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Careflows Management Systems

Careflow Management Systems (CfMSs) are WfMSs supporting medical knowledge management in clinical domains. They are case-based, i.e., every piece of work is executed for a specific patient. One can think of a patient care process as a Cf instance. The goal of CfMSs is to handle patients by executing medical tasks in a specific order. A Cf process definition specifies which tasks need to be executed and in what order. A task, which needs to be executed for a specific case, is called a work item. Most items are executed by a resource, either human or technological. A work item executed by a resource is called activity. To facilitate the allocation of work items, resources can be grouped into classes. The resource class based on the capabilities (i.e., functional requirements) of the HCOs members is called organizational agent. If the classification is based on the structure of the HCO, such a resource class is called organizational unit (e.g., team, laboratory, clinic, department, etc.). A CfMS may also contribute to solve the communication problem within HCOs since it is able to manage automatically a great amount of communication acts among organizational agents involved in patient care. Such view was stimulated by the "continuum view" developed by Enrico Coiera [1]: he pointed out that communication and computation tasks are related, but drawn from different parts of a task space. We strongly believe that knowledge management, in general, and CfMS, in particular, may provide an effective approach to overcome the false dichotomy between communication and computation tasks: careflow technology can be used to make communication more efficient by supporting organizational agents in sharing the needed medical and organizational knowledge. Figure 1 shows the basic elements of the organization ontology on which the model of an HCO can be based on. It represents an adaptation of the organization ontology developed within the TOVE project [2]. HCO consists of a set of organizational units (e.g., wards, laboratories, clinical units, rehabilitation units, etc.), a set of organizational agents (members of an organizational unit), a set of roles that the members play in the organization, and a set of organizational goals that they are committed to achieve.

Organization
Figure 1 - Basic elements of the organization ontology adapted from the one developed within the TOVE [2] project.

Part of the CfMS methodology consists in the definition of the roles according to the ontology presented in figure 3.1. A good example of CfMS application is given by the implementation of a system for Stroke patients care developed as a collaboration between our laboratory and the Neurological Hospital "IRCCS C. Mondino" of Pavia [3, 4]. Stroke is the commonest cause of adult disability and the third leading cause of death in most countries. It is crucial therefore that an effective strategy for prevention and treatment of stroke is implemented. Effective care of stroke requires teams of efficient, informed health care professionals, who must work together in carefully planned patterns appropriate to the problems posed by individual patients. The following four main phases can be distinguished:

A stroke care management system must match the HCO's resources with generally agreed upon guidelines (evidence-based medicine), for each of the clinical presentations of the disease. The system should also show that its patterns of care are effective and efficient.

As an example of organisational knowledge representation, figure 3.2 depicts the taxonomy of roles played by organizational agents involved into the post-stroke rehabilitation process within a rehabilitation hospital [3]. Stroke rehabilitation frequently involves the services of several rehabilitation disciplines. The skills required depend on the nature of the patient’s deficits. Medical specialties that are commonly involved include physical medicine and rehabilitation, speech therapy, neurology, geriatrics, internal medicine, psychiatry, and family practice. Consulting physicians from other specialties (for example, cardiology, haematology, etc.), are called on as needed. Figure 3.2 shows the hierarchy of roles played by the organizational agents directly involved in the rehabilitation process. They operate within either clinical wards or rehabilitation units, but they may also be involved in several multidisciplinary activities, mainly whenever some collective decisions have to be made (e.g., identification of rehabilitation needs, assessment of deficits’ recovery).

Roles
Figure 2 - Taxonomy of roles played by organizational agents involved into the post-stroke rehabilitation process within a rehabilitation hospital in the Careflow project.

The Stroke CfMS project is at the moment one of the most paradigmatic examples of clinical workflow. However, it requires a complete model of the HCO and medical and organizational knowledge have been represented and disseminated through the same formalism (precisely Oracle WorkflowTm). This leads to scalability and maintenance problems:

SAGE and Guide for “workflow awareness” »

References

[1] Coiera E.
When communication is better than computation.
Journal of American Medical Informatics Association 2000;7:277–86.

[2] Fox MS, Gruninger M.
Enterprise modeling.
AI Magazine 1998;(Fall):109–21.

[3] S. Quaglini, S. Panzarasa, A. Cavallini, G. Micieli, C. Pernice, M. Stefanelli
Smooth Integration of Decision Support into an Existing Electronic Patient Record.
Artificial Intelligence in Medicine ,ed Silvia Miksch; Jim Hunter; Elpida Keravnou (Eds.), pag. 89 - 93, (2005)

[4] S. Panzarasa, R. Bellazzi, C.Larizza, M. Stefanelli
A careflow management system for chronic patients.
MedInfo 2004 ,ed Fieschi/Coiera e Yu-Chan Jack Li, pag. 773 - 777, (2004).