tutorial: amia now conference: introduction to workflow technology: representation of healthcare...

Introduction to workflow technology Representation of healthcare

processes in a workflow editor and their execution in a workflow engine

Vojtech Huser MD PhD

AMIA NOW, Small Group session, Tutorial (1hr)

Vojtech Huser, MD, PhDVojtech Huser, MD, PhD

Agenda Part 1: Introduction, history, overview Part 2: Standards, SDO, related

theories Part 3: Practical tools demonstration

Originally 2 hour workshop converted to 1 hour tutorial (with focus on introduction and

standards) Accompanying bibliography document

Part 1: Introduction to workflow technology

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

Workflow Technology applied industries and healthcare

Future development and research challenges

Part 2: WT standards, SDOs, related theories

Workflow management coalition’s (WfMC) standards

Definition of WT terms XML process definition language (XPDL) 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

Part 3: Practical tools demos Demo of an editor and engine Example 1:

Representing a surgical procedure, discharge and RCT trial enrolment process

Example 2: Two rheumatology decision support processes (TB

screening, Pneumococcal vaccine) Process mining tool (ProM) Example 3:

Mining a progression of a chronic kidney disease from EHR data

Brief overview of other workflow technology software Case studies of use in healthcare/informatics

research Workflow engines and Decision support engines

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

Process Example

Koetter (2007)

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.

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

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

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

Humans & machines working together

Executable flowchart

Minimum componentslanguage edito

execution engine

Interfaces

WT benefits Non-programmers understand

processes Non-programmers can modify

processes Analytical tools Faster IT system development

(SOA+WT)

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

Workflow engine

Engine

Use of WT Pioneer domains

Banking Manufacturing Shipping Government authorities Pharmaceutical

Healthcare Gartner 2008 report: <5% use

Examples of WT use in healthcare

Bed managementInfections control (MRSA)

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.

Stroke guideline (WfMS)

Soarian

Current Soarian Example

Use at Marshfield Clinic

HealthFlow: RetroGuide, FlowGuide

HealthcareWorkflow.wordpress.com

EHR system

Event Listener

Notifications

Actions

Knowledge Base(workflow process

definitions)

Data Inquiry

Workflow Execution

Engine(Shark)

EHR System layer:

Prospective mode (FlowGuide):

Retrospective mode(RetroGuide):

Reports

Data Warehouse

Workflow mining(ProM)

Workflow editor(JaWE)

Data Visualization

Additional Components:

Event Data Model

Ontology Model

Host EHR Passive Interaction Model

Host EHR Active Interaction Model

Additional External Services(Terminology services, NLP services,

Statistical Analysis)

Workflow log analysis

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

Workflow patterns

http://

workflowpatterns.com/

Adaptive workflow

informationcentric

process centric

structuredprocess

unstructuredprocess

computer-supported collaborative work

ad-hoc workflow

production workflow

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

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

Definition of WT terms XML process definition language

(XPDL) Other standardization efforts

XPDL XML file based on a XSD schema

http://wfmc.org/xpdl.html First introduced in 1999 Conformance testing available

http://www.xpdl.org/Validate/ValidateXpdl

Exchange format Adoption (70+ products)

http://wfmc.org/xpdl-implementations.html

Standards Timeline

Example.xpdl

Process Schema

Activities

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

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)

Definition of Petri Net C = ( P, T, I, O)

PlacesP = { p1, p2, p3, …, pn}

TransitionsT = { t1, t2, t3, …, tn}

Input I : T Pr (r = number of places)

OutputO : T Pq (q = number of places)

Together workflow suite Editor

JaWE Together Workflow Editor (TWE) v1.4, v2, v3

Engine Shark Together Workflow Engine

(TWS) Web-based module Integration with Outlook

Log schema

Example 2: Two rheumatology decision support processes (TB screening,

Pneumococcal vaccine) Process mining tool (ProM) Example 3:

Brief overview of other workflow technology software

Case studies of use in healthcare/informatics research Workflow engines and Decision support engines

Other WT software components Editor, engine

Administration (load a process) Monitoring (exception) Analysis (bottleneck finding)

Workflow simulation Workflow mining

Use case studies Marshfield Clinic MainLine Health U of Pavia Einthoven University (NL) Chester County hospital

See bibliography for references

Mining a progression of a chronic kidney disease from EHR data Brief overview of other workflow technology software Case studies of use in healthcare/informatics research Workflow engines and Decision support engines

WT and DSS Clear overlap

Many decision support engines have workflow features Many workflow engines have decision support features

Workflow support vs. decision support What to do and when

Published case studies of use of WT for decision support

Related work Peleg at al.

