Optimising workflow &
business processes in the
delivery of seamless care to
older people
Isobel Frean
HL7 UK
October 2006
Outline
Background / Context
 Research aims / methodology
 Analysis of requirements

• Communication intensive
• Instant communication needs
• Challenges in accessing care

Options for improving workflow
Background
Research 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
Context
Australia 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
Context
Despite 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 aim
To examine the drivers for technological
change in aged care
 To 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

Methodology
HL7 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 SIG
 Use of Standards Australia / HealthConnect
messaging standards hierarchy model

HDF
1.
2.
3.
4.
5.
6.
7.
Project initiation (business vision)
Requirements documentation & analysis
Specification modelling
Specification documentation
Specification approval
Specification publication
Implementation profiling
Dual consultation

Delphi 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 2004
 Business vision focus groups

• 20 participants

Use case focus groups (44 participants)
• Round 1 = 44 participants
• Round 2 = 53 participants
• Round 3 = 20 organisations (117 questionnaires)
Business vision
Electronic processing of eligibility
requirements
 Messaging within the multidisciplinary care
team
 Ahead-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 developed
 These 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

Round 3 feedback
Accounts Management
Clinician Liaison
Strongly Agree
70%
Agree
60%
50%
Don’t Know
40%
Percentage
responses
Disagree
30%
20%
Strongly Disagree
10%
0%
Accounts Management
Strongly Agree
Accessing Services
Clinician Liaison
Business Process Category
Agree
Don't know
Disagree
Coordinating Services
Strongly Disagree
Coordinating Services
Accessing Services
Outline
Background / Context
 Research aims / methodology
 Analysis 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 ballot
 122 message flows analyzed
 Duplicate interactions were removed to arrive
at a core set of domain concepts-of-interest &
an understanding of their static interrelationships to each other
 Domain analysis model (DAM) model
developed – UML class diagram

Interaction tables
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Sender
Receiver
Interaction type (eg Care Transfer Request)
Action
Trigger Event
AR sender / AR receiver
Data content
Clinical domain
Current form of communication (phone)
Likely future form (message, CDA)
Expected reaction by receiver
Message category (eg Care Transfer Query)
DAM
DAM 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 develop
 Concepts 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 walkthrough

Acts 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 theme
Contains 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 theme

Key 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 Steps

Feed 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 Frean
Faculty of Informatics
University of Wollongong, Australia
freani@bupa.com
Tel: +44 1753 112 999