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3rd Generation Hospital Information
Systems (HIS)
From Information Processing to
Workflow Management
13-May-2014
Dr. Siegfried Bocionek
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©2014 Siegfried Bocionek, 13-May-2014
Content
2
n Motivation
n Design goals for modern Hospital Information Systems
n Functionality
n Technology basis and System Architecture
n Where is this all going ?
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©2014 Siegfried Bocionek, 13-May-2014
Solve the “Management Equation” of all
Industries: Do more with less …
Quality
of Care
By
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3
Cost
of Care
Innovation
§ Process optimization
§
©2014 Siegfried Bocionek, 13-May-2014
Re-engineering of Healthcare Processes
Physician
Order
Administration
Documented
Medication
Administered
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Chart copy
sent to
Pharmacy
Nurse
Review
MAR
Transcription
Medication Errors in the U.S.*:
Ordering
Transcription
Dispensing
Administration
Nurse confirms drug,
dose, route, time, patient
Medication
Dispensed
Order Entry
(Rx System)
Pharmacist
Verification
* Data of 2001
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©2014 Siegfried Bocionek, 13-May-2014
Optimized Medication Management
Physician
Order
Administration
Documented
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Process simplification to reduce
medication errors. With COE*,
barcodes, and an automated
dispenser robot system.
And all data available for later
evaluation.
Nurse confirms drug,
dose, route, time, patient
Pharmacist
Verification
Medication
Dispensed
* COE = Computerized Order Entry
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©2014 Siegfried Bocionek, 13-May-2014
Positive Impact* of Clinician Order Entry on costs,
quality and compliance (examples)
Medication turn around time
(Order entry to Med. Admin.)
Lenght of stay (e.g. renal transplant)
-21%
-66%
100%
6
100%
79%
34%
Conv.
Costs
Efficiency
COE
Conv.
Verbal orders/Co-signature
COE
Total transcription
errors
Costs
+44%
-100%
99%
26%
55%
Conv. / COE / cosigned
cosigned
Safety
Conv.
0%
COE
*Efficiency study; OHIO State University Health System
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©2014 Siegfried Bocionek, 13-May-2014
Target: ALL Business Processes in Healthcare
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Modalities
Payor
connectivity schedule
EDI Billing
Physician
connectivity
Pract. Mgmt
Patient
connectivity
Homecare
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Diagnostic Cycles Rad,Card
Lab xIS, Lab, Rx
RIS, CIS,
ADT
ECG
POE
...
Therapeutic Cycles
Enterprise HIS
Surgery, Oncology, …
Clinical Cycle
Admin Cycle
ICU
document
Ward
ADT
bill
...
Care Cycles
Modalities
Monitors
©2014 Siegfried Bocionek, 13-May-2014
Content
8
n Motivation
n Design goals for modern Hospital Information Systems
n Functionality
n Technology basis and System Architecture
n Where is this all going ?
Page 8
©2014 Siegfried Bocionek, 13-May-2014
Target: ALL Business Processes in Healthcare
9
Modalities
Diagnostic
Cycles Rad,Card
Design
Goals:
Payor
Lab xIS, Lab, Rx
connectivity schedule- Workflow Automation
RIS, CIS,
ADT
ECG
Performance
Optimization
POE
EDI Billing
...
Physician
connectivity
Pract. Mgmt
Patient
connectivity
Homecare
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- Workplace Ergonomics
-Enterprise
System Integration
HIS
- Quality á, Cost â
Clinical Cycle
Admin Cycle
ICU
document
Ward
ADT
bill
...