Guidelines and workflow models Design Patterns of Clinical Guidelines (2010) (Bonita wf editor)

Mulyar at al. Comparison of Guidelines formalisms and workflow patterns

93Mulyar at al (2007)

GLIF guideline

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

Summary Part 1: Basic terms, history, use Part 2: Standards Part 3: Tools demonstration

Cross-industry modeling and execution platformwith growing vendor and tool base and healthcare use examples

http://healthcareworkflow.wordpress.com huser.vojtech@marshfieldclinic.org

informationcentric

process centric

structuredprocess

unstructuredprocess

computer-supported collaborative work

ad-hoc workflow

production workflow

Questions ?

http://healthcareworkflow.wordpress.com huser.vojtech@marshfieldclinic.org

WT vendors Gartner:

Standards Key standards

XPDL = XML Process Definition Language Delivered as: XSD file

BPMN = Business Process Modeling Notation Delivered as: PDF file

Key organizations Workflow Management Coalition

www.wfmc.org

Object Management Group www.omg.org (www.bpmn.org)

Other standards BPEL

Business process execution language Origins: XLANG (Microsoft) + WSFL (IBM) =

BPEL4WS Also known as WS-BPEL Efforts to link BPEL to BPMN

YAWL Yet another workflow language Research project

WfMC WfMC

OASISOASIS

BPMIBPMI

OMGOMG

Standards Timeline - Releases

WPDLWPDL

XMLXML

BPMN 1.0BPMN 1.0

XPDL 2.0XPDL 2.0 XPDL 2.1XPDL 2.1

1994 1998 2000 2001 2008 201020072006 20092004 20052002 2003

XPDL 1.0

BPMN 1.0BPMN 1.0BPMN

1.2BPMN

BPMN 1.1

BPMN 2.0

RefModel

Wf-XML-RWf-XML 1.0

Wf-XML 1.0

Wf-XML 1.1

BPEL4PeopleBPELBPEL

XPDL 3.0

GLIF guideline

Workflow editors and engines

Wofkflow software components

WT software components Core components

Editor Engine

Additional components Administration application (deplay, terminate, versioning)

Worklist handler User management (LDAP, MS, other)

Organizational roles Monitoring/Analytical application Simulation tools Worfklow mining

Interesting analyses Improving processes

Allocation of tasks Push (human decides)/pull (machine) strategy

(push to all or to one and then escalate) Earliest due date, first-in first-out Rules: (1)let a resource practice its specialty; (2) do

similar task in succession; (3) flexibility of staff (“save the generalist”)

Bottlenecks Number of cases in progress Case completion time Level of service (customers) Resource based indicators

BPR = business process re-engineering

Computer Supported Collaborative Work

Workflow mining Traditional approach

model your process, pilot, deploy

Alternative Take existing event data Mine process definition Delta analysis

Discovered process (current) vs. Human modelled process (goal, dream design)

Migration strategy

www.processmining.org

Conclusion

How does it affect my coding ? Worklow technology is coming to your desktop Code will be split into small pieces (SOA)

Manipulation / customization via flowchart CSCW vs. Structured processes WT future

similar impact to IT as database technology in 1980s Worklow enabled IT system

Ability to send and receive data to a worklow server Worklist handler rather then full system No need for designated monitoring pieces

Summary Workflow technology

Terms History Software components Theory

Future of WT Bright (IT users will require it, ipod generation) Gradual adoption Maturation of standards, software

WT here in Marshfield Phase 1: research use Phase 2: dev use within IT (provisioning, QI, CDSS) Phase 3: production use within Cattails sw

