Modeling in Healthcare: Requirements and Clinical Processes

1. Daniel Amyotdamyot@uottawa.ca EBC8101March 21, 2019 Modeling in Healthcare: Requirements and Clinical Processes

2. Overview • Some important healthcare challenges • Domain requirements • Requirements Engineering in healthcare • Where can modeling help in healthcare? • Clinical processes • Real-time decision support • Interdisciplinary healthcare teams • Architectures • Predictive analytics • Privacy compliance • Research opportunities Modeling in Healthcare - EBC8101 p.2

3. Partners in Collaborative Projects Telfer Health Transformation Exchange (THTEX) Modeling in Healthcare - EBC8101 p.3

4. TOH Projects Adverse Event Management System BPM, DW, BI, and privacy compliance Goal-driven methodology for developing healthcare quality metrics Patient-device association and disassociation with a Real-Time Location System Real-time, location-based hand hygiene monitoring and notification system Real-time pathology dashboard Care Ami: a mobile patient navigator for lung cancer assessment A Quality Assurance Framework for Care Process Management Valuing extraordinary patient experience and safe care for multiple pregnancy Modeling in Healthcare - EBC8101 p.4

5. Projects with Other Hospitals • Location-Aware Business Process Management for Real-time Monitoring of Patient Care (Osler) • Real-Time Simulation of Patient Care Processes in Healthcare (Osler) • BI-Driven Management of Patient Flows (Osler) • Privacy-preserving (K-anonymity) algorithm for healthcare information sharing (Privacy Analytics, CHEO) • Privacy-Preserving Patient Tracking for Phase 1 Clinical Trials (Privacy Analytics, CHEO) • Supporting Interdisciplinary Healthcare Team Dynamics with Business Process Management (Bruyère) • Real-Time Demand Capacity Tool (QCH, HealthNow) • A Mobile Self-Triage Application (Montfort) • Activity-based Process Integration Framework to Improve User Satisfaction and Decision Support in Healthcare (Montfort) • User-Centered Change Management Process for CPOE Implementation (Montfort) • Process Mining in Healthcare Processes (Montfort) • Evidence-based Newborn Screening Process Improvement (NSO) Modeling in Healthcare - EBC8101 p.5

6. Background Concepts • A requirement is: • A statement about the proposed system that all stakeholders agree must be made true in order for the customer’s problem to be adequately solved. • Requirements Engineering (RE) is: • The activity of development, elicitation, specification, analysis, validation, and management of the stakeholder requirements, which are to be met by a new or evolving system. • A model is: • A reduced representation (simplified, abstract) of (one aspect of) a system used to help understand complex problems/solutions, communicate information about the problem/solution, and direct implementation (especially in software). Modeling in Healthcare - EBC8101 p.6

7. Some important healthcare challenges Modeling in Healthcare - EBC8101 p.7

8. Healthcare in Canada, 2018 https://www.cihi.ca/sites/default/files/document/nhex-trends-narrative-report-2018-en-web.pdf Modeling in Healthcare - EBC8101 p.8

9. Healthcare Spending Trends in Canada https://www.cihi.ca/sites/default/files/document/nhex-trends-narrative-report-2018-en-web.pdf Modeling in Healthcare - EBC8101 p.9

10. How Does Canada Compare? https://www.cihi.ca/sites/default/files/document/nhex-trends-narrative-report-2018-en-web.pdf Modeling in Healthcare - EBC8101 p.10

11. Wait Times in Ottawa, Ontario http://www.ontariowaittimes.com/ Most large community and teaching hospitals operate near congestion levels, with long wait times Emergency rooms near the University of Ottawa (“Total Time” columns indicate that 1 patient our of 10 will stay longer than this) Modeling in Healthcare - EBC8101 p.11

12. https://www.hqontario.ca/System-Performance/Time-Spent-in-Emergency-Departmentshttps://www.hqontario.ca/System-Performance/Time-Spent-in-Emergency-Departments Modeling in Healthcare - EBC8101 p.12

13. Where Does Outaouais Stands? [leDroit.com, June 2, 2016] [http://www.cbc.ca/news/canada/ottawa/gatineau-hospital-coroners-report-1.3736927] Modeling in Healthcare - EBC8101 p.13

14. http://ici.radio-canada.ca/nouvelle/1064909/temps-attente-urgence-civieres-outaouaishttp://ici.radio-canada.ca/nouvelle/1064909/temps-attente-urgence-civieres-outaouais Modeling in Healthcare - EBC8101 p.14

