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a comparison of different workflow modeling tools

1. Project name Lab order process flow mapping Observer name job title Ammar Kamil Project assistant Observation place P A T T Date Aug 15 2012 Time 12 30 PM Site location Church site Physician order Clerk enter it to MT Labels printed in lab or unit Unit pages the lab tech to come to collect blood Lab tech checks two patient IDs verbally and collect samples in a lab and ECG room Initial and affix labels on tubes Lab tech takes samples to lab Result will be submitted to MT Clerk file the results to the patient s chart Tf urine test required a container will be given to patient and patient place them in a basket outside the blood work room for lab tech to pick up when arrive 239 M Sc Thesis A Kamil McMaster University Computing and Software eHealth P A T T Observation Project name Lab order process flow mapping Observer name job title Ammar Kamil Project assistant Observation place P A T T Analisa Fortalow _ Resourse nurse Date Aug 21 2012 Time 9 00 PM Site location Finch site Note Physician order Clerk enter it to MT Labels printed in lab or unit Unit pages the lab tech to come to collect blood Lab tech checks two patient IDs verbally and collect samples in a lab and ECG room Initial and affix labels on tubes Lab tech takes samples to lab Result will be submitted to MT and paper copy of the will be received
2. Date July 26 2012 Time 3 00 PM Location Church site 1 What type of samples you collect at these clinics Mostly blood 2 How many orders normally placed per day 100 day 3 Who is placing the orders Physician 4 How physicians placing an order Paper chart verbal gt Nurse or Clerk enter it to MT 207 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 15 16 17 What are the methods of adding another test request to a sample Paper telephone order gt Nurse or clerk enter it to MT Where are labels printed or received from In unit Do the nurse technician confirm the information in labels with the test request Yes How staff notified there will be test needed Check the order sheet Patient chart Nurse check the Kardex Who is collecting the samples nurse or lab technician Nurse How do nurse technician identify the patient for sample collection for sample test Arm band two ID check H D O B Is there any difference in flow between different samples No Where normally samples are collected Dialysis station Where collected samples are normally labeled Dialysis station How samples delivered to the lab Porter How the clinics receive the results MT How long it will take to receive the results Long time What do you do if results not received missing Call the lab and mak
3. Keep open when analysis completes Stop Close Figure 18 YAWL analysis progress box Analysis result notes The results of the analysis will reveal some of the following information about the workflow design examples as shown below e The number of elements in the original YAWL net with mentioning the name of the net e Number and name of YAWL reduction rules used in the analysis example 2 rules FSPY FAND e Duration in milliseconds See Figure 19 for analysis result of Current general lab work process workflow J Analysis Notepad File Edit Format View Help Elements in the original YAWL net Current General_tab_work_Process 71 YAWL Reduction rules 2 rules FSPY FAN Reduced net size 64 Elements in the original reset net 136 Reset Reduced net 4 rules FSPR FSTR FPPR DEAR Reduced net size 52 Immediate successors Immediate successors Immediate successors Immediate successors Immediate successors 3 Immediate successors Immediate successors Immediate successors oo Reachable markings gt 5000 Possible infinite Toop in the net Current_General_Lab_work_Process Elements in the original YAWL net Ordering 43 YAWL Reduction rules 1 rules FSPY Reduced net size 35 Elements in the original reset net 84 Reset Reduced met 2 rules FSPR FPTR Reduced net size 34 Immediate successors 4 Immediate successors 7 Immediate successors Immediate successors 7 Rea
4. OMON VERBAL ORDER F Start task End task ros PMM Transition TOLNEW ORDER F Atomic task a AND spit y il of DMOMI XOR joint L TONEW ORDERF va we OM OM MOM 10 A00 0N TEST J TONENORDER foo VERBAL ORDER F IINA DMNI TO ADD_ON TEST Transition Atomic task Dat 4 XOR joint a TO_NEW_ORDER_U TO_NEW_ORDER_F PATHOLOGY ORDE TOADD ON TEST PATHOLOGY ORDE TO_ADD_ON_TEST BLOOD BANK ORDER GLUCOMETER_ORDER 43 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 0M0M gt REFERRED_T0_LAB 0MOM f gt TO_NEW_ORDER F I OOM Fi r aeea D m I PHONE NURSE_OR_CLERK sn 20 1 OMOM f rr TO_ADD_ON_TEST joMoM i TO NEW ORDER F 0MOM P L gt gt f J VERBAL NURSE OR CLERK fin 26 Start task k 3 IMOM f o End task TO_ADD_ON_TEST joM on Transition f TO_NEW_ORDER_F Atomic task J m J AND split CPOK INM jomom XOR joint TO_ADD_ON_TEST Figure 10 NOVA workflow ordering design Together all of these aspects act as a barrier for users when designing a new workflow process and will not help the users when designing a workflow process see Table 5 for a comparison between the tools 4 2 C
5. 19 20 21 How long it will take to receive the results Depend on the type of test What do you do if results not received missing Call the lab Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT No Any issue with the current system No Recommendations and suggestions Need lab abbreviation sheet for test names Do you use blood bank service amp how to order Yes e Physician order paper e Clerk enter to MT e Lab call when blood ready e Send the face sheet with porter or clerk to lab e In blood bank clerk or porter confirm the info in face sheet with blood and signature sheet e Pick up the blood e Two nurses confirm and check the blood then do the blood transfusion 235 M Sc Thesis A Kamil McMaster University Computing and Software eHealth B 600 Medicine Nephrology Observation Project name Lab order process flow mapping Observer name job title Ammar Kamil Project assistant Observation place B 600 Medicine Nephrology unit Date Aug 15 2012 Time 9 30 AM Site location Church site Routine lab order e Physician order the day before or before 6 00 AM same day e Lab tech arrived at 9 30 AM e Labels already printed in lab or unit e Lab tech checks labels and leave them outside the patient room for isolation purpose tubes will be cleaned when lab tech leaves the patient room and that could era
6. MEDITECH Submit the results to MT in a normal process Storing samples based on type Storing samples based on type If MT fails and is not functioning the results should be stored in MT later when MT becomes functional The process will be as follows Submitting a paper copy to units Send a paper copy to the unit s printers Submitting to physician phone or device Send results to the physician s devices or phones if the results are critical Calling the unit Informing the unit about the by phone if the results are critical Storing samples based on the type Storing samples based on type 142 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 9 Storing Samples Storing samples is determined based on the samples type For example blood samples are stored for days while urine samples are stored for hours only Differences between the current and future lab orders Most of the main workflow process steps in the current and future lab order workflows are the same The future process consists of some new introduced processes and other re engineered key steps Analyzing the current process helped finding the bottlenecks and deficiencies in the system and eliminating them from the design of the new future process The points below will show the major differences between the two systems 1 Ordering The current process uses paper forms to place lab orders while the future pro
7. https scholarworks iupui edu bitstream handle 1805 2265 Brian_Pearson_Thesis Final pdf 42 JBPM JBOSS Community Online Available Http www jboss org jbpm 43 XPDL Tool Online Available http www wfmc org xpdl html 156 M Sc Thesis A Kamil McMaster University Computing and Software eHealth APPENDIX Forms Interviews and Observations Questions and Answers Forms Laboratory Interview Project name Lab order process flow in lab department Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Terry Calabrese DIRECTOR LABORATORY SERVICES Date Monday June 4 2012 Time 9 00 AM Location Church site Lab Methods of collection Unit collection In unit technician collection 1 2 3 In unit nurse RT collection 4 In lab technician collection Methods of delivery Transferred by technician to the lab 1 2 Sent by porters to the lab 3 Sent by taxi cab Keele to Church 4 Sent by pipe chute to the lab Emergency only 157 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Clinic s involved e Lab e ER e ICU e Chemo e Dialysis Nephrology e Outpatient surgical fracture and plastics e Respiratory therapy e Mental health e Birthing Women s and Children s Labour and Delivery Notes Labor and delivery ICU dialysis chemo and mental
8. PROGRAMS Date Tuesday June 12 2012 Time 11 00 PM Location Church site ICU 1 What type of samples ICU send to lab Blood urine and fluid 2 How many orders normally placed per day Around 20 order per day 172 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 Who is placing the orders Physician or nurse How physicians placing an order Physician write a paper request and a clerk or a nurse enter the order to MT 6 0 What are the methods of adding another test request to a sample Physician submit a paper request and a clerk or a nurse enter the order to MT 6 using ad on test feature in MT Where are labels printed or received from In clinic 2 places Do the nurse technician confirm the information in labels with the test request Yes How staff notified there will be test needed When labels printed check order in MT Who is collecting the samples nurse or lab technician Nurse How do nurse technician identify the patient for sample collection for sample test Patient name and patient hospital number on patient arm bracelet Where normally samples are collected Bed site location Where collected samples are normally labeled Bed site location after labeling nurse come and check the information on labels and compare them with patient arm bracelet How samples delivered to the lab Porter service time of pickup varies an
9. We designed the final future lab order workflow process by using YAWL workflow tool see Figure 5 One of the useful tools of YAWL is its cancelation feature with this feature the user can specify the role of tasks and determine the order of the task based on the required order process For example in the hospital breakdown operation delivering lab order samples to the lab can be done in three ways using Automated Guided Vehicles AGVs using staff or using the porter service By using the cancellation feature we can determine the order of the tasks and the order will follow the selected task and cancel the other paths see Figure land Figure 6 150 M Sc Thesis A Kamil McMaster University Computing and Software eHealth REFERENCES 1 C Pappas E Coscia G Dodero V Gianuzzi M Earney A Mobile E Health m System Based On Workflow Automation Tools Computer Based Medical Systems 2002 CBMS 2002 Proceedings of the 15th IEEE Symposium on pp 271 276 2002 doi 10 1109 CBMS 2002 1011388 2 A Jenkins and S F Eckel Analyzing methods for improved management of workflow in an outpatient pharmacy setting American Society of Health System Pharmacists Inc Vol 69 Jun 1 2012 doi 10 2146 ajhp110389 3 G Russello C Dong and N Dulay A Workflow Based Access Control Framework for e Health Applications Advanced Information Networking and Applications Workshops 2008 AINAW 2008 22nd Int
10. checking all time Serious if sample mis stored No proof of action Delay in delivering the samples Depends on human resources availability Vary between test Critical in some types cases if delayed Space for error Critical on patient health if misjudged Require time and resource Missing or losing Increase patient samples diagnostic and treatment time We developed the future process based on eliminating the errors and weak points from the current lab process considering all the new surrounding environment and equipment of the new process the key aspects of its future state is as follows 60 M Sc Thesis A Kamil McMaster University Computing and Software eHealth ORDERING Online ordering Ordering is the first sub process of the main lab order process for future ordering The physician nurse or Physician assistant will use online ordering instead of the paper based form used in the current process Through online ordering the person who places the order can use either Order Sets orders set in advance or the CPOE module by using the electronic health record MT Decision Support The new digital lab order process will have a decision support feature for physicians to support their order decision It will also provide the opportunity to review past orders in the same context as placing the new order and physicians can look at all lab tests previously performed as well as already
11. e Using MT is time consuming it is slow and needs many steps to go to a page e Some blood bank orders cannot be seen by staff Nurses e Most of the time a lab tech or nurse does not confirm the test s information on labels with test request order e Some departments receive unnecessary paper copies of the test results e Lab order page on MT has a lot of issues e A Complete blood count CBC blood order on MT is always defaulted to STAT e Labels will not be printed until a nurse or clerk changes the order status in MT to collected e The labour and delivery MT first page has the baby s mother s name by default in the second page the mother s name should be entered manually and third page has no field for the mother s name The mother s name needs to be on the three pages by default to eliminate errors e Caesarean section room e Has only one computer in the room which is used by the physician no other computer to use for orders nurses have to wait until the physician finishes working with the computer which led to an increase of processing time 55 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Has no labelling machine available there When blood is drawn from the baby the baby needs to be registered first and then the order and labels can be printed and placed on the sample e There is no available notification to inform nurses in a unit about new lab order
12. time Respiratory Observation Project name Lab order process flow mapping Observer name job title Ammar Kamil Project assistant Observation place Respiratory unit Marg Patell Respiratory Therapist Date Aug 21 2012 Time 11 30 AM Site location Finch site Pre Test e physician fax requisition to unit e clerk book the appointment for patient and enter the order to MT e print labels at the unit labels stays at the desk for isolation reasons 232 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Nurse collect blood then bring it back to desk to affix labels e Clerk call patient two days before the test e Patient arrive and register at P A T T registration then will go to respiratory clinic e Clerk prepare paper requisition patient lists to Respiratory Therapist RT An arterial blood gas ABG test e RT check patient ID verbally e RT perform test e RT change test status in MT to completed e Send samples to lab by porter sometimes RT take samples to lab when porter delay e RT check when results ready in MT to print copy of the results and attach to patient chart in file Medicine Nephrology interview questions Project name Lab order process flow in Medicine Nephrology unit Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Angila Clerk Date Aug 15 2012 Time 9
13. All types Regular collection time 7 00 AM 11 00 AM 3 00 PM 2 How many orders normally placed per day 20 day 3 Who is placing the orders Physician 4 How physicians placing an order Paper chart verbal Nurse confirm amp enter it to MT 5 What are the methods of adding another test request to a sample Paper telephone order Nurse or clerk enter it to MT 6 Where are labels printed or received from Clinic amp Lab 7 Do the nurse technician confirm the information in labels with the test request No they go by the information in the label 8 How staff notified there will be test needed By chart 9 Who is collecting the samples nurse or lab technician Nurse if patient have PICC line other will be done by lab tech 210 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 15 16 17 18 19 20 21 How do nurse technician identify the patient for sample collection for sample test Arm band two ID check H D O B Is there any difference in flow between different samples No Where normally samples are collected Bedside Where collected samples are normally labeled Bedside amp outside the room to be able to write the initial on the labels How samples delivered to the lab Stat Porter Routine Lab tech How the clinics receive the results MT If up normal the lab will call How long it will take to receive the
14. Computing and Software eHealth Based on the information we gathered from following the mixed qualitative and quantitative methodology analysis and evaluation of the four selected workflow tools displayed results of the designated workflow process sample Future lab ordering designing outcomes We can recommend YAWL Yet Another Workflow Language as the best workflow tool to design the new digital lab order workflow process The YAWL workflow tool has unique designing features and components allowing tool users to manage control and finish successful workflow design in a sufficient time The second choice among the tools is TWE Together Workflow Editor Together Workflow is a powerful tool and has excellent choices in terms of workflow features It can help workflow designers produce an effective workflow process design Out third choice is the Bonitasoft Bonita Open Solution Open Source BPM this workflow tool is easy to use and can produce workflow process in decent time It has some significant workflow features such as message call and alert which can help users control the workflow of the process The last tool among the four selected workflow tools is the NOVA workflow tool Although this tool uses a unique compensable workflow modeling language and has some workflow features it is not as easy to use as the other workflow tools YAWL Together and Bonitasoft Users could face a lot of difficulties when using the NOVA w