Care Cycles
Therapeutic Cycles
Surgery, Oncology, …
Modalities
Monitors
©2014 Siegfried Bocionek, 13-May-2014
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Workflow Automation
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©2014 Siegfried Bocionek, 13-May-2014
Patient Management Example:
Bed Turnaround Process
7
Pharm
notified
6
Pharm
fills d/c
Rx's
2
Nurse
notified
8
Dietary
notified
11
9
Resp
notified
11
Patient
education
3
Nurse
review
orders
5
Family
notified
4
Nurse d/c
process
12
Transport
notified
13
Pt out of
room
10
Family
arrives
Patient
Discharge
1
Hospital
Discharge
Order
Room
refresh
Room
assignment
17
Room
queued
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Housekeeping
advised
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Nursing
supervisor
notified
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Housekeeping
notified
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Nurse
assigned
16
Room
cleaned
20
Notify
admitting
Handoffs
Bed turnaround
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Notify ER
©2014 Siegfried Bocionek, 13-May-2014
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Bed Turnaround Process: Modeled with workflow tool
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©2014 Siegfried Bocionek, 13-May-2014
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Workflow Management System automatically triggers tasks:
- Complete Final Diagnosis for Mr. Voss
- Start Discharge Summary
- Inform pharmacy to package discharge medication
- Trigger nurse to prepare patient for going home, call relatives
- Inform housekeeping to clean room and turnover bed
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©2014 Siegfried Bocionek, 13-May-2014
Clinical Example: Microbiology Responsiveness
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n Prolonged antibiotic / sensitivity mismatch
w Resistance emergence
w Higher morbidity
w Higher costs
n Failure to react to resistant strains
w Nosocomial infections
w Plasmid transference
w MRSA
§ 10% mortality
§ $31,000 avg. case cost
n Sequential multi-departmental process
MRSA = Multi-Resistent Staphylococcus Aureus (Krankenhauskeim)
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©2014 Siegfried Bocionek, 13-May-2014
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Objective: automatically trigger isolation
©2014 Siegfried
13-May-2014
measures in case of MRSA
or Bocionek,
VRE suspicion
Case Study with US Clinic:
Predicted Clinical Benefits
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©2014 Siegfried Bocionek, 13-May-2014
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Workplace Ergonomics
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©2014 Siegfried Bocionek, 13-May-2014
Multi-Workstation or Multi-Work Station?
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©2014 Siegfried Bocionek, 13-May-2014
Workplace integration, easy access
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Biometric
Identification
Desktop Integration
Web Access Everywhere
Patterson,
Patterson, Maria L. Date of Birth: 02/06/1932
Mobility
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©2014 Siegfried Bocionek, 13-May-2014
Smart User Interface
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n Browser Based
w Universal Access
w Basis for Integration
w Easy Deployment
n Graphical Design
w Intuitive
w Easy to Use
w Consistent
n Process Efficiency
w Workflow based screens
w Actionable
n Contextual
w Provider
w Task
w Patient
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©2014 Siegfried Bocionek, 13-May-2014
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System Integration
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©2014 Siegfried Bocionek, 13-May-2014
Knowledge based Clinical Process Automation
Level Of Knowledge
Aggregation
Optimized Processes
Best Practices
Repository
Care Plans
Smart Orders
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Process Design
& Automation
Guidelines,
Pathways
Advanced
Clinical Decision
Support
Rules Engine
Order Sets
Normalized
content
Integrated
Infrastructure
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©2014 Siegfried Bocionek, 13-May-2014
Content
23
n Motivation
n Design goals for modern Hospital Information Systems
n Functionality
n Technology basis and System Architecture
n Where is this all going ?
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©2014 Siegfried Bocionek, 13-May-2014
High-level Application Structure of a modern HIS
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Connectivity to
Devices and networks
External Solutions
Enterprise
Scheduling
Image Access
Revenue
Management
Care Management
Global Registration
Common WorkflowWorkflow-Based Web UI
Service & Object-Oriented Application Architecture
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©2014 Siegfried Bocionek, 13-May-2014
Workflow Automation: Example “Alerts in Worklists”
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Alerts
critical notifications
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©2014 Siegfried Bocionek, 13-May-2014
- Workflow = Coordinated Activities
- Step = Worklist Item = Activity
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Available
step
Actions
STEP
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©2014 Siegfried Bocionek, 13-May-2014
WfMS items are presented on work lists
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Notification/Alert
(at discharge)
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©2014 Siegfried Bocionek, 13-May-2014
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©2014 Siegfried Bocionek, 13-May-2014
Nurse is Alerted to decide on Action
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©2014 Siegfried Bocionek, 13-May-2014
Doctor is Alerted to decide on Order
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Action
(consider
discontinue
Filgrastim)
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©2014 Siegfried Bocionek, 13-May-2014
Further examples of Automated Workflows
(Hospitals are starting to exchange their WF models)
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©2014 Siegfried Bocionek, 13-May-2014
Content
32
n Motivation
n Design goals for modern Hospital Information Systems
n Functionality
n Technology basis and System Architecture
n Where is this all going ?
