Workflow-technology-tutorial-amia12-vojtech-huser-harm-scherpbier-

Introduction to workflow technology Representation of healthcare

processes in a workflow editor and their execution in a workflow engine

Vojtech Huser MD PhDHarm Scherpbier, MD, MS

AMIA 2012, Tutorial (3hrs)

Vojtech Huser, Harm Scherpbier: workflow tutorialVojtech Huser, Harm Scherpbier: workflow tutorial

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Agenda Part 1: Introduction, history, overview Part 2: Standards, SDO, related theories Part 3: Practical tools demonstration Part 4: Conclusion

This presentation is also at this URLhttp://www.slideshare.net/vojtech_huser/presentations

Accompanying bibliography and other fileshttp://code.google.com/p/healthflow/downloads/list

http://www.slideshare.net/vojtech_huser/presentations

http://code.google.com/p/healthflow/downloads/list


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Part 1: Introduction to workflow technology(WT)

Need for specifying workflow within IT systems History of workflow technology

prior 1960s-1980s development after 1990

Components of workflow technology (process definition, execution engine, analytical components)

Benefits of implementing a workflow server within a generic IT system

Major workflow vendors and open-source workflow technology tools

Future development and research challenges Published case studies in Healthcare Difference: Workflow engine vs. Decision Support engine WT in healthcare (HS)


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Part 2: WT standards, SDOs, related theories

Workflow management coalition’s (WfMC) standards

Definition of WT terms XML process definition language

(BPMN 2.0 (stored as XPDL 2.2)) Other standardization efforts

Business Process Execution Language (BPEL) Business Process Modeling Notation (BPMN) Research-originated WT standards

Petri Nets theory and its relationship to workflows


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Part 3: Practical tools demos MainLine Health case study Demo of an JaWE editor (and engine) Process mining tool (ProM, Nitro, DISCO)


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Part 4: Conclusion Momentum behind BPM Future of workflow technology Conclusion Questions & Discussion

Links General:

http://wfmc.org http://en.wikipedia.org/wiki/Xpdl http://en.wikipedia.org/wiki/BPMN http://en.wikipedia.org/wiki/Workflow_patterns http://books.google.com/books?id=I1KOAfiqfxYC http://books.google.com/books?id=O1xW1_Za-I0C

From tutorial authors http://healthcareworkflow.wordpress.com http://code.google.com/p/healthflow/downloads/list http://code.google.com/p/processmining


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http://wfmc.org/

Software Download the following software:

JaWE Java Workflow Editor http://sourceforge.net/projects/jawe

Shark Workflow Engine (optional) http://sourceforge.net/projects/sharkwf


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Part 1

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Part 1: Introduction to workflow technology






Workflow Technology applied industries and healthcare

Future development and research challenges


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Workflow technology BPM = business process management Adaptive workflow (Adaptive Case

Management) Computer supported collaborative

work (CSCW) Why workflow?

Separation of data into databases Separation of UI from IT system core Separation of process knowledge


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Process Example

Koetter (2007)


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Workflow patterns examples Parallel Split: When an intrusion alarm is

received, trigger the dispatch-patrol activity and the inform-police activity immediately.

Exclusive Choice: After the review election activity is complete, either the declare results or the recount votes activity is undertaken.

Multi Choice: Depending on the nature of the emergency call, one or more of the despatch-police, despatch-fire-engine and despatch-ambulance activities is immediately initiated.


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WT development 1960s

Petri Nets (Carl A. Petri PhD work)

1960s-present Workflow components of various systems

1999 WfMC: terminology

2000s 2002: XPDL 1.0 2005 XPDL 2.0 2008 XPDL 2.1 BPMN standard

2010s BPMN 2.0 XPDL 2.2


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Automating Workflow Defined by Workflow Management

Coalition (WfMC) www.wfmc.org

Terminology and Glossary http://www.wfmc.org/standards/docs/TC-

1011_term_glossary_v3.pdf

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Terms Workflow

The automation of a business process, in whole or part, during which documents, information or tasks are passed from one participant to another for action, according to a set of procedural rules.