15. Date July 31 2012 amp Aug 01 2012 Time 117 30 AM amp 9 00AM Site location Finch site The ED unit in Finch site consists of the following subunits 1 Triage 2 O Zone 3 O Zone hallway 4 Miner treatment 5 Acute 6 Sub acute Triage o If blood work need to be done in triage e Nurses will decide what type of blood work need to be done according to the medical directive they have from the physicians they order blood work directly on MT e Labels will be printed in triage room label printer e Triage or of load nurse will collect the blood in triage phlebotomy room e Samples labeled in the same room 222 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Samples sent to lab by the pneumatic tubes e Results will be submitted by lab to patient record in MT Glucometer Flow in triage unit e Nurse start by scanning their badges so the system writes the name of the person who collect the sample e Nurse scan or write patient information in the device e Nurse scan the blood stripe e Perform the test on the patient e Nurse enters the result directly to patient record in MT o They don t use loading deck to download the data to lab Minor Treatment unit The work in this unit starts after 9 30 AM e Triage nurse decide that the patient need to go to minor treatment normally they don t need blood work e Patient walk in e Physician check the patient e If lab order n
16. Routine Lab technician How the clinics receive the results Normally in MT If result required by surgeon notification of result will be by call or verbal How long it will take to receive the results 10 min What do you do if results not received missing Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT Yes Nurse sign when they put sample in the basket for porter to pick up Any issue with the current system Recommendations and suggestions See results in MT right away 218 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 21 Do you use blood bank service amp how to order Yes e Patient do blood test in lab before surgery e OR call the lab for blood units e OR Porter take face sheet to lab amp sign to pick up the blood units no confirmation e OR Nurse check the Anesthetists Emergency Department interview questions Project name Lab order process flow in ED Clinic Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Sonia Clinical practice leader Date July 31 2012 Time 11 00 AM Location Finch site 1 What type of samples you collect at these clinics All types CBC electrolyte majority troponen pregnancy urine blood lever function test 2 How many orders normally placed per day 400 day 3 Who is placing the order
17. The new process flow consists of the following tasks ordering receiving the orders collecting the samples delivering the samples processing the samples delivering the results and order confirmation and verification The first part of the study is dedicated to examining and choosing a reliable workflow tool to help in designing the new digital lab order process Due to some limitations of time duration of the study and preset criteria we examined various open source workflow tools but chose only 15 tools Some studies have previously reviewed some of the workflow tools as shown by Fish et al 4 and Brogi et al 5 A study by Adriansyah et al 7 about the design and implementation of performance tools analyzes a variety of performance criteria using information from existing process models logs these tools also help in making more effective improvements and decisions The authors chose the YAWL process model M Sc Thesis A Kamil McMaster University Computing and Software eHealth language for applying their techniques A comparison is performed between process instances and YAWL process models and performance characteristics obtained from replaying the log in the model are projected onto the model The study by Fish et al 4 identifies some workflow concerns and difficulties researchers found with previous research the authors try to examine some workflow challenges that other researchers missed the stud
18. The process starts by placing the received samples in the processing instruments one by one and then the lab instrument will process the samples and write the results into MT Finally the samples will proceed to be stored The process in the hospital involves Add on test A physician can request to add other test on collected sample and the lab technologist makes sure to add the new test into the system and reruns the test on the sample to get the required result Urine process A process of analyzing urine samples Blood and specimens o Manual A process of analyzing blood samples manually o Automated A process of analyzing blood samples by an analyzer instrument o Pathology amp Micro Pathology A process of analyzing pathology samples Cytology amp Histology 129 M Sc Thesis A Kamil McMaster University Computing and Software eHealth b Out of hospital process The process of sending samples that requires unavailable processing instrument to outside the hospital for processing 8 Analyzing Results The process of analyzing some of the samples that show concerning results by categorizing them differently and process them as follows a Abnormal results This process will take place if the results have abnormal expectations The technologist analyzes samples as follows Abnormal that meet repeat criteria o Repeat Process Analyze the result as abnormal or critical if it meets or does not meet repeat cri
19. requests nurses sometimes know from Order sheet Patient chart MT page Kardex Verbal communication from physician e No manual is available to know where to send bronchiole samples Respiratory e Sometimes the initial on labels does not represent the persons who collect the samples Endoscopy e In some departments samples stay for 4 hours and are later picked up Endoscopy e In most departments nurses have no training for blood collection e Most night blood collection will go missing Current process issues and deficiencies The previous information contains relevant data for developing a new lab order process but not all of the data is useable but the collected data is essential however some of it is used to develop the new digital lab order process We used the previous information to develop two tables Both tables were discussed with the lab director lab technicians and nurses for authentication and approval The sources of these collected data are from the questionnaires interviews and observation of the daily lab order processes and no other substantiation is available The 56 M Sc Thesis A Kamil McMaster University Computing and Software eHealth first table shows the current process deficiencies process and issues metrics performance quality and patient safety and the proposed technology Please see Table 8 for more details Defici
20. t recognizes the patient or takes long time to complete the process Outpatient Observation Project name Lab order process flow mapping Observer name job title Ammar Kamil Project assistant Observation place Outpatient units Stephaney Resource Nurse Date Aug 14 2012 Time 10 00 PM Site location Finch site e 10 30 AM Physician order on paper e Nurse entered the order to MT e Print labels in units e Nurse check ID verbally no armband used in outpatient clinics e RN Collect blood and label the tubes e 10 45 AM Nurse toke samples to lab Note o There is no Clerk in the Unit to help with entering the orders unit dels with 100 patient day o Unnecessary paper copy of the results always received o Difficulties in printing old results from MT o CBC blood order on MT always defaulted to STAT 179 M Sc Thesis A Kamil McMaster University Computing and Software eHealth L amp D Clinic interview Project name Lab order process flow in L amp D Clinic Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Mary Sackeyfio CLINICAL PRACTICE LEADER Date July 17 2012 Time 12 30 PM Location Church site 1 What type of samples you collect at these clinics CBC blood culture routine blood baby blood in OR blood gas with delivery 2 How many orders normally placed per day Depends on the numbe
21. After defining all of the required workflow tasks and variables for the workflow process sample process the results of the process designing time differed among the four tools 117 M Sc Thesis A Kamil McMaster University Computing and Software eHealth With the YAWL workflow tool we needed 30 minutes to complete the design and 15 minutes to fix the errors The design was as planned with 15 tasks two start and end tasks and we needed 30 branches flows The number of workflow component we used in YAWL became 47 in total With the Together Workflow tool we needed 60 minutes to complete the design and 15 minutes to fix the errors The design was as planned with 15 tasks two start and end tasks and we needed 40 branches The number of workflow component we used in Together become 57 in total With the Bonitasoft workflow tool we needed 40 minutes to complete the design and 15 minutes to fix the errors The design was as planned with 15 tasks two start and end tasks and we needed 41 branches The number of workflow component we used in Bonitasoft become 58 in total With the NOVA workflow tool designing the workflow was not as easy as with other tools The NOVA workflow editor does not provide much control in terms of the direction of the branches flows especially when connecting two branches to one task We had to add some extra tasks and use more branches changing the design of the flow to get the results we needed
22. All the critical results will be submitted to MT regardless of any other method of results notification Normal results This process will take place if the results have normal expectations and will proceed to submitting results directly o Blood bank operations The process of all the blood bank activities including the following three sub processes e Blood preparations A process of i Defining the patient blood type ii Analyzing and preparing the blood bags by the lab iii Getting blood from the blood bank e Blood supply A process of providing blood bags to the unit A nurse or porter can obtain the samples of blood and deliver them to the units The AGV could be used to deliver the blood bags too and the tube system could also be used to deliver the blood bags if pneumatic capsules are large enough to hold a blood bag e Analytical Instrument A process of analyzing blood samples by an analyzer instrument for the purpose of blood bank activity 141 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 8 Submitting results Analyzers will process the samples and submit the results to MT automatically for the following processes a b C Blood Urine and Specimen collections Blood bank results Glucometer results MEDITECH failure This process is a conditioned process of MT failure and consists of o No If MT did not fail the process will be as follows o Yes
23. Identifying bottlenecks is useful when designing the digital lab order process For example in the design of sample delivery process using Y AWL tool the process analysis showed that the process of defining the delivery path is time consuming and by using the cancelation feature we were able to eliminate the wasted time and the system was able to choose the right process path based on the choice of the user Identifying the bottlenecks 81 M Sc Thesis A Kamil McMaster University Computing and Software eHealth in the process helped accelerate process and shorten the delivery time and affect the total lab processing time as well Tool modeling capability The tool has multiple modeling capabilities and consists of the following mapping tasks to human participants web services external applications and Java classes The tool is also capable of using split and join manual automated routing tasks atomic composite tasks multiple instance and conditions YAWL User Manual 2 3 14 18 Modeling features Concurrent duration of activities is one of The YAWL tool powerful modeling features but the most significant feature that the YAWL tool has is the cancellation feature This feature is not available in any other tool except YAWL The cancellation feature allows users to set the process to follow a unique path and cancels all the other paths making it easier for the users when designing a workflow process as well as more
24. Project assistant Observation place A 300 South Rehab amp Medicine Date July 25 2012 Time 10 00 AM Site location Church Contact person Candice Clerk Most orders done by lab tech except orders for patients with PICC line If there is a routine lab order the collection will be during the lab round trip times 6AM 10AM 1 30PM 3 30PM If order is urgent it will be specified as STAT the clerk enter the order and call the lab to notify them about the order lab tech will come right away No notification from lab that the result is ready unless the result is abnormal then the lab will call amp send paper copy Results Note Regular results takes about 2 hours from the time of entering the order to the time of receiving the results STAT results takes about 1 2 hour Stat amp PICC line samples will be picked up by porters Routine samples will be taken to lab by lab tech after doing the collection Clerk writes OE Order Entered on the paper order after finishing entering the order in MT 197 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Observing the lab technician work Technician come arrive at 11 45 AM Collect sample Affix labels Take samples to lab Lab tech duties 6AM 10AM gt technician 6AM 2PM 2 technicians 2PM 3PM 1 technician Endoscopy unit Observation Project name Lab
25. Yes some missing Any issue with the current system Porter service slow Missing sample with no confirmation Recommendations and suggestions Direct order by physician Do you use blood bank service amp how to order Note Bilirubin and most stat tests will be process in Finch Microbiology will be process in Church 189 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Inpatients surgical interview questions Project name Lab order process flow in Inpatients surgical Clinic Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Cathy Brandt Manager Jully Resource Nurse Date July 18 2012 Time 10 30 AM Location Church site 1 What type of samples you collect at these clinics Blood culture Swaps Urine and mostly all type 2 How many orders normally placed per day 3 Who is placing the orders Physician 4 How physicians placing an order Paper chart gt Nurse confirm amp enter it to MT 5 What are the methods of adding another test request to a sample Paper gt Nurse or clerk enter it to MT 6 Where are labels printed or received from In unit when nurse take samples In lab when technician come to the unit 7 Do the nurse technician confirm the information in labels with the test request Yes 8 How staff notified there will be test needed When changing shift MT Verbal 9 Who is collecti
26. department e Due to reported issues from some of the hospital departments porter service slowly responds to requests and samples are easily lost during delivery e Samples from the Keele site are always sent by a carrier or a taxi cab to the lab at the Finch site e Some samples stay in cart with lab technicians until they go back to the lab to deliver them Processing Samples Labs process samples automatically and manually at the same time The laboratory instruments normally comes in three parts or groups pre analyzer analyzer and post analyzer and the lab instrument currently available at Humber River Hospital is missing the automated pre and post parts Plus some of the process confirmations are done manually by the technologists These issues result in a delay in the complete process of the lab order flow Time issues e Collection time shown in MT is the time that technicians put manually in the system 48 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e The current processing time is calculated from the time of placing the order in MT not from the time of processing the sample Submitting Results In the current system submitted results can be done in different ways depending on the type and status of the test e Direct submission to MT e Calling the unit and informing them if results are critical e Calling physicians or sending the results to their devices when results
27. eHealth 4 CHAPTER FOUR RESULTS 4 1 Workflow Tool Evaluation This section contains an overview and the evaluation result of the workflow BPM tools The results of the analysis and evaluation of the workflow tools consist of both qualitative and quantitative data Sixteen workflow tools were selected and examined We filtered the tools based on the specified criteria and selected four tools to perform an in depth analysis and evaluation see Table 1 The results of the analysis and evaluation of the four workflow tools were collected and shown as follows YAWL Workflow Tool Results YAWL is a workflow language based on Petri nets theory which will be discussed in chapter 5 with a graphical representation and well known workflow patterns YAWL User Manual 2 3 18 The tool offers comprehensive support for control flow patterns resource patterns and exception handling With YAWL the users always get an instant update about the workflow design in the analysis result tab provided at the bottom of the tool The tool has the advantage of having a cancellation feature which is not available in other tools Together Bonitasoft and NOVA Workflow designers using the YAWL tool can design any workflow task and direct the process flow based on the need of the flow by using this cancellation feature The analysis of the workflow tools revealed that YAWL editor workspace is designed in an efficient way The graphical editor is designed to m