15. Wait Times in Outaouais, Québec • Some stats on ER patients waiting on stretchers on March 17, 2019 (https://www.indexsante.ca/urgences/): Modeling in Healthcare - EBC8101 p.15

16. Resource Management • Too often, resources are waisted • For example, in 2017, Gatineau used its IRM equipment only 56% of the recommended 16h/day • Partly explains long wait times • Too many attempts to optimize locally • Only move bottlenecks to other steps of the process • Need for global optimizations and real-time monitoring • Domain requirement • Healthcare systems shall consider the impact of designs on the end-to-end journey of patients Modeling in Healthcare - EBC8101 p.16

17. Physicians and Nurses are Busy • Survey of 20,000 U.S. Physicians Shows 80% of Doctors are Over-Extended or at Full Capacity • The Physicians Foundation, September 2014 • Physicians and nurses have to make way too many important decisions every day! • Decision fatigue (e.g., with antibiotic prescriptions) • Domain requirements • Healthcare systems shall not add to the workload of health practitioners • Healthcare systems shall help reduce the number of daily decisions made by physicians Modeling in Healthcare - EBC8101 p.17

18. Making Sense of the Data • Healthcare generates HUGE quantities of data • Extracting useful knowledge from that data is still difficult • Sharing and aggregating data is difficult • Privacy legislation gets in the way… • Data often becomes available too late to help • Domain requirement • Healthcare systems shall help providing the right information to the right people in the right format at the right time Modeling in Healthcare - EBC8101 p.18

19. Clinical/Healthcare Processes:Patients are not Products • Healthcare processes and clinical pathways deal with human beings, not industrial products • Many patients with a similar health problem need to be treated slightly differently • Somewhere between conventional Business Process Management and Case Management • Clinical pathways for many types of morbidities are well defined, but many patients have multiple morbidities • Domain requirement • Healthcare processes shall adapt to the unicity of patients (patient centricity) in a way that enables treating multiple morbidities Modeling in Healthcare - EBC8101 p.19

20. Funding Model and Legislation • Private vs public funding • In Canada, physicians are not hospital employees • Payment based on acts or on value • Traditionally: funding based on the volume of care delivered to patients. • Trend: funding based on the outcomes of the care and its end-to-end value for the patient • A procedure in Ontario is now reimbursed according to the provincial average cost • Competition! Modeling in Healthcare - EBC8101 p.20

21. Funding Model and Legislation • HITEC and Meaningful Use in the USA • Force the harmonization and evolution of systems • In Canada, little harmonization; hospitals use different systems, augmenting the need and effort for integration (although this is changing) • Laws and regulations in constant evolution • Healthcare undergoing major transformations! • Domain requirement • Healthcare systems shall be designed according to the relevant legislation and funding model Modeling in Healthcare - EBC8101 p.21

22. Increasing U.S. Healthcare Regulation CCHIT MU Stage 1 HIPAA HITECH (ARRA) MU Stage 2 Meta-Standards Rule 2007 2008 1996 2009 2010 2011 2012 HIPAA Omnibus Regs NwHIN Governance DEA EPCS Data Breach Notification Various State Laws … and each of these laws evolves too (multiple versions!) Requirements Management J.C. Maxwell, A.I. Antón, P. Swire: Managing Changing Compliance Requirements by Predicting Regulatory Evolution. Intl. Conf. on Requirements Engineering, IEEE CS, 2012.

23. Almoaber, B., Amyot, D.: Barriers to Successful Health Information Exchange Systems in Canada and the USA – A Systematic Review. Int. J. of Healthcare Information Systems and Informatics, 12(1), 2017 Modeling in Healthcare - EBC8101 p.23

24. Requirements Engineering in healthcare Modeling in Healthcare - EBC8101 p.24

25. RE for Digital Health (2015) Modeling in Healthcare - EBC8101 p.25

26. What is Actually Used (419 Projects, 8% Healthcare)? Modeling in Healthcare - EBC8101 p.26 S. Fricker, R. Grau, A. Zwingli (2014). Requirements Engineering: Best Practice. Requirements Engineering for Digital Health. Springer.

