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 PhD
Harm Scherpbier, MD, MS

AMIA 2012, Tutorial (3hrs)

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 URL
http://www.slideshare.net/vojtech_huser/presentations
 Accompanying bibliography and other files
http://code.google.com/p/healthflow/downloads/list

2
Vojtech Huser, Harm Scherpbier: workflow tutorial

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) 3

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

4

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

5

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

6

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

7

Software
 Download the following software:

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

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

8

Part 1: Introduction to workflow technology
 prior 1960s-1980s
generic IT system
technology tools
 Workflow Technology applied industries and healthcare

10

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

11

Process Example

Koetter (2007)

12

13

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.

14

15

 prior 1960s-1980s
generic IT system
technology tools

16

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 17

18

19

20

 prior 1960s-1980s
 Components of workflow technology (process
definition, execution engine, analytical components)
generic IT system
technology tools

22

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

23

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

24

Humans & machines working together

27

Executable flowchart

28

Minimum components
editor
language

execution engine

30

 prior 1960s-1980s
 Benefits of implementing a workflow server within
a generic IT system
technology tools

32

WT benefits
 Non-programmers understand processes
 Non-programmers can modify processes
 Analytical tools
 Faster IT system development (SOA+WT)

33

 prior 1960s-1980s
generic IT system
 Major workflow vendors and open-source
workflow technology tools

34

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

35

36

37

38

39

40

Workflow engine

41

Engine

42

 prior 1960s-1980s
generic IT system
technology tools
 Workflow Technology applied industries and
healthcare

43

Use of WT
 Pioneer domains
 Banking
 Manufacturing
 Shipping
 Government authorities
 Pharmaceutical
 Healthcare
 Gartner 2008 report: <5% use

44

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 45

Process Definition
 A process is:
 Multiple steps…
 For multiple people…
 Over time…
 To achieve a goal.

46

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

50

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

55

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

Randomization
Study/Control

Automate Study
Protocol

Collect Data

Clinical Trial Management
 Goal: Identify Candidates for Clinical Trials, and Track
Enrolled Patients
 Implement Protocols – including randomization

Heparin Alert Utilization for Sept. 2011 thru Jan. 2012
Percent Alert Utilization Per Site

100
90
75 
80 74
69 68 67 71 67
70 61 64 60 61
60 54 54 September
October
50 November
37 December
40 January
30
17
20
10
0
LMC BMH PH Volume of Alerts Per Site

300

234

200 187
171 173 September
October
143 November
113 December
January
100 87
69 73
55 50
35 38
24 15
0
LMC BMH PH

Workflow Engine vs. Rules
Engine
Workflow Engine with Rules Engine Rules Engine
 Process Automation / Business  Rule-based Clinical Decision
Process Management Support

 Multiple steps, over time, for  Single decision point for single
multiple users user
 State-aware: keeps track of point
in time and waits (listens) for  Not State-aware – runs at trigger
next event to happen event
 Asynchronous
 Plug-in services (EAI)  Synchronous
 Graphical programming

 prior 1960s-1980s
generic IT system
technology tools

63

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

64

Workflow patterns

http://
workflowpatterns.com/

65

Adaptive workflow

66

theories
standards
 XML process definition language (XPDL)

68

theories
standards

69

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

…

70

theories
standards

71

72

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
73

theories
standards

74

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
75

Standards Timeline

76

Example.xpdl

77

Process Schema

78

Activities

79

theories
standards

80

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

81

Standards trending

82

theories
standards
 Petri Nets theory and its relationship to
workflows

83

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)

p1 t1 p2
84

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

85

86

Petri Net for Math lovers

87

Part 3 - DEMOS

88

HS Demo (30 min)
 Editor and EMR portions
 Activy example
 Basic editing
 Roundtrip between editor and EMR
(changes)
 MLM logic vs. flowchart logic

89

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

91

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

92

93

94

More CDS examples
Workflow mining tour

Vojtech Huser, Harm Scherpbier:
workflow tutorial 95

Log schema

96

97

98

99

100

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
101

Editor live demo

Vojtech Huser, Harm Scherpbier:
workflow tutorial 102

Part 4: Conclusion

103

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

104

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)
105

Healthcare is different
 Current workflow standards
 YAWL
 Current workflow vendors implementations

 Complexity of medicine

106

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

107

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

108

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

109
Vojtech Huser, MD, PhD

Mulyar at al (2007)
110

GLIF
guideline

111

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/

112

Splitting the CDS representation format

113

 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; 114
    if

115

Approach comparison

116

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

117

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

118

Harm Sherpbier’s conclusion

119

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

120

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
121

Platform for outsourced knowledge
 Currently: managing decision rules
internally, linked into the workflows
 Future: opportunity to call outside
knowledge sources
 HL7 DSS, OpenCDS standards

122

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…

123

Questions ?

 Covered topics
 Introduction to workflow technology
 WT standards

Examples

WT and healthcare
 Contact us
 vojtech.huser at nih.gov

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