28. workflow process models The model checker translates the model for simulation and verification by using a reduction algorithm to accelerate the verification time of a normally large and complicated workflow model NOVA Workflow User Manual 2 0 23 Analysis the Tool Can Perform Analysis definition The NOVA workflow tool offers the analysis features run debug error message and quick fix features through the eclipse tool When using the run or debug feature eclipse determines whether there is an error or warning associated with the workflow design It then displays it in a problem s tab with some definition to help the user solve the problem 101 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Analysis role The role of the available analysis features is to spot workflow design problems errors and warnings such as missing libraries or build path error then list them in the problems tab as in see Figure 22 or display it as a message in a message window see Figure 23 fit Problems 53 Javadoc Declaration EJ Console 4 errors 0 warnings 0 others 7 Description Resource Location Type 4 Errors 4 items Sa Archive for required library src cwf property in project futurelabprocess futurelabprocess Build path Build Path Problem fa Project futurelabprocess is missing required library cwf property futurelabprocess Build path Build Path Problem a Project futurel
29. 00 AM Location Church site 1 What type of samples you collect at these clinics INR Electrolyte CBC Potassium etc 2 How many orders normally placed per day 233 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 15 gt 30 day Who is placing the orders Physician Nurse Sometimes for INR Potassium How physicians placing an order Paper chart gt Nurse confirm amp enter it to MT What are the methods of adding another test request to a sample Paper order Nurse or clerk enter it to MT Where are labels printed or received from In clinic amp lab Do the nurse technician confirm the information in labels with the test request No How staff notified there will be test needed Notified by clerk check patient chart Who is collecting the samples nurse or lab technician Lab Technician Nurse PICC line How do nurse technician identify the patient for sample collection for sample test Arm band two ID check H D O B Is there any difference in flow between different samples No Where normally samples are collected Bedside Where collected samples are normally labeled Front desk for isolation How samples delivered to the lab Porter Lab tech when they go to lab How the clinics receive the results MT Paper critical 234 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 16 17 18
30. 182 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Physician order e Clerk enter it to MT e Labels printed in unit e Nurse collect samples e Porter deliver samples to lab e Result will be submitted to MT e If critical a paper copy will be sent to the unit Cardio Respiratory interview questions Project name Lab order process flow in Cardio Resp Clinic Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Lori Smith CLINICAL PRACTICE LEADER Date July 17 2012 Time 10 00 AM Location Finch site 1 What type of samples you collect at these clinics Blood gas 24 7 Microbiology fluid Biopsy 2 How many orders normally placed per day About 10 day 3 Who is placing the orders Physician Bronchitis test Brushing Respiratory Therapist RT Blood gas Nurse 4 How physicians placing an order Paper chart Phone verbal Nurse or clerk enter it to MT 183 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 15 16 What are the methods of adding another test request to a sample Paper Nurse or clerk enter it to MT Where are labels printed or received from In clinic Do the nurse technician confirm the information in labels with the test request Yes How staff notified there will be test needed For Stat t
31. AM Site location Church site 8 50AM Specimen taken by Nurse 9 000 AM Nurse call porter 9 30 AM Porter pick up the sample 10 15 Results come from lab Note A paper copy of the result always sent by la to ICU unit If test critical the lab will call the ICU when result is ready Outpatients interview questions Church Project name Lab order process flow in Outpatient Clinics Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Boodth Claudette CLINICAL PROGRAMS MANAGER Date Wednesday June 13 2012 Time 9 30 AM Location Church site F SURG PRGM ADMIN 1 What type of samples outpatient clinics send to lab Blood urine fluid 175 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 How many orders normally placed per day Around 60 order per day Who is placing the orders Physician How physicians placing an order Physician write a paper request and a clerk or a nurse enter the order to MT 6 0 What are the methods of adding another test request to a sample Physician submit a paper request and a clerk or a nurse enter the order to MT 6 using ad on test feature in M Where are labels printed or received from In clinic Do the nurse technician confirm the information in labels with the test request No How staff notified there will be t
32. CPL Resource Nurse Date July 18 2012 Time 10 00 PM Location Finch site 1 What type of samples you collect at these clinics Bilirubin Baby blood CBC blood culture PKU 2 How many orders normally placed per day About 6 8 day 3 Who is placing the orders Physician 4 How physicians placing an order Paper chart gt Nurse confirm amp enter it to MT 5 What are the methods of adding another test request to a sample Paper telephone order Nurse or clerk enter it to MT 6 Where are labels printed or received from In clinic 7 Do the nurse technician confirm the information in labels with the test request Yes 193 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 15 16 17 18 19 How staff notified there will be test needed Who is collecting the samples nurse or lab technician Nurse Baby Mother Lab Tech How do nurse technician identify the patient for sample collection for sample test Arm band two ID check H D O B Is there any difference in flow between different samples Where normally samples are collected Bedside Where collected samples are normally labeled Bedside How samples delivered to the lab Porter Nurse sometimes How the clinics receive the results MT Sometimes for mother a paper copy will be printed How long it will take to receive the results 1 3
33. Church site Stat order 12 45 PM physician order stat blood test at 12 50 PM clerk enter the order to MT 12 55 PM clerk call lab for stat blood work 1 55 PM lab technician arrived for routine blood work amp stat at the same time Lab tech already brought labels from lab Left labels outside patient room Collect blood and get outside patient room Initial date the labels and affix them on tubes Lab tech toke samples to lab PICC line collection e physician order blood work e clerk enter the order to MT e print labels at the unit labels stays at the desk for isolation reasons e Nurse collect blood then bring it back to desk to affix labels 231 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Notes e If collection done by nurse labels normally will be printed in unit and if the order is stat and collection will be done by lab tech then the labels will be printed in lab but sometimes lab tech ask the staff in unit to print stat labels especially when lab tech is in round trip or to speed up the process of collection e Routine blood collection will be done during the round trip times 6 AM 10 AM 1 PM 3 20 PM e Stat blood collection could be done in anytime e There are a lot of duplicated orders e Lab technicians have to stop the round trip sometimes and go to lab to pick up some supplies e Lab tech do round trip collection and receive pager alerts for stats at the same
34. Computing and Software eHealth 3 Printing labels After entering orders to MT the system will print labels automatically either in the unit or the lab For example with routine orders the system prints labels in the lab so that the technicians can pick up labels and go to the destination of the collection 4 Receiving lab orders Receiving the orders should be performed by the person who will perform the collection For instance lab technicians in a unit always receive and do STAT orders 5 Collecting samples Collecting samples is assigned based on the order type or the status of the patient For example a lab technician cannot do a PICC line collection and a nurse cannot do a tissue collection for a dialysis patient a Registered therapist A registered therapist is able to do the following types of collections Specimen collection Pathology Cytology amp histology Arterial blood gas ABG collection Physician Endoscopy collection A physician can do a collection of endoscopy samples in the endoscopy room OR Collection A physician can do a collection in the OR Nurse in the unit Nurses can do a routine sample collection in a unit for a patient with PICC line Nurses also give glucometer orders Endoscopy collection A nurse can do endoscopy collection based on the physician s directions in the endoscopy room Glucometer collection 126 M Sc Thesis A Kamil McMaster Univ
35. For example with NOVA workflow editor to insert a new component task to the process you need to first select the left and the right element where you want the new component to be inserted then after that you double click the new component and the editor will insert it in the position While with other tools YAWL Together and Bonitasoft you only need to drag and drop the new task to the new position NOVA workflow editor doesn t allow the designer to use the transitions separately or redirect the process based on the need of the design transitions comes already connected to a task and if you want to redirect the transition you need to insert a new transition with a task attached to it 118 M Sc Thesis A Kamil McMaster University Computing and Software eHealth With the NOVA tool we needed 90 minutes to complete the design and 30 minutes to fix the errors We couldn t finish the design with 15 tasks only as we planned with other tools and some of the features are restarted and not flexible in use We added an extra 34 tasks and we needed 60 branches to finish the design see Table 4 for results We needed 49 tasks and two start and end tasks The total workflow components we used in NOVA became 111 after all see Table 5 Installation of the tools varied YAWL Together and Bonitasoft Workflow tools were easy and fast to install while the installation of the NOVA workflow version 0 1 was complicated and version 2
36. New order or Add on a test Computerized Physician Order Entry CPOE This process is the primary method of entering an order by a physician In the current lab order flow CPOE is not fully implemented to the system but in the future digital flow physicians will have direct access to write an electronic requisition using CPOE including the lab order requisition The system will then enter it into MT directly 132 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Verbal This process is typically used in units where physicians are busy and unable to write orders like in the endoscopy clinic A physician could perform a sample collection and then verbally request another sample at the same time The order in this case will be entered by a nurse into MT Phone Physicians can also place an order by calling the unit A nurse or clerk can answer and enter the order details into MT as a new order or add on test order Referred to lab Physicians can refer patients to the lab for a new order only This sub process is preferred because sometimes test results take several days to be completed and need to be ready in advance when the physician sees the patient Glucometer order Physicians can place a glucometer order only as a new order Blood bank order Physicians can place an order for blood bank only as a new order Pathology order Physician can place a pathology order as a new order o
37. Thesis A Kamil McMaster University Computing and Software eHealth 29 30 31 32 33 34 35 36 37 What are the methods of adding another test request to a sample Physician submit a paper request and a clerk or a nurse enter the order using ad on test feature in MT How long it will take to receive the results 4 6 hours required to be 1 2 hour What do you do if results not received missing Call the lab and ask for the status How do you identify the patient for sample for sample test Tow piece of identification plus asking the patients of their names How do you label samples Labeling the samples will be beside the patient except the 24 hour urine collection will be labeled when patient bring the bottle Where are labels printed or received from Labels will be printed in clinic Do you prefer to have confirmation on sample at lab sample receiving and clinic result receiving Yes because when samples received by lab there will be no confirmation of receiving samples put in fridge then it will be confirmed as received when it will be on the instrument Samples could be lost between fridge and instrument and never found Samples always lost when sent with porter Need screening to confirm receiving the sample Recommendations and suggestions a Considering phlebotomy in one place close to the lab b Pneumatic tube system sample delivery c Now doing blood test the day befor
38. Thesis A Kamil McMaster University Computing and Software eHealth This process is typically used in units where physicians are busy and unable to write an order A Physician assistant would receive the order and either write a paper request or directly order it with MT c Nurse practitioner order In the current process nurses have two options when placing a lab order Using medical directive This sub process is the only way of placing lab order process by nurse practitioner Nurses cannot place lab orders unless they have a medical directive signed by a physician the nurse can access the MT electronic health record and begin a new lab order or pathology order Verbal order from the physician This process is typically used in units where physicians are busy and unable to write an order like in the Endoscopy clinic A physician could do a sample collection and verbally request for a sample at the same time o Pathology order A respiratory technicians physician assistant or nurse in OR Day Surgery Radiology Endoscopy can place pathology cytology amp histology orders as a new order or add on test The next step after ordering in the current process flow is explained as follows 2 Entering order to MT In the current process physicians have no access to write direct orders by using CPOE A nurse or clerk is the one who enters a physician s order into MT 125 M Sc Thesis A Kamil McMaster University
39. X appears in the upper right corner of the element This indicates that there is a correction needed 21 e Run a process This feature is used to test the process through executing it To run a process from inside Bonita Studio is one means to execute it in a development environment to be used for testing as you develop a process e Debug This feature is used to re run the process in development or test mode to disconnect any unsuccessful connectors Use Debug in Bonita Studio to disconnect any connectors that you know cannot run successfully when you run the process in development or test mode e Test a connector With this feature you can test the function of some types of connectors while still in design development mode 95 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Process simulation This feature is used to assess the process path or technique using simulation to evaluate the way a process runs under different resource availabilities and different load profiles Analysis configurations Since there is no analysis tool for the Bonitasoft workflow tool there is no configuration as well The available problem detection features have different configurations based on the purpose of every feature The available options for check BPMN model feature are activate or deactivate The users can activate the feature if they want to see any missing configuration in
40. a Physician assistant can place pathology cytology amp histology orders as a new order or add on test 134 M Sc Thesis A Kamil McMaster University Computing and Software eHealth MT Electronic Health Record Humber River Hospital uses the MT electronic health record to save and maintain patient records In the future digital process flow physicians have direct access to write lab orders using CPOE Nurse practitioners as well have access to write orders through accessing MT directly After ordering the future lab order process will continue as follows 2 Confirmations and Verifications This part of the process is where the confirming of sub processes takes place Status of the lab order will flow from MT the status board will be updated with the information of receiving orders collecting samples delivering samples processing samples and submitting results Confirmation and verification will also consists of notifying the staff or lab of new orders accepting orders by lab technicians or nurses 3 Receiving orders Receiving the orders should be performed by the person who will perform the collection For instance lab technicians in the unit always receive and carry out STAT orders 4 Collecting samples Collecting samples could be assigned based on the order type or the status of the patient For example a lab technician cannot perform a PICC line collection and a nurse cannot collect a tissue from a dialysis pat
