What is a pathway? (in human and computer terms)

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21

Hi Kevin,

I’m not sure what you mean by “Do you envisage the WHAT openEHR being both clinical and technical?”

i.e what do you consider clinical vs. technical.

openEHR does support what I think Adrian has discussed as a declarative approach.

i.e what do we want to do? Where are, we in doing what was supposed to be done?

Sits on top of a generic state machine but allows ‘clinical’ terms to be overlaid for specific content.
The procedure archetype is a good example - look at the Pathway tab
Most openEHR vendors use this alongside some sort of workflow engine (using hooks into openEHR) to handle the who/when aspects.

This should play very nicely with FHIR as the interface mechanism between heterogenous systems.

Ian

22

Hi Adam,

openEHR content can be easily transformed into HTML and then to PDF if required. The specs also include openEHR Extract, which allows messaging of pure openEHR content but most messaging of openEHR content actually is by embedding structured content inside CDA headers. We did that with some ophthalmology content in the UK as part of the ITK awards a few years ago and it is an approach regularly used in other parts of the world.

However, we have to be realistic that, for the moment, FHIR is likely to be the interface mechanism for this kind of distributed processing, so openEHR might be used within systems or broader platforms, but using FHIR to communicate across systems, based on openEHR content definitions.

Ian

23

Maybe you don’t need to model the edge cases or go into too much, they may make the diagram so complex it fails to get the simple model across? [Model the 20% that occurs 80+% of the time].

That’s fine for a high level design, and getting the simple model across, but to fully implement a complex workflow in an electronic system you need all the exceptions.

If you are baking the workflow into the code then the top down approach is fine as it is for normal process of of sw dev. However using a generic workflow engine you need to be able to express the whole thing as this sort of diagram up front, or your analysts need to have deep technical knowledge of the tooling.

At your top level our electronic discharge summary workflow was indeed fairly simple. All the difficult knotty stuff was hidden beneath. Which sounds good until it bites. :slight_smile:

24

Thanks Ian. Is it the aim then, in the fullness of time, for openEHR to cover the full messaging domain as well including recipient addressing, routing, business/clinical acknowledgements?

25

thanks Adam,

Not sure if I’ve shared this article with you in the past?

In it I position openEHR as the “clinical kernel” of the open platform that
healthcare awaits.
Alongside I suggest integration/middleware (for messaging etc) and user
interface framework as key elements.

You will see the common ground with PPM+, LCR in philosophy.
As you’ll note the Ripple stack is aimed at the 5 key requirements outlined
here…

Hopefully helpful…

Tony

26

hi,

thanks, i am a clinically switched on technician (over 30 years working with health data)

good to talk, i have spoken far more with clinical people when not working for the nhs than working for it, that

is down to one of the many significant problems the nhs has, a hierarchical management approach which will not be

subservient to "the" team, and i am not just thinking about role playing

notes:

i think what the nhs "does" with flow diagrams and process maps relates to care pathways (aka pathway templates), in my experience the organisation that produces the best of these is NICE, i ignore the rest (that is another significant problem the nhs has, too many quangos)

i get your idea, flow diagrams can play a part but from a data modelling perspective PATIENT pathways (please, please, please, do not join the rest of the bull shitters and just use the expression pathways - it is too vague) can follow any path, any activity can be recorded against them at any time

you are not complicating things, health is the most complex of all domains, it is not4the faint hearted, however there is a solution to your problem and that has come from the leader of NHS England (SS), he has laid a trail for others to follow, the solution is integrated care models:from a data modelling perspective:

  1. PATIENT pathways allow care activity to be recorded against different care settings (e.g. a surgery, hospital or a place in the community)2. integrated care models integrate physical and mental health by associating PATIENT pathways (in technical terms there is a many to many relationship between PATIENT pathways which can be realized through an integrated care model

in practical terms, an integrated “cancer” care model could be created which would associates the two cancer PATIENT pathways, the integrated care model would inherit the ID and HNA of the first PATIENT pathway to be linked

i hope to find some time and a way to upload a visual representation of my data model on to this site for all to share, please try and find some time to look at it, caring words are not always enough, they don’t always dot it :slight_smile:

if it still does make sense …give me a shout

nice to talk

ps just between you and me i don’t think SS bullshits, it’s many of those surrounding him, (he does talk too qlickly tho :-))

On 07 March 2016 at 22:44 wongwaikeong <discourse-system@openhealthhub.org> wrote:

wongwaikeong

March 7

@clive.spindley I think it is fair to say that I'm a technically switched on Doctor.

