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Transcript of Optimising workflow & business processes in the delivery of seamless care to older people Isobel...
Optimising workflow & business processes in the
delivery of seamless care to older people
Isobel Frean
HL7 UK
October 2006
Outline
Background / ContextResearch aims / methodologyAnalysis of requirements
• Communication intensive • Instant communication needs• Challenges in accessing care
Options for improving workflow
BackgroundResearch funded under an Australian
Research Council Linkage Grant at the University of Wollongong, NSW
Industry Partners:• Southern Cross Services NSW & ACT• Our Lady of Consolation Aged Care• Illawarra Retirement Trust
ContextAustralia is actively formulating strategies to
increase adoption of ICT by providers of aged care
Drivers for this technological change:• Population ageing reforms• Concerns about quality & safety of healthcare• Global strategies encouraging governments to
transform the way they do business
Context – sample of activities
National documentation framework for residential aged care
Clinical IT in aged care project – 3 years e-Commerce – electronic claims Aged care e-Connect – electronic forms IT Road shows – in partnership with aged
care providers – 2 years HISA national aged care informatics
conference – 3 years
ContextDespite the increased emphasis on
population ageing reforms - there had been no or at best tokenistic inclusion of the substantial non-government sector of aged care providers in e-Government agendas
‘IT projects’ were taking place within a strategy void
National strategy had been on the agenda since 2000
Research aimTo examine the drivers for technological
change in aged careTo document the communication
requirements of a representative sample of aged care providers
To describe a hierarchical structure of standards to support these communication requirements
Identify the policy implications for a national information technology strategic plan for aged care
MethodologyHL7 3 Development Framework (HDF) Supplemented by use of a Delphi approach to
capture requirements from domain experts Active participation in HL7 Patient Care TC
& Community Based Health Services SIGUse of Standards Australia / HealthConnect
messaging standards hierarchy model
HDF
1. Project initiation (business vision)
2. Requirements documentation & analysis
3. Specification modelling
4. Specification documentation
5. Specification approval
6. Specification publication
7. Implementation profiling
Dual consultationDelphi approach was applied to each of two
separate groups of domain experts: • Business vision group - Industry Partner senior
management• Use case group – Industry Partner line staff
Domain expert involvement Conducted Sept 2003 – Oct 2004Business vision focus groups
• 20 participantsUse case focus groups (44 participants)
• Round 1 = 44 participants• Round 2 = 53 participants• Round 3 = 20 organisations (117 questionnaires)
Business visionElectronic processing of eligibility
requirements Messaging within the multidisciplinary care
teamAhead-of-time (not just-in-time) exchange of
discharge referrals Electronic processing of financial claims Ability to express care requirements in
holistic terms
Summary of requirements gathering
Round 2 use cases were streamlined from 66 to 55
82 storyboards were developedThese were structured according to one of
four core business processes:• Accessing Services• Clinician Liaison• Coordination of Care• Funding Services
Packaged into 4 booklets
Summary of requirements gathering
117 booklets were sent to each of the 3 Industry Partner & 17 non-Industry Partner organisations
Domain experts were asked to review & rate the feasibility of the storyboards & to add their own comments
33 individuals returned 45 the feedback sheets - 38% response rate
Accounts Management Clinician Liaison
0%
10%
20%
30%
40%
50%
60%
70%
Percentage responses
Accounts Management Accessing Services Clinician Liaison Coordinating ServicesBusiness Process Category
Strongly Agree Agree Don't know Disagree Strongly Disagree
Accessing Services
Coordinating Services
Strongly Agree
Agree
Don’t Know
Disagree
Strongly Disagree
Round 3 feedback
Outline
Background / ContextResearch aims / methodologyAnalysis of requirements
• Communication intensive • Instant communication needs• Challenges in accessing care
Options for improving workflow
Summary of requirements analysis
Storyboards (82) were short listed to 29 9 published in HL7 V3 Patient Care ballot122 message flows analyzed Duplicate interactions were removed to
arrive at a core set of domain concepts-of-interest & an understanding of their static inter-relationships to each other
Domain analysis model (DAM) model developed – UML class diagram
Interaction tables
1. Sender2. Receiver3. Interaction type (eg Care Transfer Request)4. Action5. Trigger Event6. AR sender / AR receiver7. Data content8. Clinical domain9. Current form of communication (phone)10. Likely future form (message, CDA)11. Expected reaction by receiver12. Message category (eg Care Transfer Query)