41. and Software eHealth IT 18 19 20 21 Note What do you do if results not received missing Call the lab Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT Yes but should not intervene with nurse work Any issue with the current system Recommendations and suggestions Need lab tech in ED to do blood work Lab need to call when blood bank have the blood ready Do you use blood bank service amp how to order Yes e Physician order on paper only e Nurse do the test cross amp type group amp screen and send to lab e Nurse order the needed blood e When blood ready lab don t call but result will be on MT e Nurse or unit aid take face sheet when pickup blood e When blood arrive two nurses should check 1 Order 2 Consent form 3 Patient ID 4 Face sheet When pneumatic system broke they use basket to collect samples and then nurse unit aid or volunteer take the samples to lab Pneumatic tube system samples containers are not enough and some of these containers stays open Containers sometimes stuck inside the tube system 221 M Sc Thesis A Kamil McMaster University Computing and Software eHealth The system in easy to use and very useful Emergency Department unit Observation Project name Lab order process flow mapping Observer name job title Ammar Kamil Project assistant Observation place ED unit
42. and package tree panels The fourth part of the user interface is located at the bottom side of the interface and contains the property search problems Wf MC XML WfXML and LDAP based system panels Together User Manual 20 Although the graphic and XPDL panels are surrounded with all the required features the graph layout itself contains all the required components It offers the possibility to insert 85 M Sc Thesis A Kamil McMaster University Computing and Software eHealth new elements into the graph and to visually define the flow logic of the workflow process you are modeling Together User Manual 20 pp 10 Execution engine The Together Workflow Tool uses the open source WfMC XPDL Enhydra Shark workflow engine to run and execute the workflow design this engine interprets and executes the final XML file output produced by the workflow editor Together User Manual 20 The available configuration for Together Execution Engine is the configuration specific to TWE usage with shark engine including a specific property panel for editing some of the extended attributes Together User Manual 20 To run the engine users need WfMXL components and a valid registry service URL to be able to connect to the engine Simulation The Together Workflow Tool provides users with access to simulation information Simulation information is available as part of the activity property panel Using the tool
43. are critical e Sending a paper copy to the department s printer mostly done as an unnecessary action in most departments even when the department didn t request a paper copy Storing Samples Samples are normally stored based on their type The lab stores blood and specimen samples for days but store urine samples only for hours Current Strategies The current strategy mostly depends on a manual process flow in all of the processing stages and tasks No automation is available in the current system except in some parts of the process and in the submission of the result to MT Analysis Process The analysis used questionnaires interviews and observation as the three types of methods to collect necessary information of the process see Figure 11 for sample of the questionnaire form used in the collection of the data to categorize the processes and issues of the current system 49 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Medicine Nephrology interview questions Interviewee name jobtitle _ es Date i Agt5 20120 S What typeof samples you collect at these clinics INR Electrolyte CBC Potassium etc How many orders normally placed per day gt 30 day Whois placing the orders Physician Nurse Sometimes for INR Potassium How physicians placing an order Give paper chart to nurse to confirm amp enter it to MT What are the methods of adding another t
44. clinics they use porter system hospital carrier system and taxi cab to deliver the samples Orders submitted to the lab should be done the day before by midnight There are some orders for three days in a row Emergency clinic in Church uses pipe chute amp Finch uses pneumatic Inpatient unit they use MT 6 0 order entry to order a test Order will be placed by physician not nurse After order placed label will be printed in the lab contain patient name location DOB test required and a barcode generated by the system matching barcode with patient information will be done by system too When order received technicians will go in two rounds 7 00 AM amp 8 00 AM to units discharge first to collect samples Samples go to the power processor instrument to be processed current style involves human interaction delay the process Instrument reads the barcode on the blood tube and will process it based on the type of test required some tubes will be sent to a different process out of the instrument 158 M Sc Thesis A Kamil McMaster University Computing and Software eHealth and the rest will go to be centrifuged and then will go to the analyzer to be processed results will be written by the analyzer on a MT 6 0 a technologist check the results on MT and correct add comment or perform some extra tests on the sample then verify the result and release it to MT Patient will be identified by name and DOB on
45. count an abbreviation used in lab orders when physicians order complete blood count test CPOE An abbreviation for Computerized Physician Order Entry a system for placing lab or pharmacy orders online by using electronic health record software CSS Cascading Style Sheets is a language used for describing the formatting of XML or HTML files Cytology amp Histology A procedure where the pathologist checks samples of tissue or cells under the microscope ebXML Electronic Business Process using extensible Markup Specification Language EMR EHR EMR is an abbreviation for Electronic Medical Record a patient s medical record within a healthcare setting clinic hospital or practice patient information will stay within the organization Xi EHR is an abbreviation for Electronic Health Record electronic storage of patient and other data practitioners medical letters etc belonging to the healthcare system and available to authorized practitioners patient information moves beyond one healthcare organization to specialist hospital or clinic and contain more than patient medical record and contain all patient medical and nonmedical information related to the patient HTML An abbreviation for Hyper Text Markup Language for designing website pages IEEE An abbreviation of the Institute of Electrical and Electronics Engineers IHE Integrating Healthcare Enterprise an automated system to share clinical data and tasks betw
46. day Church 300 day Finch 250 day 7 Why in your opinion most clinics complain about the delay in porter service 241 M Sc Thesis b C d A Kamil McMaster University Computing and Software eHealth Too many orders to deliver Up to the management schedule First in the morning run to department takes time to be completed Some stat pickup could disturb other departments pickup 8 What are the services you provide We provide service of the following a b C d e Lab order and stat specimen Medicine pharmacy Patient pickup Solid linen Equipment 9 Any issue with the current system Porter service should be determined as delivering from point A to B 10 Recommendations and suggestions Need better management schedule Need routine work Note Dialysis clinic they have separate porter service 242
47. device Meditech wireless phlebotomy piloted to print labels by bedside used by Halton healthcare to reduce patient identification 159 M Sc Thesis A Kamil McMaster University Computing and Software eHealth and specimen labeling errors The current scenario technician take printed labels and empty tubes to clinics tech leave labels on cart go to patient room to collect blood Identify patient by the name on the bracelet Collect blood Take blood samples outside patient room where the cart is Take labels with patient name and place them on blood tubes Error can t be noticed unless patient has previous record so technologist can only compare results of previous and current record otherwise for first time patients there is no record to compare with errors will not be identified By implementing this device not only errors will be reduced but also time will be managed properly technicians will stay in floor to collect blood and if any update comes to the patient request technicians will be notified by MT through the device and will be possible to them to see updates on current orders and arriving of new orders Time of the collection will be entered directly to MT when technician print the label and no need for manual entry to the system 2 Need for pneumatic tube for delivery Technicians run between clinics collecting blood and delivering the sample to the lab at the same time this action wil
48. gt ure R Activity task oS 5j XOR Gateway K ae X Verbal Order a From Phyhsician AND Gateway D Using Medical Directive RE g Bank Order X E Nurse or Clerk Add on Test X New Order End Figure 8 Together workflow ordering design 37 M Sc Thesis A Kamil McMaster University Computing and Software eHealth These aspects together make the design easy for users when designing a new workflow process see Table 5 Bonita Workflow Tool Results Bonita Open Solution is a combination of a user interface process modeling studio and a BPM and workflow engine The graphic interface of Bonita studio allows the user to draw processes directly by using a notation compatible with the Business Process Modeling Notation BPMN standards The Bonita execution engine runs behind the graphical interface which connects the processes to the existing system to deploy and run the process The Bonitasoft tool has decision tables add and test connectors multi instantiations timer configuration and conditions a selection of workflow designing options which can be useful when designing the lab order process for a healthcare setting The Bonita tool uses the Hibernate lightweight relational database with the Bonita execution engine 21 Although the tool has a lot of useful features the tool does not generate code for users to modify and users will have no excess to the html css and Javascript codes that t
49. hour What do you do if results not received missing Call the lab Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT Yes some missing Any issue with the current system Porter service slow Missing sample with no confirmation 194 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 20 Recommendations and suggestions Pneumatic delivery system 21 Do you use blood bank service amp how to order Endoscopy Med day care Church interview questions Project name Lab order process flow in Endo Med day care Clinic Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Maryam Pourtangestani Manager Date July 18 2012 Time 10 00 AM Location Church site 1 What type of samples you collect at these clinics All types 2 How many orders normally placed per day 100 day 3 Who is placing the orders Physician 4 How physicians placing an order Paper chart verbal gt Nurse confirm amp enter it to MT 5 What are the methods of adding another test request to a sample Paper telephone order Nurse or clerk enter it to MT 6 Where are labels printed or received from In clinic 7 Do the nurse technician confirm the information in labels with the test request No 195 M Sc Thesis A Kamil McMaster University Computing and Software
50. lab technicians lab technologists and the director of laboratory who is responsible of following the order from the time of issue to the receiving of the results the information include the time of process and capability of the laboratory instruments The calculation of the current process time involved calculating a real time lab orders process by observing the processes from the time of placing the orders to the submission of the results to the hospital department where orders take place The future digital process is predicted based on information we received from the questionnaires interviews with the laboratory director and from the specification of the new instruments involved in the new digital process The result of the turnaround time shows a clear difference between the current and future process times see Table 12 69 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Process Current process turnaround time Future process turnaround Ordering 5 minutes 1 minutes Entering orders to MT 15 minutes 0 minutes Receiving orders 15 minutes 5 minutes Collecting samples 15 minutes 10 minutes Delivering samples 30 minutes 2 minutes Processing Analyzing Submitting 55 minutes 22 minutes Total Minutes 135 minutes 40 minutes Table 12 Process turnaround time With the current process a complete lab order takes 135 minutes to complete while with the new di
51. offers run debug error message and quick fix features as an analysis features through the eclipse tool The tool uses NOVA workflow translator to reading the 4 M Sc Thesis A Kamil McMaster University Computing and Software eHealth workflow model and its properties file and translate it to a DIVINE process the initialize method will be translated first then action and finalize methods at last The DIVINE model checker uses two types of variables global or local in the task property file Most of the available tasks are human use tasks and are not to be run automatically by a system The analysis of the tool showed that the tool contains limited set of features and conditions task properties and split join features are constricted when used in the designing of the designated Future lab ordering sample The NOVA workflow tool supports Java and CWML The tool is free to download and offers the required plugin but it is not open source software Through examining the tool we found that the NOVA workflow tool has 13 technical workflow features and 6 non technical features Designing the designated workflow process sample Future lab ordering took 120 minutes to complete when using the NOVA tool and used 111 workflow components task and branches to satisfy the design see Figure 10 42 M Sc Thesis A Kamil McMaster University Computing and Software eHealth START O
52. or messages to users when needed The other option is the data type validation which is a unique feature available in YAWL its role is to alert the user about any invalid data type definitions by turning the whole XML code to a red color or to green when the data type definition is valid Most of the previously mentioned tool features the use of the tool analysis to spot the workflow problems unnecessary or join note and problem display panel where used when designed the workflow sample process and future lab order process 78 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Analysis configuration There are two options to configure YAWL analysis The first choice is to Reset Net Analysis which allows users to select the necessary options from the configuration dialog box examples of Reset Net Analysis are using YAWL reduction rules before analysis for optimization checking for unnecessary or joins or showing observations in analysis results The second option WofYAWL Analysis allows more options for the users but will be available in the configuration dialog if the optional YAWL specification analysis utility wofyawl exe is supplied in the same directory as the editor YAWL User Manual 2 3 14 18 pp 92 see Figure 17 Configure Specification Analysis zs Reset Net Analysis WofYAWL Analysis R Use the reset net analysis algorithm Use YAVVL reduction
53. order process system The research collected lab order process data and used the qualitative methodology to analyze these data to find the critical phases in the current process and eliminate it from the new digital lab order process flow design The result of this research will have tremendous effects on eHealth and the healthcare system futures by recommending the right tool for designing a new process system for a healthcare setting and providing valuable data about transferring the lab order process from a paper based system to a digital based system The recommended workflow tool has unique designing features and components allowing the tool users to manage control and finish a successful workflow design in sufficient time The new digital lab order process flow design will save the hospital time and money contribute to patient satisfaction and provide more security to patient information than the old paper based system 145 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 6 1 Workflow Tools Evaluation Conclusion The first part of the study is devoted to the effort of selecting the best BPML tool To help in designing the new digital lab order process flow we started by selecting 15 open source workflow tools and filtering them based on certain criteria This consists of availability of an analysis tool tools features support graphical editor execution engine and simulation We also
54. other test will be sent hospital lab or which lab and what are the types Some of the tests are too costly or the hospital doesn t have the right instruments to process it examples factor studies call marker blood and C Reactive protein 161 M Sc 2 3 4 5 6 7 8 9 Thesis A Kamil McMaster University Computing and Software eHealth What is the current process time for a sample Stat 1 hour Routine 2 3 hour Oncology longer time due to the nature of the test and most oncology tests done manually For how long samples will be stored Storing depends of the type of specimen for example Hematology 3 days Chemistry 7 days Urine hours How the processes go if one of the instruments broke Follow the backup procedures redundancy probably another instrument will cover up if the other down will sent to other hospital Is there any difference in the process flow of each specimen General flow is same for every specimen Why patients come in person to lab for test Could be test for dialysis Or patients do the test before the appointment to be ready at the time of the appointment How many orders you process every day in the lab Around 2500 total In Care 2000 Micro 250 300 Pathology 500 Do you see the lab inventory system as part of the lab process Inventory system doesn t break the flow of the lab round trip but it is important to maintain the speed of the proces