I completely get your what you mean by having a Pathway ID that can be linked to the particular care activity. For eg. a cancer OP appt can be linked to a Pathway ID for a cancer pathway, scans, blood tests, chemo and so forth.

The tricky bit is when the pathway becomes a bit of like process map. For example one that can be represented by a BPMN diagram. Gets even worse then there are different actors and the progression on the steps on the pathway is conditional.

For eg. 2ww cancer referral -> Triage -> If scans done already go to [1] else go to [2]

-> [1] book OPA

-> [2] book scan -> have scan -> go to [1]

You get the idea. And each point of the pathway can act as a trigger. For eg. once scan is done, inform MDT coordinator via an email.

And then of course the same activity can be related to two pathways! For eg. a patient with two cancers, on two pathways can have the same Holistic Needs Assessment, so then a HNA will have two pathways IDs?

Maybe I'm complicating matters! IMHO, BPMN provides most of the requirements for a pathway modelling specification on which a pathway tool/ service can be based on.

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27

Just a plain PDF but carrying the information a clinician needs to see or get across.

We have a mixed economy at the moment and some organisations won’t be able to support openEHR but they can provide the same information in a PDF (or even a word document or paper). openEHR tells us what is needed in the pdf/letter, such as the medications, relevant clinical history, etc.

It’s not just organisation, it’s also systems and people. It’s where I’m coming from with distinction between clinical and technical.

28

Or you need a system that’s more flexible - the reason people love paper and email for managing their workflow is that they cover a variety of sins.

Having been doing workflows for clinical and non-clinical settings for a long time, my No.1 lament is always that you end up spending a vast amount of the SMEs valuable time on specifying a workflow with a number of negative properties ;

  • Tries to replicate their current manual workflow
    • Even if the capabilities of the software render parts of it moot - e.g. a manual check of something that can be checked faster and with more rigour by a software component
  • Inevitably never covers every exception or workaround
  • Completely rigid - step Y must occur after step X, must be approved by particular user, etc
  • Then, as it’s “baked into” the tools as you say, improving it requires technical intervention

What users need to do their job is tools to accomplish the tasks they need to get done. In my experience, asking SMEs to specify workflow (often “argue about workflow”) steals valuable time with them that you could be using to produce these tools. It’s my firm belief that requirements gathering should focus on the tasks that need accomplishing and that workflow should be as minimal, standardized, and flexible as possible.

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29

It’s from IHE Cross Enterprise Referral Workflow. http://www.ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_Suppl_XBeR-WD.pdf

I modified names slightly to get my head around e-Referral process. So ‘Scheduling for consultation’ is what we call e-Referral NHS e-Referral Service - NHS Digital with ‘Clinical Report’ being Transfer of Care (https://www.england.nhs.uk/digitaltechnology/info-revolution/interoperability/transfer-of-care-edischarge/).

I was looking at ideas to digitize the ‘consultation’ process by using a workflow engine to upload the referral document into our document management system (it’s currently being printed and scanned).

30

I’d agree with that sentiment Adrian.

It should be acknowledged that within complex adaptive systems (eg
Healthcare) , often acknowledged to be at the “edge of chaos” … that we
often see non-linear > linear workflow…

So flexibility (aka “loosely coupled”?) technology is key to success in
may settings…

Just visit a typical ED to see this in action…

Tony

31

@tony.shannon if you use a # at the start of a line the MarkDown interpreter in Discourse converts it into a <h1> tag heading

32

Thanks Marcus

#lesson learnt

…use # carefully!

Dr. Tony Shannon
Director, Frectal Ltd


tony.shannon@frectal.com
+44.789.988.5068 (UK)
+353.89.457.6011 (Ireland)

33

IT is not difficult, you ID the PATIENT pathway, maybe click on a picture, then record the activity against it. Or you could ID the patient, then select the PATIENT pathway from a list.