WfMS = Workflow Management System

BPM = Business Process Management BPMS = Business Process Management System

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Humans & machines working together


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Executable flowchart

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Minimum componentslanguage edito

r

execution engine

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Interfaces

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WT benefits Non-programmers understand

processes Non-programmers can modify

processes Analytical tools Faster IT system development

(SOA+WT)

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Choice of Wf vendor Major player

TIBCO BEA Global 360 IBM

Other Fujitsu IBM Oracle Microsoft SAP Lombardi

Open source JBOSS Taverna Together Bonita YAWL http://java-source.net/open-

source/workflow-engines


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Workflow engine


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Engine


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Use of WT Pioneer domains

Banking Manufacturing Shipping Government authorities Pharmaceutical

Healthcare Gartner 2008 report: <5% use

Overview of Healtchare WT articles Haux R, Seggewies C, Baldauf-Sobez W, Kullmann P, Reichert H, Luedecke L,

et al. Soarian - workflow management applied for health care. Methods Inf Med. 2003;42(1):25-36.

J. Emanuele and L. Koetter, "Workflow Opportunities and Challenges in Healthcare," in 2007 BPM & Workflow Handbook, 2007.

L. Koetter, "MRSA infection control with workflow technology," Spring AMIA Conference, Orlando, FL, 2007.

R. Hess, "The Chester County Hospital: Case Study," in 2007 Excellence in Practice: Moving the Goalposts., 2007.

Process Mining of Clinical Workflows for Quality and Process Improvement http://chuckwebster.com/process-mining/HIMSS12/process-mining-clinical-

workflows-quality-process-mprovement.pdf Huser V, Narus SP, Rocha RA. Evaluation of a flowchart-based EHR query

system: a case study of RetroGuide. J Biomed Inform 2010;43(1):41-50. Huser V, Rasmussen LV, Oberg R, Starren JB. Representation and execution

of clinical decision support using workflow engine technology. BMC Med Res Methodol


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Process Definition A process is:

Multiple steps… For multiple people… Over time… To achieve a goal.


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Main Line Health examples Clinical Guidelines and Core Measures Infection Control - e.g. CLABSI Adverse Drug Events prevention Heparin Protocol, Insulin Drip Rate

Calculator Research Protocols … and more

First: look at the Alerts worklist to see these at work…

Foley Reminders, ADE’s Foley Workflow Goal: Timely removal, reduce risk

for UTIs ADE Workflow Goal: Early detection of ADEs,

change medications

AMI and CHF Pathways Identify patients, initiate pathway, apply Core

Measures AMI:

CHF:

Video: CHF pathway Video of CHF pathway


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Central Line Insertion Checklist

Guidance to most preferred line location

Guidelines

Checklist!!

Central Line Insertion Checklist - continued

Checklist!!

Central Line – Procedure Note

Line Follow-up – Removal reminders

Dr. Clark Piatt Short video – Dr. Clark Piatt on

automated Central Line management


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Workflow Engine for Clinical Trials

Osteoporosis Research Study - Dr. Matthew DiPaola MD, supported by Sharpe-Strumia Foundation, performed at Lankenau Hospital, with LIMR research staff – 2008 – 2009

Objective: identify patients >65 years old, with hip fracture, and initiate endocrinology management in the acute phase of the care. Identify and treat osteoporosis, by endocrinologist, to prevent future fractures.