55. proposed technology and whether or not this technology is required for the new design see Table 7 Current Process Finding Weak Points Based on the analysis of the current process data we found the following weak points in the current lab order process system Lab related Time e Collection time showed in Meditech MT is the time that technicians put manually in the system e The current system calculates the time of processing a sample from the time an order entered to MT The system calculates the sample delivery time as part of process while the calculation of the processing time should start after delivering the samples to the lab some samples could take 1 30 hour to be delivered to the 51 M Sc Thesis A Kamil McMaster University Computing and Software eHealth lab and 30 minutes to be processed and based on the current system calculation the 1 30 hour delivery time will be added to the 30 minutes processing time and the process time will show as 2 hours Oncology tests take longer due to the nature of the test and a required portion of oncology tests are done manually Priority or type is determined based on the letter on the right side of the label number 05 66 C00045R where the R means routine lab order Delivery amp Confirmation Methods of delivery consist of the following porter nurse lab technician volunteer carrier and taxi cab All of these methods delay the process and could cause a loss o
56. results 3 2 hours What do you do if results not received missing Do another test Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT No Any issue with the current system Night time is hard to do collection because RT is busy Nurses not trained for blood collection Most night blood collection will go missing Recommendations and suggestions Nurses need proper training to do blood collection Do you use blood bank service amp how to order Yes 211 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Order cross and mach e Lab come to check the type e When ready lab call or shows in MT e Nurse or porter take the face sheet and go to lab for pick up Note If stat the unit will page the lab tech till 11 30 PM for collection and after this time the collection will be done by the RT ICU CCU Observation Project name Lab order process flow mapping Observer name job title Ammar Kamil Project assistant Observation place ICU CCU Date July 27 2012 Time 11 00 AM Site location Finch e The unit has a satellite unit and the satellite unit has its own label printer e Collection will be done by lab tech unless it s PICC line Observing lab technician work STAT Start at 11 25AM take labels and tubes to the patient room Identify the patient Bracelet two ID C
57. rules before analysis for optimisation Use Reset reduction rules before analysis for optimisation Check for weak soundness property using coverability Check for unnecessary cancellation regions ID OSS Check for unnecessary or joins Check for or joins in a cycle Check for soundness property using reachability results from bounded nets O N N Show observations in analysis results These tests may overlap in identifying unreachable tasks in the specification potential deadlocks and possible unfinished work in completed workflow cases 5 Keep Analysis progess dialog open when Analysis completes Done Cancel Figure 17 YAWL analysis configuration Progress dialog box The progress dialog box displays updates and messages about the progress of the analysis this information is useful to the user in understanding the status of the process design and resolves any fix required see Figure 18 79 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Analyse Specification zs Analysing Specification Completed Elements in the original YAVVL net Ordering 42 ira i YAWL Reduction rules 0 rules Reduced net size 42 Elements in the original reset net 87 Reset Reduced net 1 rules FSPR Reduced net size 67 Immediate successors 14 Immediate successors 19 Immediate successors 11
58. step lab orders processes Phase two consisted of analyzing the collected information and creating step by step flowcharts of the current lab order workflow process followed in the hospital A general flowchart for the lab orders role of the hospital was created for broader understanding see Figure 4 for the current general flow chart In Phase three we conducted follow up interviews with the hospital departments managers to confirm if the data was recorded correctly and to verify the design of the current lab order workflow process Phase four involved defining the major activities and flow of the current process by drawing the current lab order process flow as a first step toward determining the correct flow for the future process see Figure 26 and Figure 27 The analysis of the collected data show that the current paper based order has multiple issues for example lab orders taking long time to be completed lab orders containing samples that were mislabeled increasing the samples processing cost due to the long processing time lack of mobility with the current order placing and the need to improve sample taking quality The current lab order process flow is performing using old paper based methods containing multiple issues and weak points in different areas of the process specifically laboratory delivery and confirmation labeling and ordering The most noticeable issue in the current process is the turnaround time
59. supports available e Number of technical and non technical features available in the tool 114 M Sc Thesis A Kamil McMaster University Computing and Software eHealth The evaluation of the tools includes comparing the finally selected four tools YAWL Together Bonitasoft and NOVA When we used the workflow tools to design a workflow process we experienced different types of errors and problems with each tool We did not consider the number of errors the tools produce while designing a workflow process as a factor when comparing different tools We found that it is inaccurate to evaluate the tools and compare them based on the amount of errors and problems they produce due to the fact that errors could be caused by the user of the tool when designing a workflow process such as selecting the wrong event or specifying unrelated parameter Instead we measured the ability of the tools to find and direct the user to fix the error or problem in each tool and consider it as one of the development time factors Studying the tools The work in this section includes describing and explaining the procedure of studying the selected tools We worked with each tool independently and researched for several weeks to accumulate and collect as much as possible data on the tool its capabilities features the work consists of e Reading about the tool s documentation and do research on the tool features functionalities abilities use of the
60. teed ea eo ae ea ane a Rade iv ACKNOWLEDGEMENTS ienssisneo etisi tne aseina t eod aeea a i ke se aes vi TT STOVE PT Gr IRS E E E ang E E E E EEE ix LIST OF TABLES vssissscscccssavesciunsvaiiathanaetejane a aE E E e EA ATE da eae E A TEREE A x LIST OF ABBREVIATIONS AND SYMBOLS 0000 ceceeeecsescceseeeseceeeeaceenceseeeaeeaeeneeene xi 1 CHAPTER ONE INTRODUCTION AND PROBLEM STATEMENT 000 1 2 CHAPTER TWO LITERATURE REVIEW ccssossscsssectscosssccaterseesersansenseincesess 9 2 1 eHealth Applications i cciiaduciand watunancsiadadaddsnanndeiiatucdes 9 22a Patient SOE GLY erie ts th ra E reg doses saa saat ese Peay esa anes 10 2 3 Workflow EOGIS ices ceinesatleadpaapedst Maca yangt cesseeal a aae enis oni sass 10 24 Workllow languages oo ARGS ek OEE Eao EN aR a ai 11 25 MUSeor Workflowsan Healthcare cenin sorta cares dogs enn eases eee 11 2 6 The Power of Workflow Tools seca cps n5 eiaess ho coes tet eee han lemons pte cure tata 12 Zi Workflow LIMItANONS lt 9 3 5 ceases cet k are a sh cease recs tiasaddel Secale 2s ss ceased ae 13 2 8 The Use of Business Process Languages and Business Rules cceeeeeeee 14 29 Related Work tid Set oe a eee deed eho Ge ate deel eee aaa 15 ZAO SUMMAT eeart E a a E eE ETE EE NEES 16 3 CHAPTER THREE METHODOLOGY s sseeseeeseesesseseesesseesrssesresessesersesseeeesseseese 18 Dic Desig Moora a a EE a E E E A AE E A E E T A Teat 18 3 24 Participants and SettiNt
61. the process flow was based on the needs of the flow process For example delivering a blood sample from one of the hospital departments to the hospital laboratory can be done in three ways using the Pneumatic Tube Transport PTT Automated Guided Vehicles AGV or by sending the sample with one of the hospital staff nurse or a lab technician to the lab The benefits of using a powerful BPM tool gave us the opportunity to design the process flow so that if one of the delivery methods mentioned above worked the system would automatically cancel the other two modes of delivery see Figure 1 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Delivering_Samples Pneumatic Tube Systemf Starttask gt EndTask Cancellation sign W Split sign i D E EED aa il Figure 1 Sample Delivery Cancelation The new digital lab order process flow design will save the healthcare organization time and money and contribute to patient satisfaction It will also give the healthcare staff physicians lab technicians nurses etc the opportunity to control and manage all the new lab orders in a more efficient way With the new lab order digital system physicians will have the ability to order lab order by using the Computerized Physician Order Entry CPOE as one of the ways of placing an order In the second part of the study we calculated some of the new d
62. the results automatically analyzers process the samples and submit results to a MEDITECH EHR Submit the result into MT in all situations b Submitting a paper copy to units Send a paper copy to the unit s printers c Submitting to physician phone or device Send results to the physician s devices or phones if the result is critical d Calling the unit Informing the unit by phone if the results are critical 131 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 Storing Samples Storing samples determined based on the samples type For example blood samples being stored for days while urine samples are stored for hours only Future lab order process The future lab process flow will include 10 main tasks ordering MT electronic health record confirmations and verifications receiving orders collecting samples delivering samples processing samples analyzing results submitting results and storing samples Each of these tasks contains sub processes to reach the next tasks and can be explained as follows 1 Ordering The lab order process starts with placing an order either by a physician a Physician assistant or nurse practitioner The main method of entering orders by a physician is CPOE The main method of entering orders by other staff is by direct entry into MT e Physician order This process consists of seven sub processes all of which will lead to one of two tasks
63. tool in healthcare or any other field and reading the user manual e Applying and checking up installation process of the tool to experience any errors or difficulties e Getting familiar with the tool s functions and the graphical interface by using it to design some workflow samples create variables e Analyzing the tool by assessing all available features in the tool checking the ease of use when designing a process availability of analysis and problem detection and error fixing e To be fair and avoid bias when comparing and evaluating any tool and due to the difference between tool we had to use all the tool s components proficiently to 115 M Sc Thesis A Kamil McMaster University Computing and Software eHealth design workflow samples fix errors analyze process create parameter until we have the same level of proficiency with all tools e The time for getting familiar with the tools varied most tools needed several weeks except with the NOVA workflow tool we needed more than two months but finally we were able to have the same level of expertise with all tools e We evaluated each tool based on preset criteria consists of the information we collected from studying the tool searching about the tool and its capability and features and by measuring the processes designing and development time of a sample workflow process the tool s technical and non technical features number of components used when designing
64. tool is missing some important technical features the process analysis process property create variables check validity and problem detection The tool does not generate code and is mostly intended for business processes developments and not for system or technical processes development 34 35 Joget Workflow Tool This tool comes in two editions one is a community edition which is an open source and web based software the other an enterprise edition which is a commercial edition The free edition tool has some useful workflow features but they not as flexible and powerful as the features of YAWL or Together Additionally some features are not as strong nor as explained in the tutorial such as when working with properties or defining variables 36 ProcessMaker Open Source Workflow Tool This tool comes in three editions cloud enterprise and open source Although the description of the tool feature shows some useful workflow tools the study of the tool revealed that the tool s features are limited and not useful for designing a powerful workflow process Some of these features are not available and the tutorial videos and screen shots are for different editions of the software The other main concern with this 112 M Sc Thesis A Kamil McMaster University Computing and Software eHealth tool is affecting the computer system preventing other tools like Aperte from working properly 37 RunaWFE Workflow Too
65. turnaround time is one of the major benefits of the future digital process We developed a turnaround table showing the difference between the current lab order process time and the future digital 149 M Sc Thesis A Kamil McMaster University Computing and Software eHealth process time The result of the turnaround time check shows an enormous difference between the current and future process times see Table 12 With the current system a complete lab order process lifecycle takes 135 minutes to complete while with the new digital process a complete lab order process lifecycle should take no more than 40 minutes to complete A difference of 95 minutes between the two processes shows the benefits of the new design see Figure 14 for more details 6 3 Future Process Design Conclusion The new digital lab order process flow design should save the healthcare organizations time and money and contribute to patient satisfaction It should also give the healthcare staff physicians lab technicians nurse etc the opportunity to control and manage all of the new lab orders in more efficient way With the new system physicians will have the ability to order lab order by using the CPOE Designing the new digital flow system starts by 1 defining the process tasks 2 outlining the future process required to match the new system requirements 3 designing the Draft of lab order process flow diagram see Figure 26 and Figure 27
66. 0 was long and caused many difficulties The instructions on how to start a new workflow design were available in the YAWL and Bonitasoft workflow tools However the instructions for the Together and NOVA workflow tools on how to start a new workflow process were not clear It was sometimes available within the text but without a specific title The new NOVA user manual version 2 0 is missing a lot of valuable instructions on how to complete the process s configurations guard conditions and branches flow orders making it much more difficult to complete the workflow design The new digital processing time is one of the important factors of choosing the right tool the type of workflow tool plays an important role in getting the desired digital process time Designing the process in different tools results in getting different processing times We collected important data in the evaluation phase of this study some of that data shows the difference a tool can make on the digital process time if the new digital process is designed using these tools The features cancellation identify bottleneck automated tasks timer event discover infinite loop probability of failure plus the all features you find in Table 2 will affect the process time if used in the designing of the process 119 M Sc Thesis A Kamil McMaster University Computing and Software eHealth For example the identify bottleneck feature helps the process desig
67. A bpmn2bpel Apache Airvata jBPM Anduril Kepler nexusBPM Apert joget Process Maker Open Source RunaWFE and Yaogiang BPMN Editor 2 1 21 The final selection of the best tool in section one of the study helps in the design of a new digital lab order process flow The second part of this study consists of lab order processes in all Humber River Hospital departments that involve laboratory work Laboratory ICU Oncology Emergency Outpatient Acute care Birthing Mental Health Surgical Nephrology Dialysis and Inpatient Information was collected from a variety of sources the head of physicians the laboratory service director departments resource nurses departments clerks four lab technicians one lab technologist departments clinical leaders and managers two pathologists six nurse practitioners four special care nursing a porter service manager one porter employee a chief nurse officer three endoscopy nurses a director of surgery and one respiratory therapist 3 3 Procedures The study was performed in two parts Part one of the study involved collecting information and examining 15 workflow tools this investigation is the first to assess workflow tools with the best easiest and most useful features across all 15 tools an 18 M Sc Thesis A Kamil McMaster University Computing and Software eHealth essential first step toward the ultimate goal developing digital flows in a hospital lab env