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©2014 Siegfried Bocionek, 13-May-2014
Basis: Multi-tier Web architecture
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Web Client
Web Server
Presentation Tier
Event Manager
Financial
Workflow
Image
Mgmt
Lifetime
Record
Patient
Mgmt
Clinical
Workflow
Schedling
App Server
EMPI
Application Tier
DB Server
Database Tier
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©2014 Siegfried Bocionek, 13-May-2014
Typical Server Configuration (can be virtualized, e.g. on
mainframe, for hosted services or Clouds)
Web Clients
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Integration Engine
External
Systems
Web Servers
Application
Server Farm
Output
Management
Server
Multi-entity
Database Servers
(SAN, NAS)
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©2014 Siegfried Bocionek, 13-May-2014
Integration Engine helps Define Migration Paths
à Interfacing via HL7, DICOM
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EPR = Electronic Patient Record
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©2014 Siegfried Bocionek, 13-May-2014
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Example: Cardiologist Exam Workstation
Cath Network
Cath Reports
Cath Data
Cath Lab
Echo Reports
Echo Data
Echo
Rest EKG
EKG Mgmnt
System
Cardiology
workplace
EKG Reports
EKG Data
EP Reports
EP Data
EP Lab
Stress Lab
Lab Results
Registration
Tracings
Nuclear Reports
Nuclear Data
Nuclear and Post-processing
Cardiovascular Surgery
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©2014 Siegfried Bocionek, 13-May-2014
Single Sign-on, Security, Context Sharing
(via General Session Manager)
Bla bla bla
ECG
Bla
Bla bla
bla bla
bla
Hemo
Bla bla bla
Images
Bla bla bla
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Web-based
Integrated Cardiac
Exam Workplace
Cardiac Exam
ECG
Server
HL7 - DICOM
HIS
Servers
Imaging
workstation
GSM/Context Mgmt. Server
Authentication / Authorization
HIS
Database
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DICOM
PACS
Archive
PACS/RIS
workstation
©2014 Siegfried Bocionek, 13-May-2014
Integration of a Workflow Engine
Workspace Manager
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External Communication
Engine
(Common UI Framework)
MXS*
Service Broker
MXS*
Messaging API
Event Manager
Common Healthcare Objects
Database
Tier
Event Management
Statistics & Research
Common
Tools
Medication
Rules
Engine
Order & Results
Invision LCR
Activity Handling
Schedling
ADT
Patient
Financials
Elect. Medical Record
Business Layer
Clinical Documentation
Clinicals
Worklist
Predefined Clinical Documents
Security Management
Persistence Framework
Document Management
Data Versioning
* MXS = Message Exchange Services
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©2014 Siegfried Bocionek, 13-May-2014
Rules Engine and Workflow Engine
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©2014 Siegfried Bocionek, 13-May-2014
Difference Rules Engine – WF Engine
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n Rules Engine
w Has no process context
w Cannot readily synchronize parallel paths
w Cannot visualize process flows
w Would need many complex rules to implement workflows
w “rule + rule + rule = mess”
w Is simply the wrong tool for the job
n BETTER: Use rule as step in a workflow
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©2014 Siegfried Bocionek, 13-May-2014
Rules can be utilized for decisions & branching within the41
workflow definitions - Example: Stroke Management
order CT service in RIS
Condition can be evaluated by the Rules Engine
TPA = Tissue plasminogen activator
CVA = Cerebrovascular Accident (Stroke)
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©2014 Siegfried Bocionek, 13-May-2014
Typical Trigger Events for the WfMS
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n Save Patient Registration
n Chart an Assessment
n Save New Patient
n Receive a Result
Registration
n Receive a Patient
Registration
n Save Visit Information
n Save New Visit Information
n Save a Result
n Select a Service
n Administer a Med
n Sign an Order
n Patient Transfer
n Patient Discharge
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©2014 Siegfried Bocionek, 13-May-2014
Typical Actions
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n Merge Patient Records
n Discontinue an Order
n Move Patient Visit
n Enter a Comment
n Display Results
n Link to a URL
n View Visit Overview
n Trigger a Workflow
n Route/Print Report
n Enter an alert or
n Place an Order
n Sign an Order
n Display Result Detail
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notification
n Initiate an A28 Transaction
n Display a Form
©2014 Siegfried Bocionek, 13-May-2014
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Technical Design Considerations
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©2014 Siegfried Bocionek, 13-May-2014
Design Considerations: Scalability and Portability
45
· A typical HIS needs to be embedded in IT infrastructure
· Connectivity to ERP system
· Interoperability with legacy systems
· Utilize available campus licenses (OS, DB, others)
· Various operational models (in-house, outsourced, remote/cloud)