Identify Candidates – Consent/Enroll – Randomize - Automate Study Protocol – Collect Data

Osteoporosis Research Study Workflow

Identify Candidates for Study

Osteoporosis Research Study Workflow

Obtain Consent

RandomizationStudy/Control

Automate Study Protocol

Collect Data

Data Collection Form

Clinical Trial Management

Goal: Identify Candidates for Clinical Trials, and Track Enrolled Patients

Implement Protocols – including randomization

Volume of Alerts Per Site

234

69

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171

87

50

143

5535

173

73

38

187

113

15

0

100

200

300

LMC BMH PH

SeptemberOctoberNovemberDecemberJ anuary

Heparin Alert Utilization for Sept. 2011 thru Jan. 2012

Percent Alert Utilization Per Site

37

69

17

54

686061

67

5464

7161

74 7567

010

20304050

607080

90100

LMC BMH PH

SeptemberOctoberNovemberDecemberJanuary

Workflow Engine vs. Rules Engine Workflow Engine with Rules

Engine Process Automation / Business

Process Management

Multiple steps, over time, for multiple users

State-aware: keeps track of point in time and waits (listens) for next event to happen

Asynchronous Plug-in services (EAI) Graphical programming

Rules Engine Rule-based Clinical Decision

Support

Single decision point for single user

Not State-aware – runs at trigger event

Synchronous


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Future of WT Improvements

Adoption is growing Software tools sophistication is improving Competition, consolidation

Future similar to a database server inclusion in IT systems

Standards consolidation Research challenges

Process model visualization challenges Process model cross-vendor portability Adaptive workflow


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Workflow patterns

http://

workflowpatterns.com/


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Adaptive workflow

informationcentric

process centric

structuredprocess

unstructuredprocess

computer-supported collaborative work

ad-hoc workflow

production workflow

Part 2

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Definition of WT terms XML process definition language (XPDL) Other standardization efforts




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WfMC Started in 1990 5 interfaces XPDL 1.0, 2.0, 2.1,2.2 Yearly Workflow handbook

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Workflow Technology Business process management system (BPMS)

Workflow = The automation of a business process, in whole or part, during which documents, information or tasks are passed from one participant to another for action, according to a set of procedural rules.

Workflow Process = A set of one or more linked procedures or activities which collectively realize a business objective or policy goal, normally within the context of an organizational structure defining functional roles and relationships (definition vs. instance)

Worklist Handler = A software component that manages the interaction between the user and the worklist maintained by a workflow engine (task display, completion, acceptance, referral)

WfMC: Terminology & Glossary, Document Number WFMC-TC-1011, Feb 99 http://www.wfmc.org/index.php?option=com_docman&task=doc_download&gid=93&Itemid=74


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Definition of WT terms XML process definition language

(XPDL) Other standardization efforts




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XPDL XML file based on a XSD schema

http://wfmc.org/xpdl.html http://www.xpdl.org/standards/xpdl-2.2/bpmnxpdl_40a.xsd

First introduced in 1999 Conformance testing available

http://www.xpdl.org/cloudapps.html Exchange format Adoption (70+ products)

http://wfmc.org/xpdl-implementations.html


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Standards Timeline


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Example.xpdl


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Process Schema


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Activities


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WT standards Historical

WSDL Current major

XPDL, BPMN, BPEL Proprietary (vendor specific):

JBPM (JBoss) Win Workflow Foundation (Microsoft) T2Flow->SCUFL2 (Taverna) internal format (Weka)

Research ones YAWL

Standards trending


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p2 p1

t1

Petri Nets Mathematical theory Basics

Petri net consist two types of nodes: places and transitions.

A place may have zero or more tokens.