68. A COMPARISON OF DIFFERENT WORKFLOW MODELING TOOLS A COMPARISON OF DIFFERENT WORKFLOW MODELING TOOLS CHOOSING THE MOST ACCURATE TOOL FOR DESIGNING A RELIABLE HEALTHCARE SYSTEM By AMMAR KAMIL B A Sc A Thesis Submitted to the School of Graduate Studies in Partial Fulfillment of the Requirements for the Degree of Master of Science in eHealth McMaster University Copyright by Ammar Kamil July 2014 McMaster University MSc E HEALTH 2014 Hamilton Ontario TITLE A Comparison of Different Workflow Modeling Tools Choosing the Most Accurate Tool for Designing a Reliable Healthcare System AUTHOR Ammar Kamil B Sc Baghdad University B A Sc Centennial College SUPERVISOR Professor E Sekerinski NUMBER OF PAGES xiv 242 ii Dedicated to my family iii ABSTRACT The growth of software use in healthcare increases the need for designing and developing accurate systems which raises our need to find precise tools for designing the digital flow of lab order process This study consists of two main parts first determining the best BPM Business Process Management tool for designing digital lab order process flows The chosen tool was used to design an improved digital lab order process flow for Humber River Hospital s lab order process in a highly advanced way the new workflow tool enables the workflow process developer to better represent and analyze the process tasks based on the needs of the process flow I
69. Clerk fax the results to the surgeon s office Clerk file the results to the patient s chart If different tests being requested for a patient in one order the P A T T department receives the patient test results as single pages for every type of test being requested not as list of tests for one order in one page 240 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Transporting specimens interview questions Project name Lab order process flow in Endo Med day care Clinic Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Scott Horn Date July 19 2012 Time 1 00 PM Location Church site 1 How do you determine the priority of a sample Subject to how many calls and the type of the order 2 How do you receive pickup request Clinic call the call center gt Call center book an appointment and display orders on the central screen Some departments have direct access to the booking system website 3 What are the methods of delivering a sample a Morning round trip use basket if needed b Regular pickup c Packaging the specimens is up to the department 4 Do you use confirmation Porters confirm their orders internally only on the porter pager no confirmation with units or lab 5 How many porters all together working in church and Finch sites Church 18 day Finch 12 day 6 How many orders being processes every
70. L Order Entered to MT 6 0 Results will be submitted to MT 6 0 Different colors does not represent specific meaning but to separate process stages only v v Submitting to nae Calling the unit physician s phone or Seay e device Storing Samples Flowchart shapes units translation Process Paper Document External Data TR OIE Subprocess Data Connector Figure 4 Current lab order process design 22 M Sc Thesis A Kamil McMaster University Computing and Software eHealth In phase three follow up interviews were conducted with the hospital departments managers after the completion of phase two to confirm that the data was recorded correctly and to verify the design of the current lab order workflow process Phase four involved designing a Draft of the new digital lab order process as a first step toward the final design of choosing a workflow tool We used the recommended YAWL workflow tool to design the new digital lab order process see Figure 5 Future_Lab_Process Flow Pz Stattask Pk EndTask m e E E ered Cancellation sign W EREE a ae a
71. Pneumatic Tube Transport PTT System With the new process design technicians deliver the samples back to the lab via the Pneumatic Tube Transport PTT system The lab technician or nurse would then pop the tubes into the PTT and deliver the samples to the lab When the samples arrive at the lab the tubes are then manually transferred from the PTT station to a lab track pre analyzers and at this point the lab will confirm its receipt of the tubes Processing and Analyzing The new lab will be fully automatic pre analytical processor analyzer and post analytical processor The pre analytical instrument will scan the incoming tubes and will determine the work required for process update the status of the sample stage to in process on the whiteboard and update the process starting time The lab technologists will then follow up with the automated process and intervene when required The automated analyzer will analyze the sample results and determine if reprocess the sample required based on repeat criteria see Figure 13 64 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Analyzing Results Blood Bank Operations Use of colors only to separate the Analytical Abnormal That Meet ti Blood Preparations Blood Suppl Abnormal That Meel sections Repeat Criteria gt gt To MT 60 To MT 6 0 Figure 13 Draft of fu
72. Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 15 16 17 18 Do the nurse technician confirm the information in labels with the test request No How staff notified there will be test needed From Doctor s order Who is collecting the samples nurse or lab technician Lab tech Nurse if there is a PICC line How do nurse technician identify the patient for sample collection for sample test Arm band two ID check H D O B Is there any difference in flow between different samples No Where normally samples are collected Bedside Where collected samples are normally labeled Outside the room How samples delivered to the lab Porter stat Lab tech routine How the clinics receive the results MT paper copy Abnormal results gt lab call the nurse How long it will take to receive the results Depend What do you do if results not received missing Call the lab look for it Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT No 227 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 19 Any issue with the current system 20 Recommendations and suggestions Porters should carry baskets or containers to carry the samples 21 Do you use blood bank service amp how to order Yes e Physician order e Clerk nurse check the MT record if there already blo
73. University Computing and Software eHealth run again The call activity could be used as an alternative to the message flow when designing the digital lab order process With the Bonitasoft tool users can define two types of variables global variables for the entire process and local variables for an individual task To define a variable users have to choose the pool by clicking it for global variable then they must choose the task by clicking it for local variable Next from the general detail panel they must choose data and then add the variables 21 When defining the variables users will also have the choice of defining the variable either as a single variable or as multiple variables Users can also define checkbox or dropdown list as variables from the same add variables window With the Bonitasoft tool users can define conditions of the transitions to determine the path of the transition in the process workflow Defining a condition on a transition can be done in many ways Bonitasoft User Guidance 21 e By defining the transition as default flow e Entering script directly into a condition field e Create a script by using the expression editor e Create a script by using decision table Requirements To run Bonita workflow tool a user needs to install Java Runtime Environment JRE version 6 or 7 installed To develop software using Bonita workflow a user you need the Java Development Kit JDK version 6 or 7 The
74. Workflow Editor TWE or also known as Enhydra JaWE is a Java workflow editor for creating editing managing and reviewing workflows The tool relies on Workflow Management Coalition WfMC and XML Process Definition Language XPDL Specifications V2 1 using the Business Process Modeling Notation BPMN graphical notation process definition files 6 The TWE sources and user manual provides users with a clear understanding and extensive overview of process definitions Using BPMN graphical notation the editor symbolizes all XPDL graph components and elements graphically through property 83 M Sc Thesis A Kamil McMaster University Computing and Software eHealth panels Together User Manual 20 Although there is no clear indication in the TWE sources about using Petri Nets in the TWE workflow tool but from understanding the concept of Petri Net and its relation to the workflow models we can realize that Petri Net represents a mathematical form in the TWE workflow tool Workflow models use events conditions and transitions to specify and control a process and places and transitions in Petri Nets represent the conditions and events in a workflow model The TWE workflow tool provides analysis of a workflow model to specify any problem related to the workflow The TWE list the problems or errors in a problem table see Figure 20 The display of errors at the designing time is one of Petri Net concepts used in analyzing w
75. abprocess is missing required library lib cwf property _ futurelabprocess Build path Build Path Problem da The project cannot be built until build path errors are resolved futurelabprocess Unknown Java Problem Figure 22 NOVA problem tab S Message Ex oe No task selected Figure 23 NOVA error message This problem list of errors or warnings was designed based on the eclipse tool configuration in order to display all of the necessary information to fix any error or warning It offers some suggestions through a quick fix feature from the eclipse problem tab the quick fix feature provides suggestions to fix only a Java code error of the classes and not for the process design like with other tool YAWL Together and Bonitasoft see Figure 24 and Figure 25 for examples of problem window and editor window 102 M Sc Thesis A Kamil McMaster University Computing and Software eHealth V oui Fix amp ss J Quick Fix Select the fix for abstask seniorcare SCWorkflow Check_Access canno t be resolved to a type y Select a fra S amp S Create class Check_Access in package abstask seniorcare SCWorkflow Create class SCWoerkflow in package abstesk senicorcare Fix project setup an R rce w gt Location Select All Check Access Java hn
76. ackage e Paths to display the error or warning path in the process if available e Locations to describe the error or warning location in the process files e Type to describe the error or warning type Java problem build path See Figure 22 Technical Issues Executable model The tool translates in principle by using the NOVA Workflow translator It translates each of the tasks by reading the workflow model and its properties file If a task does not have any property file the tool will translate the flow only The DeVinE model checker will do the simulation and verification after translation NOVA Workflow User Manual 2 0 23 Tool modeling capability Most of the available tasks are for workflow processes tasks normally done by a human and not to be run automatically or set to be done by a system Variables can be declared as global or local and only in the program code 104 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Modeling features Modeling feature of the NOVA tool consists of the main features of graphical editor translator and workflow engine The tool contains limited features conditions task properties and split join The NOVA tool is missing the essential features of cancellation the tool uses compensable transactions instead A compensable transaction is pair of programs runs together one to do a required action and another runs the compensable action when needed if th
77. ake the work easy for the users when working with a workflow design Users can configure the YAWL engine based on several parameters and the requirements of the process such as enabling persistence used for backup and restore work in progress when engine restart default work list to handle 32 M Sc Thesis A Kamil McMaster University Computing and Software eHealth the works that aren t passed for process enabling logging to record data of running process for later analysis allowing generic admin ID allows the admin to be disable user account when password changed by using the generic admin account initialization announcement timeout used in some process when waiting for response enabling hibernate statistic gathering and interface X listener used to receive event notification on interface The YAWL tool provides simulation support by Process mining environment ProM through the link www processmining org ProM is an open source framework for Windows Mac OSX and UNIX platforms 19 YAWL provides several options through the tool analysis to help users define workflow specification problems The available options consist of a verification option analysis option note and problem panel engine and resource service status hint and message panel and data type validation YAWL User Manual 2 3 18 The verification option is to verify the process design specification file against YAWL s sche
78. al outpatient pharmacy dispenses typically 250 prescriptions per day The analysis performed through direct observation of this pharmacy s operations for a period of eight weeks the pharmacists dispensing oriented activities were characterized as either value added or non value added The suggestions resulting from this study were to shift pharmacist time more toward value added and away from non value added activities The same study defined an application of two proposed models of the enhanced workflow model A and model B Model A expansion of pharmacy technicians standard duties to include prescription preparation stock container retrieval and prescription processing predicted a reduction in the pharmacist non value time by about 6 minutes or 55 of time spent and model B technician performance of checkout procedures in addition to expanded standard duties projected a reduction of 74 2 6 The Power of Workflow Tools Workflow tools give process designers control of directing a process based on the needs of the work In our study we focus on finding a reliable workflow tool that will help the designer of a workflow process to gain control when designing a digital lab process The study by Geebelen et al 11 defined the need for a portable dynamic framework able to enforce and manage adaptive work policies based on the job required by workflow tasks using a General purpose language This language wa
79. an XML document For example XPath can be used to create an unordered list of data from a subset of an XML document while XQuery can be used to create a more complex list XPath is an essential part of XQuery XPDL XML Process Description Language a process format for storing a representation of a process diagram YAWL Yet Another Workflow Language is an open source software platform used to design workflow patterns It has design features to set rules and conditions for the workflow process XIV M Sc Thesis A Kamil McMaster University Computing and Software eHealth 1 CHAPTER ONE INTRODUCTION AND PROBLEM STATEMENT In recent years computer use in hospitals has increased dramatically Hospitals have switched many of their administrative operations from paper based to electronic by using different types of software and technology such as Electronic Medical Record EMR and Electronic Health Record EHR systems see Pappas et al 1 These new computer systems have saved processing time and provided the opportunity to all related hospital departments to edit to follow up with the updates of their data and to save documents in a secure database for future needs as shown by Jenkins and Eckel 2 and Russello et al 3 The main reason behind selecting the topic of this thesis is to find the best workflow business process modeling and designing tool for this environment The need for a reliable modeling tool required u
80. and storing samples Tasks either contain sub processes to reach the next task such as ordering or split and link to multiple or single tasks like collecting samples the design of the tasks is based on the requirements of the process see Figure 26 and Figure 27 121 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Porter Service Lab Technician NYA Ordering eceiving i i elivering and Process Entered to Lab Order Samples Samples ram Meditech Start task Pe System F End Task E Samples Collection Cancellation sign By Physici J Printing Split sign Tabel Carrier Human task Her Automated task f Collection Time task SEN By Registered Repeat task 4 Therapist epeatin The Test if No Result is Abnormal n Hospital Process Abnormal Critical Submitting to and Process analyzing Physicians Sample Storing Results Samples Phone or Device Start task P gt AS End Task E y Ne 2S Canccllaticn sign Wl Out of eK Submitting Be Split sign Hospital Result gee Process Submission j Hunan task Hek Automated task ia Time task aj Repeat task gt Order_Entered_to_Meditech_System Figure 27 Current lab process designed in YAWL part 2 122 M Sc Thesis A Kamil McMaster U
81. andling The tool uses Hibernate hibernate org as a database framework which provides a transparency layer between YAWL and the back end database used to support it With YAWL the users always get an instant update about the workflow design in the analysis result tab provided at the bottom of the tool Analysis results show the task name problem type and suggestions to fix the problem When there is no problem the analysis results tab still shows a note of not finding any validation problem with the current design YAWL User Manual 2 3 18 The YAWL tool has an advantageous cancellation feature which is not available in other tools Together Bonitasoft and NOVA Workflow designers using the YAWL tool can design any workflow task and direct the process flow based on the need of the flow by using this cancellation feature We used this cancellation feature with the design of the new digital delivering sample process see Figure 1 Requirements To install and run YAWL workflow tool a user need the following software YAWL User Manual 2 3 18 e Java SE Runtime Environment JRE 1 6 or greater java sun com 75 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e YAWLAStudy for Linux requires installed xdg utils portland freedesktop org which should be supported by the desktop environment GNOME and KDE do support xdg utils in order to visualize YAWL editor menu entries YAWL 2 3 has been succ