Questions / Comments

EXTRA SLIDES

Workflow / BPM Reference Model

BPEL Wf-XMLBPAF

WfMC WfMC

OASISOASIS

BPMIBPMI

OMGOMG

Standards Timeline - Releases

WPDLWPDL

XMLXML

BPMN 1.0BPMN 1.0

XPDL 2.0XPDL 2.0 XPDL 2.1XPDL 2.1

1994 1998 2000 2001 2008 201020072006 20092004 20052002 2003

XPDL 1.0

BPMN 1.0BPMN 1.0BPMN

1.2BPMN

BPMN 1.1

BPMN 2.0

RefModel

Wf-XML-RWf-XML 1.0

Wf-XML 1.0

Wf-XML 1.1

BPEL4PeopleBPELBPEL

XPDL 3.0

TimelineNovember

1998October

20021997

XPDL 1.0

October 2005

May2004

BPMN 1.0

XPDL 2.0

ReferenceModel

Glossary

19961994 2000

Wf-XML Wf-XML 2.0

XPDL Support in Market

Over 70 XPDL Implementations… Adobe –

Adobe LiveCycle Workflow ADVANTYS - WorkflowGen Amazonas Workflow Appian - Enterprise Arachnea - EverSuite Ascentn - AgilePoint Server Aspose Pty Ltd -

Aspose.Workflow BOC - ADONIS 3.7 BEA - Fuego Brein BV - InProces Bonita v2.0 Box UK - Amaxus Canto - CanFlow CapeVisions CARNOT - Process Engine CHALEX - BPM Framework ComActivity Cubetto Toolset Dessault Systems - ENOVIA Eclaire Group –

Lynx Flow Designer EMC Documentum -

ApplicationXtender Workflow

Empresa Solutions - Kinnosa Workflow

Enhydra Shark

• OpenPages• Oracle - 9i Warehouse Builder• Pentaho• Projekty Bankowe Polsoft –

BPB Workflow• Proforma Corporation - ProVision• Rodan Systems - OfficeObjects®

Workflow• Simprocess• Software AG- crossvision BPM• SpeechCycle - LevelOne• TIBCO iProcess™ Suite• Together Workflow Editor• Transware - Ambassador• Vignette –

Process Workflow Modeler• W4 - BPM Suite• WfMOpen• Workflow::Wfmc• Workflow4r• ZAPLET 3 - PROCESS BUILDER• Zynium - Byzio

• Enhydra JaWE• Finantix Studio (FXS)• Fujitsu - Interstage BPM• FileNet - Process Manager• GA Communications• Global 360 –

Business Optimzation Server• HOGA.PL• IBM - FileNet• IDS Scheer –

Business Architect• Integic –

e.POWER WorkManager• Interwoven - WorkRoute MP• Infor - SSA Baan, SSA BPCS,

SSA MANMAN, SSA• Masterpiece• ITP-Commerce –

Process Modeler Professional• IT Pearls• jawFlow• Jenz & Partner GmbH• Kaisha-Tec - Avantage• Metoda S.p.A - OpenMet

BPMF• Mindfire Solutions• Nautica • Open Business Engine

Six Standard BPMN / XPDL Examples

Six Standard BPMN / XPDL Examples As of Feb 17, 2007, these vendors

had implemented:

Workflow standards

Workflow vs. Java Workflow is basically graphical coding Workflow language offers contructs

for branching AND split AND joint OR split OR joint

Conditions Pre-condition Post-condition

Transition condition

Tools Workflow editor

Workflow Engines Commercial

Oracle Workflow Open Source

Shark OpenWFE (does not use XPDL, but it’s own

format)

1. Editor - JaWE XPDL Editor

http://jawe.objectweb.org written in Java Open Source

2. Engine - Shark Workflow Engine Open Source In beta stage

http://shark.objectweb.org/

Conclusion/Questions How can we best separate logic of a

protocol from workflow?

Can HealthCare be automated using same approach as Business Processes?

Are the workflow standards and tools mature enough?