Graphic representations :Places (circles), transitions (bars), arcs (arrows), and tokens (dots)


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Definition of Petri Net C = ( P, T, F)

Places (circles) P = { p1, p2, p3, …, pn}

Transitions (bars) T = { t1, t2, t3, …, tn}

Flow relations (arcs) F ⊂ (P × T ) ∪ (T × P )

Extensions Hierarchical Petri Netns Coloured Petri Nets


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Petri Net for Math lovers

Part 3 - DEMOS


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HS Demo (30 min) Editor and EMR portions Activy example Basic editing Roundtrip between editor and EMR

(changes) MLM logic vs. flowchart logic


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Main Line Health Demo Integration points to EMR via services:

Events Decision Rules Tasks, messages, actions

Wait-steps Nesting Workflow Engine Demonstration:

http://intranet/Soarian/Support/Links.htm

VH Demo part (30 min) Screenshot tour of editor, processes

and process mining editor process mining tool


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Software shown Editor

JaWE Together Workflow Editor (TWE) v1.4, v2, v3, v4.3 Engine

Shark Together Workflow Engine (TWS) Web-based module Integration with Outlook

ProM (processmining.org)

V5.2, V6 Fluxicon (www.fluxicon.com)

Nitro Disco


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More CDS examplesWorkflow mining tour

Vojtech Huser, Harm Scherpbier: workflow tutorial 95


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Log schema


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2012: Mercy Health case study

Process Mining of Clinical Workflows for Quality and Process Improvement http://chuckwebster.com/process-mining/HIMSS12/process-mining-clinical-

workflows-quality-process-mprovement.pdf


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Editor live demo

Vojtech Huser, Harm Scherpbier: workflow tutorial 102

Part 4: Conclusion


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Agenda for part 4 Vojtech’s points Harm’s points


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Modelling paradigm Flowcharts

Several historical revisions Different vendors used different paradigm Standardization (BPMN) Swim lanes example Split/Join example Annotation elements

Complex flowcharts Flowchart can’t remove it

different views, hierarchical layers Exception handling General standards (XPDL) vs. medicine specific standards

(GLIF, SAGE)


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Healthcare is different Current workflow standards

YAWL Current workflow vendors

implementations

Complexity of medicine


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WT and EHR vendors Current status

One vendor uses a third party workflow engine

Variable support for workflow constructs Work list (push [single clinician, team], pull) Obtain current performer of a certain role Obtain patient data Maintain process state

Limited or now workflow features


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WT and EHR vendors Future state

Status quo stays More vendors adopt 3rd party workflow

engine Internal “CDS [rule] engines” gain more

workflow features New CDS standard with workflow

components HL7 DSS


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Vojtech Huser, MD, PhDVojtech Huser, MD, PhD

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Sage flowchart example P. Ram (2004)

“Executing Clinical Practice Guidelines Using the SAGE Execution Engine,” Medinfo, pp. 251-5, 2004

SAGE’s decision maps subflows

Rule-in and Rule-out contructs

Linking workflow engine with a rule engine


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GLIF guideline

Sharing CDS content MLM content (code logic) Workflow content (flowchart + code

logic)

2 levels of sharing (WT) Share complete process definition Share only the flowchart (description)

http://healthcareworkflow.wordpress.com/2012/02/09/healtflow-hepatitis-a-scenario/


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Splitting the CDS representation format

maintenance: title: Hepatitis A Immunization MLM;; library: links: to be added;; knowledge: type: data_driven;; data: /* text within curly brackets would be replaced with an institution’s own query */

Let PatientIDRecord BE OBJECT [AccountNum, Name, Birthdate, Sex]; LET Patient BE Read As PatientIDRecord Latest {select accountnum, name, dateofbirth, sex from EHR} ;

LET HAVRIX BE Read As Medication {select med, form, dose, route, schedule from EHR where med = ‘HAVRIX’} ; LET TWINRIX BE Read As Medication {select med, form, dose, route, schedule from EHR where med = ‘TWINRIX’} ; Let GenericMessage BE OBJECT [MessageID, MessageCode, Message_Text]; Let Vaccine_Message BE New GenericMessage; ;; evoke: outpatient_visit;; logic: /* Check age */ if Patient_Age Is Null then /* Rules-one previous vaccination. */ if Count(VAQTA) + Count(HAVRIX) + Count(TWINRIX) = 1 then Needs_second_dose := true; endif;