82. ar Kamil Project assistant Observation place Outpatient units Stephaney Resource Nurse Date Aug 14 2012 Time 3 30 PM Site location Church site 177 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Routine lab order e Physician order on paper e Patient will be sent to lab for blood work e Lab enter results to MT Stat amp Emergency Physician order on paper Clerk enter to MT Clerk call lab collection team Print labels in units Collect blood and label the tubes T UUU Send samples to lab in one of the folioing ways o With collection team o Nurse from unit o Porter service Glucometer e Physician order blood sugar test on paper only no MT available e Nurse get the order from the patient chart or from the nurse sheet e Nurse start by scanning their badges so the system writes the name of the person who collect the sample e Nurse scan patient arm band or write patient information in the device e Nurse scan the blood stripe e Perform the test on the patient e Write the result on a paper sheet e Nurse place the glucometer on the loading deck results will be sent to the lab e Nurse could enter result shown on the device screen to the patient record in MT directly 178 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Notes In outpatient clinic when nurse place the glucometer on the loading deck computer sometimes doesn
83. as to compare the current process with the future digital process including all the activities collecting labeling processing etc needed to achieve the goal of digital flow Information was collected from the hospital staff in all of the departments of the three Humber River Hospital sites Church site Finch site and Keele site Information was then obtained through three types of methods questionnaires interview and observation by analyzing the collected data We found the delay of the current process is caused by deficiencies and errors issues in the process and current process can result in more critical outcomes if new technology is not implemented We used the captured data to write the current step by step workflow process see Figure 4 We analyzed the data by using different tables and comparisons to identify strategic objectives current standings deficiencies and plans needed see Table 6 Strategic Objectives Current Standings Deficiency Action plan To identify the lab order Most of the services are Current paper based Use a digital system and clinical laboratory running on a paper based process has multiple as the main base of services systems process errors issues service interfaces and processes electronic process can decrease the number of errors To map and identify the existing lab services Currently the lab covers most of the services required for the hospital either t
84. ased lab orders to a new fully digital lab orders Lab orders contain significant amount of information information related to patient safety information related to patient privacy By switching from paper based to digital based system we would be able to save processing time manage the flow of the orders control the process and secure patient information We collected current lab orders data from all process stages and found that the current lab order process orders consists of placing an order printing labels receiving the order collecting the samples delivering the samples to labs processing the sample analyzing results and submitting the results to be implemented on paper and performed as manual procedure The current lab order process affects numerous aspects of the healthcare system the paper based system uses more resources requires more time to complete and has a higher chance in producing errors The work on the current lab order process consists of four phases phase one involves collecting information about the current lab order process including observing the 148 M Sc Thesis A Kamil McMaster University Computing and Software eHealth workflow process for all the departments of the three Humber River Hospital s sites Church site Keele site and Finch site and hospital main laboratory The work included designing an information collection form to collect interviews data and write step by
85. based on the activity being considered M Sc Thesis A Kamil McMaster University Computing and Software eHealth 2 2 Patient Safety Patient safety is an essential component of quality Most studies define safety as protecting patients from unnecessary or potential harm due to healthcare practice errors Patient information security is considered as a factor of quality it becomes difficult to ensure secure care due to the sheer number of people working in healthcare ranging from doctors to lab technicians and medical laboratory technologists unless the design of the system facilitates complete information made available to all health care professionals in a secure way Labeling error is one of the factors that can lead to adverse events which affect patient safety Miller and Zhan 8 The study of the current lab order in our research also showed that labeling errors are the most frequent errors that occur in the current ordering system Recently in December 2004 the Institute for Healthcare Improvement IHI launched the 100 000 Lives Campaign in the Unites States Their primary goal was to set firm targets and timelines for healthcare improvement see Berwick et al 9 One important aspect in improving patient safety is designing a reliable system To reach this goal we need a reliable workflow tool to design a system that can provide accurate process steps and lead to a safe practice environment There are multiple wor
86. beled Bedside How samples delivered to the lab Emerge gt send by the nurse 186 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Routine sent by Porter 15 How the clinics receive the results MT Printed 16 How long it will take to receive the results 15 20 up to 45 Min 17 What do you do if results not received missing Look in MT Call the lab 18 Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT Yes some missing 19 Any issue with the current system Porter service slow could take 1 hour to arrive 20 Recommendations and suggestions Direct order by physician 21 Do you use blood bank service amp how to order Yes Paper order in advances MT Lab will be notifies by copy of the paper order Nurse takes the face sheet to the lab and sign in lab to pick up the blood bottles Nurse pick up the blood This operation will take about 45 min 187 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Birthing Finch interview questions Project name Lab order process flow in Birthing Clinic Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Sandra Brodie Special Care Nursing Date July 17 2012 Time 2 30 PM Location Finch site 1 What type of samples you collect at these clinics Blood gas and mostly a
87. belling outside patient room bar coded tubes Labeling error printing every other one in labour amp delivery mother s name is not on baby s blood label Delivering Porter Nurse Lab Technician Volunteer Carrier and Pneumatic Tube Transport samples Taxi Cab system main porter AGV Staff Processing Technologists perform multiple duties including lab Pre analytical processor samples instruments pre and post analytical process analyzer and post analytical processor Analyzing results Manually Automated main Manual Submitting results MT amp Paper copy for some clinic Phone call MT main Devices Phones Paper 68 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Storing amp Manually Automated process using Inventory bar code system to identify the lab samples for storing and detect any shortages in lab supplies to order as needed Table 11 Process comparison table Turnaround time Turnaround time is an essential issue of future digital process benefits We developed a turnaround table showing the difference between the current lab order process time and the future digital process time The current process time is measured based on a regular lab order process and data obtained from the three sources of information questionnaires observations and interviews The information of the current process is acquired from the
88. bracelet Noresult will be on paper Outpatient clinics inpatient surgical fraction and plastic collection will be sent to the lab other departments they do it in clinic No confirmations when receive of complete the tests All clinics perform lab orders electronically except cytology clinic uses paper requisition and technician has to inter it to the MT Collection time showed in MT is the time that technicians put manually in the system Technicians write down the collection time and then have to fine a PC station to enter it to MT or when they deliver the samples to the lab Current system calculate the time of a sample process from the time order placed in MT while samples could take 1 30 hour to be delivered to lab and if sample take 30 Min to be completed the time in the system show 2 hours The current instrument available doing only identifying of blood tubes process tubes that Ifthe analyzer shows up normal patient results the technologist will have to perform a manual test on the sample to make sure the results are right the technologist will check if the patient has a previous to compare with Priority determined based on the letter on the right side of the label number 0566 C00045R R gt means regular current identification of the ER department is the yellow label due to the absence of the other white labels in ER Suggestions for improvements 1 Technicians need hand held
89. cess will use CPOE 2 Dispatching Lab orders are dispatched manually in the current process while with the future process orders will be dispatched automatically by the system 3 Confirmation and Verification The current process has no confirmation or verification on any process while with the future process every process will be confirmed and verified for different purposes 4 Receiving the order In the current process lab technicians or nurses receive orders manually by picking up printed labels while with the future process orders will be send through a mobile device to the receivers at their point of work 5 Labeling the samples The current system prints labels in the lab or in department when orders entered to MT while with future process labels will be printed at the bedside using a mobile printer or use pre labeled tubes and eliminate the use of labels completely 6 Delivering the samples With the current process samples are delivered manually by porters staff or carriers while with the future process samples will be delivered by using pneumatic tube system or AGV 143 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 7 Processing the samples With the current process lab uses only analyzer instrument to process the samples while with the future process lab will implements new instruments and uses pre analyzers analyzers and post analyzers to process a sample 8 Submitting
90. chability set size 11 Duration 1684220 millisecs Figure 19 YAWL analysis notes 80 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Technical Issues Executable model The YAWL workflow tool captures data perspective by using XML Schema XPath and XQuery The tool offers simulation support and conducts post execution analysis The tool is also capable of identifying bottlenecks in the process YAWL Foundation 19 The data in YAWL are passed as an XML documents from net to task and back all parameters in YAWL are defined using XML schema language YAWL also allow users to define their own languages XPath expressions are used in YAWL tool to specify how data is passed between the net and task theses expressions are needed to fetch and populate the values of parameters with that of its corresponding net parameters XQuery parameters are defined using XQuery expressions input or output parameters use an XQuery expression to specify a value that can be passed to single selected task or net variables see YAWL User Manual 2 3 18 Identifying bottlenecks is done by conducting post execution analysis of YAWL process through the link with the ProM www processmining org environment to extracting information from event logs The use of process mining is to observe deviations and compare the observed elements with predefined models or business rule see YAWL User Manual 2 3 18
91. d Software eHealth 15 16 17 18 19 20 b If critical nurse will receive a phone call about the results and lab send copy of the result to the department printer results will be entered to MT too How long it will take to receive the results Less than an hour What do you do if results not received missing a Call the lab and ask for the status b Physician can check status on their MT page Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT Yes Why related to question 15 Easy to manage assessing patients when result known when to arrive Any issue with the current system a Specimen labeling error b Too many label printer uses too many ink cartridges c Noconfirmation when receive samples Recommendations and suggestions a Using mobile labeling machine b Need receiving confirmation c Need test status report d Need Point of care testing POCT in every room to get result quickly e Quality control QC need to be done every day Note Emergency department uses yellow labels for labeling the tubes 170 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Emergency Department Observation Project name Lab order process flow mapping Observer name job title Ammar Kamil Project assistant Observation place Emergency Department Date Aug 15 2012 Time 10 00 AM Si
92. d based on the availability of the porter in the department How ICU receives the results a MT 173 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 15 16 17 18 19 20 b If critical nurse will receive a phone call about the results and lab send copy of the result to the department printer results will be entered to MT too How long it will take to receive the results Depend on the type of the test normally within the normal time no delay What do you do if results not received missing Call the lab and ask for the status Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT Yes Why related to question 15 Make sure samples delivered Any issue with the current system a Porter service b Some blood band order cannot be seen in MT c Some test names have been changed with the new MT Recommendations and suggestions a Fix MT bugs b Provide MT user guide c Using reliable pneumatic tube system to deliver samples Note ICU department uses yellow labels for labeling the tubes 174 M Sc Thesis A Kamil McMaster University Computing and Software eHealth ICU department Observation Church Project name Lab order process flow mapping Observer name job title Ammar Kamil Project assistant Observation place ICU Department Date July 18 2012 Time 8 45
93. d for the new system Ordering Paper based CPOE Direct entry to MT Yes Too many steps to get to the status Status board Yes Duplicated orders Detection system Yes Printing Labels printed in lab or unit Mobile devices or bar coded Yes labels tubes Verification by staff Mobile scanning verification Yes 30 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Receiving No specific method Mobile devices amp notification Yes lab orders system Collecting Collection time Management system Yes samples Initial on labels Mobile labeling device Yes Scanning verification Filling up cart supplies Carts contain supplies on Yes board set rules Labeling Mobile devices or bar coded Yes tubes Delivering Manual process Pneumatic Tube Transport Yes samples Processing Processing time Pre Post Analytical Instrument Partially samples Process location Implement the required Yes instruments Analyzing Mostly manual process Automated Instrument Partially results Submitting No Notification available when Notification system Partially results result submit to MT Unnecessary paper copy MT 6 0 update Yes Storing Manual Automatic storing system Yes samples Confirmati Not available in most departments Confirmation system Partially on Table 7 Process data analysis 31 M Sc Thesis A Kamil McMaster University Computing and Software
94. d is called the Compensable Workflow Modeling Language CWML see 22 The framework includes a graphical editor a translator and a workflow engine The graphical editor of the tool is an eclipse plugin and uses Hibernate and Spring Framework workflow components and DeVinE model checker for models execution Although the tool uses a unique language and has some workflow designing features it is not as easy to use as the other tools YAWL Together or Bonitasoft The workflow engine instructions are mostly for programmers and the user manual is missing instructions on how to create or modify all of these required files and classes in a workflow design Users of the tool are required to have some coding knowledge or need to have worked with eclipse before The NOVA workflow tool uses the eclipse user interface as the tool graphical editor plus some extra workflow features The NOVA workflow engine was developed using the Hibernate and Spring Framework the NOVA workflow engine and the client application needs a certain configuration in order to be ready to run The NOVA workflow tool uses the DIVINE model checker to simulate and verify the workflow process models by reviewing any required design correction in the problem panel the description include specifying the description resource path location and type or the error or warning according to the NOVA Workflow User Manual 2 0 23 more details are in Chapter 5 The tool