Workflow engine project

Agenda Workflow project: people contacts, resources

Fujitsu go/no go criteria ability of Fujitsu to acknowledge current limitations Improvements to the editor (close collaboration vs. one-of-

many-customer)

Long term plan (phase 2, phase 3) If Fujitsu is chosen If other vendor is chosen

Small items Longer workflow technology talk (taped)

(scientific seminar (Wed), grand rounds (Fri), IT brown bags)

Shadowing

Workflow project Phase 1: Research use: BIRC, Vojtech+BIRC is

the main developer Scenarios: clinical scenarios based on Vojtech’s work on RetroGuide (e.g.,

osteoporosis, diabetes, chronic kidney disease)

Phase 2: dev use in IT within CattailsMD suite, Vojtech + IT workflow person/team

Scenarios: Provisioning (assigning user rightes, managing users), Decision Support (JohnF), Ancilarry services (TammyF), Radiology (preping prior imaging studies)

Phase 3: production use in IT, many IT developers/managers involved

Transforming dev processes to production systems

Current status Fujitsu’s visit of July 28th

Early experiments on VMWare Fujitsu’s image (dev image) Focus on breath of features (rather then full working scenario) Counting with future support MC’s server full install only finished on the last day at noon

After the visit MC server Transport of tested features from dev image to MC’s server Demo access

Mike’s flowchart Workflow follow-up meeting #1 (Aug 1st)

Rule systems in current CattailsMD suite (

Evaluation See separate document

Advantages Disadvantages

Key Benefit of Wf Technology Ability for non-expert to review or author

processes (strong editor)

Level 1: processes developed via consulting Level 2: processes developed by MC’s workflow person Level 3: processes developed by chief of Pediatrics

Using Wf Engine will decrease development cost

Basic functions (no need to develop them) Advanced analytical/monitoring functions

Requirements for Wf Editor/Flowchart

Complexity: Ability to express all my processes

Complexity (it can support MC’s business, clinical processes (DSS, QI), daily administrative processes (coordinating staff and clinicians, departments)

User-friendliness: Ability to express them in a level 3 friendly way

User-friendliness (buy in of MC’s users)

Requirements for the flowchart The flowchart can be read without

additional drill down Can become quite complex and have many extra

nodes (split, join, conditions)

Readability of the flowchart is most important.

Certain elements are hidden to improve readability

Mousing-over, drill-down click reveals additional detail

Choice of Wf vendor Feature set Price Special relationship

(partnership)

TIBCO Fujitsu Lombardi BEA Global 360

Evaluation perspectives data perspective

deals with the passing of information , scoping of variables

resource perspective deals with resource to task allocation,

delegation exception handling perspective

deal with the various causes of exceptions and the various actions that need to be taken as a result of exceptions occurring

WfMC glossary

[X]OR or AND split

Route A Route B Route C

“Otherwise” routeIf B If CIf A

Always or if not (A or B or C)

Flowchart and execution Complexity decision

Flowchart will have everything (no drill-downs necessary)

Flowchart will be a simplified view

Type of process specific knowledge Design time Run time

Deadlock situation (how bullet-proof is your process definition)

Flowchart level Engine level (default behavior) (simpler flowchart)

Petri Nets (PN)

Screenshots of Wf editor/engine (Fujitsu and

some TIBCO)

(will be commented orally)

Theory

Petri net consist two types of nodes: places and transitions.

A place may have zero or more tokens.

Graphically, places, transitions, arcs, and tokens are represented respectively by: circles, bars, arrows, and dots.

Petri Nets

Definition of Petri Net C = ( P, T, I, O)

PlacesP = { p1, p2, p3, …, pn}

TransitionsT = { t1, t2, t3, …, tn}

Input I : T Pr (r = number of places)

OutputO : T Pq (q = number of places)

Vector of places’ states Below is an example Petri net with two

places and one transaction. Transition node is ready to fire if and

only if there is at least one token at each of its input places

state transition of form (1, 0) (0, 1)p1 : input place p2: output place

Screenshot tour

EHR system

Event Listener

Notifications

Actions

definitions)

Data Inquiry

Workflow Execution

Engine(Shark)

EHR System layer:

Reports

Data Warehouse

Data Visualization

Event Data Model

Ontology Model

192HealthcareWorkflow.wordpress.com

193HealthcareWorkflow.wordpress.com

Code Layer (node; right click properties)

code.google.com/p/HealthFlow

EHR system

Event Listener

Notifications

Actions

definitions)

Data Inquiry

Workflow Execution

Engine(Shark)

EHR System layer:

Reports

Data Warehouse

Data Visualization

Event Data Model

Ontology Model

Together Workflow Engine (Community edition)

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