DAMDAM provided an intuitive visual model
for the structure of the aged care business processes that were the subject of this research
Took 10 iterations to developConcepts of interest revolved around the
act class – derived from several V3 domain standards
Revealed the complexities in accessing aged care
Aged Care DAM
Aged Care Domain Use Cases
DAM walkthroughActs fell into four themes
• Care Transfer• Care Delivery• Care Coordination• Financial Management
Each theme describes the series of acts relevant to stakeholders accessing & providing care to older people in non-acute aged care sector in Australia (residential or community)
Care Transfer themeContains acts associated with the process of
referring a client for care i.e. transfer of responsibility for a condition or need - ‘Condition Transfer’
As well as more the complex process of referring a client to a service to secure a place (community) or a bed (residential) – i.e. transfer of responsibility from one care setting to another -‘Service Transfer’
Care Transfer themeKey acts at the entry to the workflow which
distinguish the ‘aged care’ DAM from a care provision DAM:• ReferralForAgedCare• DecisionToAdmit
ReferralForAgedCare is the gateway act for all activities associated with Condition Transfers – linked to CareProvision act
It is also the gateway act for describing Service Transfers – linked to DecisonToAdmit act
Business processes identified in Aged Care DAM
Service Transfer Request & Promise messages
DecisionToAdmit act
Multiple associations reflect the complex workflow activities involved in determining:• What services need to be provided • Whether they could be provided• Whether to offer to provide services
Care Transfer theme: acts
ReferralForAgedCare EligibilityCriteria ServiceAgreement Notification
ApplicationDocumentation
WaitingList AdmissionEncounter DecisionToAdmit
Service Transfer Topic: interactions
25 interactions for a proposed Service Transfer topic have been identified to satisfy aged care business requirements associated with applying for & securing an aged care service
None currently exist but are based on existing Care Provision & PA domain interactions
They fall into three groups using a new Service Transfer structured name:• Service Request messages• Query messages (to support Waiting List queries)• Event-based messages or structured documents
containing the ‘application’ details – CDA = Contract Document Architecture
Interactions associated with requesting a place in a service
Service Transfer Request + Revise
Notify Service Transfer Request + Revise
Reject Service Transfer
Service Transfer Promise
Notify Service Transfer Promise
Confirmation Complete
Abort Service Transfer Request + Notify Abort
Notify Aborted Service Transfer Request)
Query Specification Requests
Waiting List Query + Response
Interactions associated with application forms and records Service Application Record Event Activate/Revise/Complete etc
Service Application Record Event Query, Request, Response etc
Options for improving workflow
Vacancy management systems (VMS) • Requires each service provider or third party
VMS provider to maintain vacancy and ‘waiting list’ registries
• Portal &/or message based• Needs to ‘think local’ but have capability for
acting ‘globally’• Could simply streamline the vacancy sourcing
or it could handle complete service transfer workflow
Options for improving workflow
Standardised documentation at each stage of the workflow (sample):• What services do you provide?• Do you have a place?• What are you looking for?• How much does it cost?• Please provide ‘us’ some information • This is what we can offer you• I confirm my intention to take up the offer
Options for improving workflow
Cautionary note: Solutions need to address the universal challenge
of ensuring that each service user (particularly in residential care) has a GP
VMS may have to include a GP commissioning component – a reverse CAB!
Or aged care providers will need to assume responsibility for medical care of their clients (either by employing GPs or Advanced Practice Nurses) – needs a different reimbursement model
Conclusion
The process of applying for & securing a suitable aged care service is communication intensive
A scalable vacancy management & electronic application process has been proposed
Relies upon a message and document set that differentiates a ‘service’ from a ‘condition’ transfer request
Service Transfer Topic design specifications belong in either:• Care Provision domain (preference)
• Patient Administration
Next StepsFeed findings into:
• Aged care sector peak bodies & relevant government agencies (Australian Department of Health & Aged Care)
– National ICT Strategy for Aged Care
• Relevant standards bodies in Australia & UK • HL7 Technical Committees
Thank you
Isobel FreanFaculty of InformaticsUniversity of Wollongong, [email protected]: +44 1753 112 999