/* Second dose young people */ if Apply_young_patient_rules and Needs_second_dose and Exist(VAQTA) and Latest VAQTA Occurred Before 6 months Ago then Vaccine_Message.Message_Text := "Give VAQTA vaccine, 25U, IM now. This completes Hepatitis A vaccinations."; Conclude true; endif; if Apply_young_patient_rules and Needs_second_dose and Exist(HAVRIX) and Latest HAVRIX Occurred Before 6 months Ago then Vaccine_Message.Message_Text := "Give HAVRIX vaccine, 720EL.U, IM now. This completes Hepatitis A vaccinations."; Conclude true; endif; if Apply_young_patient_rules and Needs_second_dose and Exist(TWINRIX) and Latest TWINRIX Occurred Before 1 months Ago then Vaccine_Message.Message_Text := "Give TWINRIX vaccine, 720 EL.U/20ug, IM now. This is the second Hepatitis A/B vaccination."; Conclude true; endif;

/* Second dose Older people */ if Apply_older_patient_rules and Needs_second_dose and Exist(VAQTA) and Latest VAQTA Occurred Before 6 months Ago then Vaccine_Message.Message_Text := "Give VAQTA vaccine, 50 U, IM now. This completes Hepatitis A vaccinations."; Conclude true; endif; if Apply_older_patient_rules and Needs_second_dose and Exist(HAVRIX) and Latest HAVRIX Occurred Before 6 months Ago then Vaccine_Message.Message_Text := "Give HAVRIX vaccine, 1440 U, IM now. This completes Hepatitis A vaccinations."; Conclude true; endif; if Apply_older_patient_rules and Needs_second_dose and Exist(TWINRIX) and Latest TWINRIX Occurred Before 1 months Ago then Vaccine_Message.Message_Text := "Give TWINRIX vaccine, 720EL.U/20ug, IM now. This is the second Hepatitis A/B vaccination."; Conclude true; endif; /* Third dose of TWINRIX */ if Exist(TWINRIX) and Count(TWINRIX) = 2 and Latest(TWINRIX) Occurred Before 5 months Ago then Vaccine_Message.Message_Text := "Give TWINRIX vaccine, 720EL.U/20ug, IM now. This completes Hepatitis A/B vaccinations."; Conclude true; endif; ;; action: write Vaccine_Message.Message_Text;; end:


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Approach comparison

WT and healthcare institutions Current status

No adoption (majority, Gartner report)

EHR vendor supports WT 3rd party engine implementation

(Marshfield Clinic)

Different institutions are at different stages


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WT future (software components) Core components

Editor Engine

Additional components Administration application (deplay, terminate, versioning)

Work list handler User management (LDAP, MS, other)

Organizational roles Monitoring/Analytical application Simulation tools Worfklow mining

Harm Sherpbier’s conclusion


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Learnings Powerful Complex Importance of integration to EMR

EMR represents the users, the data, and the transactions

Need for services: events, work-lists, tasks and notifications, actions (e.g. orders), EAI


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Healthcare Processes Healthcare Processes waiting to be

automated: Clinical Pathways, Care Management Transitions and Discharges Surveillance and monitoring Administrative processes … and many more

Many opportunities for use of BPM technology in healthcare


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Platform for outsourced knowledge

Currently: managing decision rules internally, linked into the workflows

Future: opportunity to call outside knowledge sources HL7 DSS, OpenCDS standards


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Future of BPM in Healthcare? Opportunity, processes to be

automated? Yes! Technology available? Yes! Advantage of BPM over other decision

support and process management tools? Yes!

Can healthcare organizations manage the complexity (build and maintain)? Maybe…


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Questions ?

Covered topics Introduction to workflow technology WT standards Examples WT and healthcare

Contact us vojtech.huser at nih.gov


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Documents

Workflow-technology-tutorial-amia12-vojtech-huser-harm-scherpbier-