27. RE in Healthcare: The Literature ( requirements W/1 ( engineering OR elicitation OR gathering OR specification OR validation OR modeling OR modelling OR notation OR analysis ) AND ( medicine OR "health care" OR "healthcare" OR medical ) ) In 2017, Scopus returned 1345 publications Half coming from journals and half from conferences 75 (5.6%) involved Canadian authors Without the healthcare-oriented restriction, Scopus returned 34,185 documents Although healthcare is an essential and expensive sector (10.4% of GDP in Canada), only 4% of the RE literature addresses healthcare, with no observable change in trends Modeling in Healthcare - EBC8101 p.27

28. RE in Healthcare: The Literature (2016) [M. Baslyman, thesis proposal, 2016] Modeling in Healthcare - EBC8101 p.28

29. Informal Observations • One hospital with ~250 IT staff • Informal requirements, use cases, user stories • Business analysts between stakeholders and development team • Development and integration • One hospital with ~25 IT staff • Direct access to stakeholders (still infrequent) • Integration mainly • Requirements in Word on Sharepoint Modeling in Healthcare - EBC8101 p.29

30. What About Technologies? • Software/systems modeling technologies • UML/SysML, Logic, Goals, URN, Simulations, Feature Models, BPMN, EvSEC, Simulation, ontologies, Aspects, … • Healthcare technologies • Health Information Systems, Electronic Health Records, Decision Support Systems, Imagery, … • Health Level Seven Int. (HL7) for system interoperability • ICD 10 and SNOWMED for clinical classification • Data modeling • Business Process Management (BPMN and others)… • Clinical Document Architecture (CDA), Cross-Enterprise Document Sharing (XDS) • Simulation, BI, (predictive) analytics, … • Domain requirement • Models shall enable interoperation with existing healthcare technologies Modeling in Healthcare - EBC8101 p.30

31. WHERE CAN Modeling Help in Healthcare? Modeling in Healthcare - EBC8101 p.31

33. Clinical Processes Business Process Model and Notation (BPMN) and similar models, together with management and execution tools, already used to support clinical pathways Modeling in Healthcare - EBC8101 p.33

34. Cardiology Pathway (BPMN) Modeling in Healthcare - EBC8101 p.34

35. IBM BPM: Service Implementation

36. IBM BPM: “Coaches” (Forms)

37. Nurse Test Order (Web) Modeling in Healthcare - EBC8101 p.37

38. iPad Version Modeling in Healthcare - EBC8101 p.38

39. Modeling in Healthcare - EBC8101 p.39

41. Not So Fast... There are Modeling Challenges! • Major integration effort with health information systems (typically 100-150 different ones in a hospital) • Management of deviations and exceptions still a major problem • Getting realistic processes is also difficult • Many are investigating process miningin that context • Mans, R., van der Aalst, W.M.P., and Vanwersch, R. (2015) Process Mining in Healthcare: Evaluating and Exploiting Operational Healthcare Processes. SpringerBriefs in Business Process Management, Springer International Publishing, 2015. Modeling in Healthcare - EBC8101 p.41

42. [M. Ghasemi, 2015] [M. Ghasemi, 2015]

43. Process Mining in a Nutshell Modeling in Healthcare - EBC8101 p.43

44. Basic Types of Process Mining van der Aalst, W.M.P. (2011) Process mining: discovery, conformance and enhancement of business processes. Springer Science & Business Media, 2011. Modeling in Healthcare - EBC8101 p.44

45. Number of Process-Mining-Related Publications, Per Year (May 2016) Ghasemi, M., Amyot, D.: Process Mining in Healthcare — A Systematised Literature Review. Int. J. of Electronic Healthcare, 9(1), 20–35, 2016 Modeling in Healthcare - EBC8101 p.45

46. Number of Healthcare Process-Mining-Related Publications, Per Year Modeling in Healthcare - EBC8101 p.46

47. Challenges of Process Mining in Healthcare • Think of Process Mining as the intersection between data mining, AI, and modelling. • Data is one obvious issue! • Identifying, accessing, and integrating data sources (especially patient-related) • Data quality, granularity, and completeness (logs) • Visualization of process models, especially for complex and less-structured processes • Automated tools, but still a great amount of pre-processing and reliance on experts for applying process mining Modeling in Healthcare - EBC8101 p.47

48. Ease his pain… Modeling in Healthcare - EBC8101 p.48

49. Need for Real Time and Adaptation • Having valid process models that are executable is still not enough to ease the pains of physicians, nurses, and patients • Need to align resources with demand in real time • Simply adding more resources is unsustainable • Need to consider real-time location information • Some healthcare process instances are long lived • Days, months, years… • Need to adapt dynamically the composition of the care provider team Modeling in Healthcare - EBC8101 p.49

50. Capacity Management at 15:00 Modeling in Healthcare - EBC8101 p.50