· Scalability depends on customer specifics
· From small country hospital to 100+ hospitals chain
· National healthcare systems
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©2014 Siegfried Bocionek, 13-May-2014
Performance Targets
Scalability
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· Fast access for up to
20.000 users (sub sec
response time)
Portability
· Choice (HW, OS, DB)
· Easy migration from
legacy systems
Costs
Compatibility
· Easy to extend / update
· High availability > 99.99%
· Connectivity to other
applications
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©2014 Siegfried Bocionek, 13-May-2014
Need: Support all Standard Technologies
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Web Server
OpenSource / Apache
MS IIS
Scalability App Server
OpenSource / TomCat
COM+/.NET
Middleware
WebSphere
Other JEE
None
.NET
Portability
DB
DB2 / UDB
Oracle
OS
OS390
Linux
Hardware
IBM390
RS6000
SEQEL
Costs
AIX Solaris OS400
WIN
Compatibility
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SUN
AX400
INTEL
©2014 Siegfried Bocionek, 13-May-2014
JEE middleware good candidate for application
architecture
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messaging Service Layer (SOA) Web Services
SVCS
CAE
Façade
Façade
Façade
EJB
EJB
EJB
Business Logic
Transactions
Mail
Security
Directory
Workflow
Engine
Messaging Connectors
Database
XML
JEE Platform
DB Server
(Sequel,
Oracle, DB2)
e.g. IBM Websphere
Security
Auditing
Messaging
Logging
Common Components
Operating System (Unix, Windows, Mainframe)
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©2014 Siegfried Bocionek, 13-May-2014
Enterprise Architecture - Infrastructure (Example)
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©2014 Siegfried Bocionek, 13-May-2014
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Enterprise Architecture – Enterprise Integration (Example)
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©2014 Siegfried Bocionek, 13-May-2014
Cloud Configurations (formerly data centers J)
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Web
Clients
Firewall
Web
Servers
Firewall
Application
Server
DB
Server
Legacy Layer
Intranet
Client
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©2014 Siegfried Bocionek, 13-May-2014
Design for Scale Example (~ 2004):
Hongkong Health Surveillance Concept (SARS)
External
Organizations
Workflow Process Efficiency / Effectiveness, Risk & Outcomes
Report Generation
Report Dissemination
Data
Filter
Data
Transform
Web Publishing
Email Notification
Trending – Analytical– Real Time
Risk & Outcomes
• World Health
Internal to
Organization
•
•
•
Automated Analysis
•
•
Health Surveillance Data Repository
Real Scale
- 44 hospitals
- 27,000 beds
Data
Capture
Data
Filter
Data
Transform
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Organization
Cancer Registries
Specialty Societies
Chronic Disease
Surveys
Injury Reporting
Behavioral Risk
Factor Reporting
Firewall:
De-identification as needed;
Re-identification on return
Health
Surveillance
Engine
Health
Surveillance Engine
Data Requirements
Collection– Entry – Editing - Storage
Clinical
CMS
Information
System
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Medical
Groups
Elderly
Homes
Private
Physicians
External Data Sources
©2014 Siegfried Bocionek, 13-May-2014
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Elderly
Homes
Private
Physicians
Medical
Groups
Templates
• SARS-specific reporting
• Other communicable
disease reporting
Laboratory Results
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
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Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
©2014 Siegfried Bocionek, 13-May-2014
Content
54
n Motivation
n Design goals for modern Hospital Information Systems
n Functionality
n Technology basis and System Architecture
n Where is this all going ?
Page 54
©2014 Siegfried Bocionek, 13-May-2014
All brought together in a Digital Hospital
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Information Technology
Medical
Infrastructure
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©2014 Siegfried Bocionek, 13-May-2014
Patients Connected to the Hospital
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n Small portabel (holter) ECGs
n Multi parameter recordes
n "Telecare" by video
n "Measure & enter“ devices
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©2014 Siegfried Bocionek, 13-May-2014
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With WebCam
connection of
the patient to the
family at home ...
and vice versa ...
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©2014 Siegfried Bocionek, 13-May-2014
A Place, Patients Will Love To Stay ...
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With Internet
connection, VoIP*
and EoIP** stuff
in every room ...
* VoIP = Voice over IP
** EoIP = Entertainment over IP
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©2014 Siegfried Bocionek, 13-May-2014
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Thank you very much for your attention
Siegfried Bocionek, Martin Dugas: Hospital Information Systems
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©2014 Siegfried Bocionek, 13-May-2014