Never too late to make a start.

Clive

I gnore the waffle and politics which exists within the NHS

On 08 March 2016 at 12:05 "tony.shannon" <discourse-system@openhealthhub.org> wrote:

tony.shannon

March 8

I've also heard the term "pathway" discussed and debated more times than I

like to recall.

The challenge is that if you get clinical/IT folk in a room to try to agree

the definition of a “care plan” or “care pathway” you’ll get a different

definition every time.

Such is the state of maturity of the art/science of informatics, we have

some distance to go to get a common language between the

clinical/management/technical folk that need to be involved.

Having looked at this in the past, if you want to delve into pathways I

would draw attention to a few things.

“Designing Guideline-based Workflow-integrated Electronic Health Records”

http://www.openehr.org/resources/publications#workflowinhealthcare

& a related (brief) paper here

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1480104/

I would suggest that pathway material generally involves crafting a blend

of people + process + information + technology.

One way of explaining it, which Barretto does so well in her thesis is that

the information elements involve a mix of

WHAT needs to be done (clinical content, ie archetypes/EHR content)

WHY (rules , such as IF, ELSE etc... rules engine)

WHO #WHEN (workflow/task management .... workflow engine)

So to support any 1 pathway could require quite a bit of kit... IF you

are trying to support pathway(s) at scale…otherwise you’d hack something

together… that won’t scale ;o)

To start that journey, many of us focus on the WHAT first .. the clinical

content… which usually closely relates to the clinical process.

One other nugget is that typical business process analysis/management (eg

BPMN) usually explores a change from the Physical As-Is … to Physical

To-Be.

If you look at healthcare with those eyes you see a dizzying variety of

process.

What is missing is the fractal patterns of generic/logical clinical process

that underpin the breadth of healthcare…

So whats needed to make sense of this space is a generic/logical modelling

layer is needed in the middle…

Physical As Is

+Logical As Is

+Logical To Be

Physical To Be

That search for logical/generic clinical process support led me to openEHR,

which has 4 core/generic process-oriented classes (Observation, Evaluation,

Instruction & Action) which is why openEHR imho is the critical foundation

layer we are currently building out… the more fanciful/sophisticated

“pathway” support can come later…

More related writings here..

http://frectal.com/book/healthcare-change-the-way-forward/

Hope that helps>hinders.

Tony

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adrian.wilkins

March 8My background is a medical degree, a short spell in the clinical trenches, and 17 years experience in healthcare IT on both private and public sides of the fence. I’ve been hearing the noun “pathway” throughout those 17 years but have yet to see a compelling implementation…

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34

Hi Adam,

No, definitely not. The focus is very definitely on the clinical document, whether that is inside a system, or the payload transferred between systems. We would expect other technologies to handle the layer you described, though some clinically/patient relevant acknowledgements might also need to appear in the patient record e.g. Referral received, lab test request received.

35

As a Community Dentist (read dentist for people living with complex medical conditions/disabilities) my clinical practice is governed by my ability to adapt and flex…to get a job done (eg absess on tooth requires extraction of a tooth for an older person with memory loss and several significant comorbidities).

@adrian.wilkins - I like your idea [quote=“adrian.wilkins, post:28, topic:162”]
What users need to do their job is tools to accomplish the tasks they need to get done.
[/quote]

When work clinically, most of my clinical procedures are standard but it is the patients medical/care needs that are infinitely variable and require me to be flexible

@pacharanero - I would agree [quote=“pacharanero, post:11, topic:162”]
I think @adrian.wilkins is onto something with making the distinction between ‘imperative’ process mapping - where you map a pathway in terms of a fixed series of things that happen in a fixed order, and ‘declarative’ process mapping, in which you state the end point you want, and let the system figure out what needs to be done to get you there.
[/quote]

Because my patients have such varied disabilities and co-morbidities I have found the best approach to planning care is to ask the patient what ‘end point’ they want (and if the patient doesn’t have capacity I work with those caring for that person to allow me to make that decision in their best interest). I then work back from that end point…delivering bits of care (in a flexible way) to get to that end point.

