Optimising workflow & business processes in the delivery of seamless care to older people

1. Optimising workflow & business processes in the delivery of seamless care to older people Isobel Frean HL7 UK October 2006

2. Outline • Background / Context • Research aims / methodology • Analysis of requirements • Communication intensive • Instant communication needs • Challenges in accessing care • Options for improving workflow

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. HDF • Project initiation (business vision) • Requirements documentation & analysis • Specification modelling • Specification documentation • Specification approval • Specification publication • Implementation profiling

10. 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

11. 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)

12. 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

13. 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

14. 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

15. Strongly Agree Agree Don’t Know Disagree Strongly Disagree Coordinating Services Accessing Services Round 3 feedback Accounts Management Clinician Liaison

16. Outline • Background / Context • Research aims / methodology • Analysis of requirements • Communication intensive • Instant communication needs • Challenges in accessing care • Options for improving workflow

17. 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 inter-relationships to each other • Domain analysis model (DAM) model developed – UML class diagram

18. Interaction tables • 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)

19. 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

20. Aged Care DAM

21. Aged Care Domain Use Cases

22. 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)

23. 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’

24. 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

25. Business processes identified in Aged Care DAM

26. Service Transfer Request & Promise messages

27. 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

28. ReferralForAgedCare EligibilityCriteria ServiceAgreement Notification ApplicationDocumentation WaitingList AdmissionEncounter DecisionToAdmit Care Transfer theme: acts

29. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. Thank you Isobel Frean Faculty of Informatics University of Wollongong, Australia freani@bupa.com Tel: +44 1753 112 999