the Radiology Subcomittees and other Domain Committees who would benefit from a new SWF.

The Japan and Spain National Committees both have expressed interest in seeing SWF updated to HL7 v2.5.

The Mammography Subcommittee has expressed their need for some of the departmental workflow enhancements identified and their willingness to work with the re-factoring to support their needs.

Tech Cmte Evaluation

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

Note: Post the initial discussion it has been recommended that the estimate be bumped because of the extent of the unknown issues that may arise during the development. These increase are reflected in all of the estimates.

Technical Committee review resulted in estimates for three different approaches:

• 200% Full implementation of SWF II. It is believed that this is a multi-year effort. A major risk with this implementation is that User's have to wait at least 2 years for an implementation (note that as an interim it is recommended that a Whitepaper (or User's Guide) be developed for Mammography Acquisition).

• 105%/105% Division of SWF II into Order and Acquisition and work through the implementation of each half of SWF II separately. If the Technical Committee works through the Acquisition first, then potentially Mammography would be able to develop the Mammography Acquisition Profile earlier. Note that the risk in this scenario is that dependencies between the Order and the Acquisition pieces will not be realized until too late.

• 50%/160% Development of the Use Cases for the first year. This would concentrate the User effort in the development of the Profile. (Note from the Mammography Committee perspective this would be most desirable). Additional work could be done to review the HL7 and DICOM standards to determine if any HL7 Standards or DICOM Standards work needs to be done.

Responses to Issues:

See italics in Risk and Open Issue sections

Candidate Editor:

Chris Lindop(Lead Editor)/Ruth Berge/Tony Palmer