I often feel “at the edge of chaos” @tony.shannon its part of my job and its also I think why ALL of the current dental systems fail to support community dentistry.

36

Thanks Ian, that is the clarification I was inarticulately seeking in my question last week. :thumbsup:
The payload is definitely where I see this stuff in an inter-system messaging context.

37

hi marcus,

the nhs is gr8 at managing clinical data, it is a world leader

with regard to PATIENT admin data it may still be a world leader, but it is certainly not gr8, quiet the opposite

it is the efficient management of PATIENT admin data which will lead to significant cost savings4nhs, releasing money

to be spent on providing better care

nhs managers are not as bright (or strong? tbc) as clinciains and that is why historically the above has come about

PATIENT pathways can cope with operational, financial and clinicial indicators

...

do you know if there is any visualisation (or other easy to understand documentation) of the data model that you and you and others are working with?

do you know if there is an easy way to upload and share documents to this chatter site?

clive

On 08 March 2016 at 10:58 Marcus Baw <discourse-system@openhealthhub.org> wrote:

pacharaneroOpen Health Hub Founder

March 8

I think @adrian.wilkins is onto something with making the distinction between 'imperative' process mapping - where you map a pathway in terms of a fixed series of things that happen in a fixed order, and 'declarative' process mapping, in which you state the end point you want, and let the system figure out what needs to be done to get you there.

The difference is, that if I am being declarative, and I say the 'end point' of this stage of treatment is to get the patient to their first cancer MDT, then I just state 'get them to MDT'.

The system knows that before they can go to MDT, the patient will need

  • to have had a CT scan, and the results back
  • to have had blood tests, and the results back
  • booking for MDT made
  • transport booking

And it will arrange these with the appropriate intervals.

It has several advantages in that it allows for complete concurrency of the tasks, and if a new pre-MDT requirement is added, this is easy to add and doesn't require re-mapping of the process to find out where the new bit fits in.

It also probably encourages us to think of "small, reusable units of process" rather than heroically trying to map the entirety of cancer care onto one great big BPMN chart.

We need a domain specific language for declarative care planning. @adrian.wilkins - up for it?

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38

Hi

Re care planning I have been working for some time as a spare time project on a prototype for care planning (mainly for mental health but the principles are transferable our physios are very interested) this is based around the care process (assessment, planning, implementation, evaluation) so it ties together a number of functions and tries to replicate a care plan as we feel it should exist in the real world and incorporate things like integrated care plans, decision support and exception recording.

[cid:image002.jpg@01D17AB4.8ED08FF0]

This is no more than a functioning GUI, no current data model behind it so it really is no more than an example and needs an awful lot of work. I built this using JQueryUI and grab the care items from XML documents according to the formulation that falls out of the assessment.

When you mention a domain specific language for declarative care planning, would you be thinking about this for the data model or something for the GUI (or something else?)

Many Thanks
John

image002.jpg811×456 50.3 KB

39

My wife described pathways to me last night and I understood her!

It sounded quite like this care process you mentioned, which creates a care plan possibly from a template/pre defined CarePlan. Your screen shots are pretty similar to FHIR CarePlan CarePlan - FHIR v5.0.0

Am I using the wrong terminology? Can I replace some of this with pathway

40

please do not use the term pathway, without being more specific, it's just waffle, are you talking PATIENT pathways or what?

On 10 March 2016 at 10:49 "mayfield.g.kev" <discourse-system@openhealthhub.org> wrote:

mayfield.g.kev

March 10

john.salter:

care process (assessment, planning, implementation, evaluation)

My wife described pathways to me last night and I understood her!

It sounded quite like this care process you mentioned, which creates a care plan possibly from a template/pre defined CarePlan. Your screen shots are pretty similar to FHIR CarePlan https://www.hl7.org/fhir/careplan.html

Am I using the wrong terminology? Can I replace some of this with pathway

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In Reply To

john.salter

March 10Hi Re care planning I have been working for some time as a spare time project on a prototype for care planning (mainly for mental health but the principles are transferable our physios are very interested) this is based around the care process (assessment, planning, implementation, evaluation) so …

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