Optimising workflow & business processes in the

delivery of seamless care to older people

Isobel FreanHL7 UK

October 2006

OutlineBackground / 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

HDF1. Project initiation (business vision)2. Requirements documentation & analysis3. Specification modelling4. Specification documentation5. Specification approval6. Specification publication7. 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

OutlineBackground / 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 tables1. 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 actMultiple 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 + ReviseNotify Service Transfer Request + ReviseReject Service TransferService Transfer PromiseNotify Service Transfer PromiseConfirmation CompleteAbort Service Transfer Request + Notify AbortNotify Aborted Service Transfer Request)Query Specification RequestsWaiting List Query + Response

Interactions associated with application forms and records Service Application Record Event Activate/Revise/Complete etcService 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, Australiafreani@bupa.comTel: +44 1753 112 999