95. ded attributes Together Professional Open Source 6 Non Technical Issues Language support The Together Tool supports XPDL XML and Java Languages Together Professional Open Source 6 Use in eHealth Based on TWE sources TWE editor is used in eHealth study of clinical decision support functionality The TWE workflow tool used in the Implementation of workflow engine technology to deliver basic clinical decision support functionality biomedical research the researchers used TWE editor and engine to create HealthFlow system for clinical decision support system see Together Professional Open Source 6 89 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Tool cost The tool is available as open source software it is also available as commercial for those who want to use it in a large organization or for those who require more support Support available The tool offers free and commercial support The free support includes the workflow editor manual the XPDL tutorial a free download an email address a phone number a frequently asked questions page and server support Commercial support is also available including development of project specific extensions integration into other environments projects commercial training and custom development Together Professional Open Source 6 Bonitasoft Workflow Tool Tool overview Bonita Open Solution i
96. determine the responsibilities of the participants in the package or the process by selecting the re definable header tab from the package property Users of 35 M Sc Thesis A Kamil McMaster University Computing and Software eHealth TWE also have the ability to either specify a public access level or specify a private access level of a process see the Together User Manual 20 The user interface of TWE is configured to provide easy access to the tool features when designing a workflow process The workflow designers use the graphical editor to create manage edit and review graphical workflow and XPDL process files Together Workflow Tool uses the open source Wf MC XPDL Enhydra Shark workflow engine to run and execute the workflow design This engine interprets and executes the final XML file output produced by the workflow editor The TWE tool provides users access to simulation information The tool has a check validity feature which can produce a problem list by checking the XPDL model s validity based on the WfMC specification same as YAWL but in TWE the information viewed in a table contains type description element and location of the error or warning More information will be followed in the coming chapters The tool generates XPDL and XML codes with its workflow systems to run and execute the workflow process The tool has multiple modeling capabilities for declaring participants and their type includ
97. e and simulation We examined 15 workflow tools based on the mentioned criteria and all but four did not meet the specified criteria YAWL Together Bonitasoft and NOVA 4 M Sc Thesis A Kamil McMaster University Computing and Software eHealth The eliminated tools are bpmn2bpel Workflow Tool Apache Airavata Workflow Tool jBPM Tool Workflow Tool Anduril Workflow Tool Kepler Workflow Tool nexusBPM Workflow Tool Aperte Workflow Tool Joget Workflow Tool ProcessMaker Open Source Workflow Tool RunaWFE Workflow Tool and Yaogiang BPMN Editor 2 1 21 Workflow Tool see Table 1 Tool Name Availability Tool Vendor Graphical Simulation Execution User Qualified of an modeling support editor engine manual tool analysis tool features bpmn2bpel X X No YAWL X X X X X X X Yes nexusBPM X X No Kepler X No Aperte X X X No Apache X X X No Airavata NOVA X X X X X X X Yes jBPM Tool X X No Joget X X No Bonitasoft X X X X X X X Yes Anduril X No Together X X X X X X X Yes ProcessMak X X No er RunaWFE X X X No Yaoqiang X X No BPMN Editor 2 1 21 Table 1 Tools elimination table We evaluated each of these four tools separately based on the outcome of a new workflow design sample created for this purpose Each tool was used separately to design a new workflow process test model future lab ordering The model rep
98. e rass onsa eon a cdl R a ce 18 3 34 Proced res hissar ae a a a aot a Giclee E a 18 Dn gt Data analysis sismo e a a e E T EN a RS 23 4 CHAPTER FOUR RESULT Senanin iini siisii asesi iiss 32 4 1 Workflow Tool Evaluation jcc ave vasentvsdecs situa ve Seki vds eases aad osteo es wae aed 32 4 2 Current and Future Order Processes scai5e2s6cs Seestieus Guatol beds Seeesslutes Seeds ates 44 5v CHAPTER FIVE DISCUSSION rat naaa a a a ase eaa a 71 vii 5 1 Introduction to Workflow Tools cccccccc cece ccssesescecccccecessssssescceccessssessseecceeeeees 71 5 1 1 Overview of Other Workflow Tools eseeeseseesessesssesseeseessesrresresseseresressesses 109 5 1 2 Workflow Tool Evaluations Procedure ceecceceeececeeececeeeeeceeeeeceeeeeenteeeees 113 5 2 Introduction to Current and Future Lab order Process FIOWS cceeseeeees 121 6 CHAPTER SIX CONCLUSION ccteteccstspasvestaettievdeieargoatelemssmatersiansaeniantenuendelents 145 6 1 Workflow Tools Evaluation Conclusion 0 ceeeeeeeseceeceeceeececeeeeeceneeeeneeeeees 146 6 2 Current Lab order Process Study Conclusion eccceeeeeeceseeeeeeeeeceneeeeeeeeeens 148 6 3 Future Process Design Conclusion cceescecessceceeececeeneeceeeeeceeeeeceneeeeeeeeees 150 RE ETI IN CTS etc ac REE E ea celepaxngasteeny eae ad E S T ede 151 APPENDIX Forms 2 22s8s22 duenddie dle lieth cena eed 157 viii LIST O Figure 1 Figure 2 Figure 3 Figu
99. e selected workflow tools and discussed their similarities and differences for examination Information concerning tool descriptions and evaluations were collected through studying each workflow tool individually We finally chose four tools YAWL Together Bonitasoft and NOVA and examined them separately to design new workflows process studying all tool designing capabilities and evaluating the tools based on certain quantitative and qualitative criteria see Table 1 71 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Introduction to Petri Nets Studying workflow tools include understanding the concept of Petri Net and its relation to the workflow models we can understand that Petri Net represents a mathematical form in a workflow tool Workflow models used events conditions and transections to specify and control a process places and transitions in Petri Net represent the conditions and events in a workflow model Petri Nets are a graphical tool that represents a visual communication similar to flow charts block diagrams and networks Study by Murata 24 define Petri Nets as a graphical and mathematical modeling tool applicable to many systems to describe and study information processing systems distributed systems Petri Nets are considered modeling tools applicable for many systems characterized as being concurrent asynchronous distributed parallel nondeterministic and or stochastic Petri
100. e sure that the lab received the samples 208 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 18 19 20 21 22 Note Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT Yes Any issue with the current system MT Label printer Porter Long time to get results Recommendations and suggestions Tube system Integrating the lab model with the computers in the unit Do you use blood bank service amp how to order Yes e Physician order e Nurse collect blood sample and send it to lab e Nurse takes face sheet to blood bank e Pick up the blood Do you use Glucometer Yes e Physician order Paper base e Nurse scan the badge and the blood stripe e Nurse do the test e Nurse place the glucometer on the loading deck to upload the data to the lab e Result will be submitted to MT Lab also does some tests on water samples from the water line 209 M Sc Thesis A Kamil McMaster University Computing and Software eHealth ICU Critical Care interview questions Project name Lab order process flow in ICU Critical Care Clinic Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Yemi Adebayo Manager ICU critical care Paranjit Nurse Date July 27 2012 Time 11 00 AM Location Finch site 1 What type of samples you collect at these clinics
101. e the test to make sure results arrive Any issue with the current system 164 M Sc Thesis A Kamil McMaster University Computing and Software eHealth a Need test status report b Porter unable to support the timely flow and sometimes samples lost c Process time too long d Test required on labels need to be confirmed with test request e Date on labels represents the printing date not the test date Oncology additional questions 1 Is the 24 hour urine sample bottle will be labeled before or after the patient takes the bottle home 2 How many orders you process every day B400 Oncology Observation Project name Lab order process flow mapping Observer name job title Ammar Kamil Project assistant Observation place B400 Oncology units Date Aug 15 2012 Time 8 00 AM Site location Church site Routine lab order e Physician order the day before or before 6 00 AM same day e Lab tech arrived at 8 20 AM e Labels already printed in lab or unit e Lab tech checks labels and leave them outside the patient room for isolation purpose tubes will be cleaned when lab tech leaves the patient room and that could erase the labels 165 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Collect blood and affix labels Anew order e Physician write an order e Clerk get the order and enter to MT e Print labels in unit e Call lab for collecti
102. e work is done without failure the required action will complete its work but if the required action failed then the compensable program will undo the previously completed non transactional work While when an activity in the workflow is not completed a cancellation handles non transactional work that not completed Using the compensable transaction requires more work than using the cancellation feature especially for users with no programming background Additionally the tool has limited task property components no individual transaction available and the task property contains limited functions name description author and create property file only NOVA Workflow User Manual 2 0 23 Non Technical Issues Language support The NOVA workflow tool supports Java and the Compensable Workflow Modeling Language CWML languages NOVA Workflow Overview 22 Use in eHealth The short demo provided by the tool source website shows the tool used to develop client application referral form healthcare workflow models workflow for palliative care and a browser for electronic health record NOVA Workflow Overview 22 105 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Tool cost The tool is free to download but it is not open source software Available support The tool provides the required plugin as free to download There is also a tool user manual two short video demos of NOVA workf
103. eHealth 10 11 12 13 14 15 16 17 18 19 20 2A How staff notified there will be test needed By physician Who is collecting the samples nurse or lab technician Physician amp Nurse gt then Nurse enter it to the jar How do nurse technician identify the patient for sample collection for sample test Arm band two ID check H D O B Is there any difference in flow between different samples No Where normally samples are collected Bedside Where collected samples are normally labeled Bedside How samples delivered to the lab Porter Nurse when stat How the clinics receive the results MT How long it will take to receive the results Sometimes 3 days depend on the type of test What do you do if results not received missing Call the lab call porter look in the department Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT Yes some missing samples Any issue with the current system Porter service slow Recommendations and suggestions Porters should carry baskets or containers to carry the samples Do you use blood bank service amp how to order 196 M Sc Thesis A Kamil McMaster University Computing and Software eHealth A 300 South Rehab amp Medicine Observation Project name Lab order process flow mapping Observer name job title Ammar Kamil
104. eHealth applications eHealth technologies provide powerful tools to gain more control and management over many healthcare processes With the help of reliable workflow tools designing a new healthcare system will become easier and more manageable 2 1 eHealth Applications We need a reliable and flexible workflow tool when designing a new ehealth applications process The study by Russello et al 3 defines a process of designing an access right framework that can provide controllable entities to fulfill specified duties The authors chose eHealth application for its direct involvement with flexibility and security and used workflow tools to create a flexible process to allow users of eHealth application to access necessary tasks with maximum security There are many contributing factors in the design of a reliable healthcare process A powerful and dependable workflow tool is one of these factors The first thing that comes to a mind when thinking about designing a successful process is the workflow tool With workflow tools process designers have more control of the process In Pappas et al 1 the authors state that to create and manage proper execution based on the needs of the process suitable operation of workflow automation tools is necessary Using a workflow tool helped them to design a system that provides doctors and nurses with a list of tasks to be executed these tasks used a workflow process to schedule new tasks
105. ed from 7 Do the nurse technician confirm the information in labels with the test request 8 How is staff notified if there is a test needed 9 Who is collecting the samples nurse or lab technician 10 How do the nurse technician identify the patient for sample collection for sample test 11 Is there any difference in flow between different samples 12 Where samples are normally collected 13 Where collected samples are normally labeled 14 How are samples delivered to the lab 15 How do the clinics receive the results 16 How long will it take to receive the results 17 What do you do if results are not received missing 18 Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT 19 Are there any issues with the current system 20 Recommendations and suggestions 21 Do you use blood bank services amp how do you order Figure 3 Sample interview questionnaire used to collect data Phase two consisted of analyzing the collected information and creating step by step flowcharts of the current paper based lab order process We created a general flowchart for the lab orders role in the hospital see Figure 4 for the current general flow chart 21 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Current General Lab Process Flow Patient register amp book an appointment at LUGAET ELC CE
106. eeded either Physician can place an order or Registered Nurse RN with medical directive physician permission e Labels will be printed in the unit e Samples will be collected by RN or Registered Practice Nurse RPN o RPN can collect samples but can t place an order e Samples will be sent to lab by the pneumatic system e Lab process the samples and submit the results to MT O Zone unit e Triage nurse send the patient to O Zone 223 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Patient walk in e Physician check the patient e If lab order needed either Physician can place an order or Registered Nurse RN with medical directive physician permission e Labels will be printed in O Zone unit e Samples will be collected by RN or Registered Practice Nurse RPN e If O Zone unit is full patient will wait outside in the O Zone hallway and do samples collection in triage phlebotomy room e Samples will be sent to lab by the pneumatic system if malfunction samples will be sent by nurse or volunteer to lab e Lab process the samples and submit the results to MT after 45 min no paper copy will be sent to the unit Glucometer Flow in O Zone unit e Information and specification about the patient diabetes comes from triage e Physician order blood sugar test e Nurse get the order from the patient chart or from the nurse sheet e Nurse start by scanning their badges so the system writes the name of t
107. eeeaees 73 Illustration of transition firing rule oo lees eee eeeceeeeeeeeesaeecaecnseenseeeeaees 13 YAWL analysis configuration eeeseeeesseessesssessseeseeeesstessressersseesseeeesseessrese 79 Figure 18 YAWL analysis progress bOX essessesseseresisesesresseserssresseteresressessresresseeseseessee 80 Proure 19 YAWEanalysigs Notesin a RE a a RTE 80 Figure 20 Together problem tabin n aa a elope 87 Figure 21 Bonitasoft error message esessseseesseseesstseeesresstserssressesstertensesstesresseeseeseeesee 95 Figure 22 NOV A problem tabe os eni i pe ee es 102 Preure 23 NOV Averror Messages ss isto ccc ct on ana aE toed Soma paca ee 102 Figure 24 NOVA quick fix from problem Window cesceeeseeeseceeeeeeeeeseeenteeeseeeenees 103 Figure 25 NOVA quick fix from editor window eecesseesseceseeeeeeeeneeceeeneesseeeenees 103 Figure 26 Current lab process designed in YAWL part 1 oo cece eeeeessceesteceseeeeeeeenees 122 Figure 27 Current lab process designed in YAWL part 2 0 eeeceeeeeeseecseceseeeeneeenees 122 1X LIST OF TABLES Table Fools elimination table ass een niet etcastati a tended eee eae mas gt Table 2 Workflow tools technical features x3 32 52 se sesou sos cesdasedesscsacsgaceodeaddesssabecadeecssbents 26 Table 3 Workflow tools non technical features ceesceceeeeceseceeeeeeeceeeeeceeeeeesteeeesaeees 26 Table 4 Workflow sample designing time eeeseceecceceeceeceeceeceseeececeecee
108. eeecseeeeesaeees 27 Table 5 Workflow components used in the sample design eeecceeeseeeeeeeceeeteeeeeeees 28 Table 6 Strategic data analysts ivi cise aes See a a N R a 30 Table 7 Process dataanaly sis sty hiss lye E E E E Sascha A ER 31 Table 8 Current process deficiencies 5 225 scssaygcesdeeasdueseadenseasiot auiancadensdhacscedantenesoetey ieee 59 Table 9 Current process 1SSUCS 3 csssiivssisceeasecveesdeossacduse seaedastesactasnehacedavseceds Sedescaaveractesndeeee 60 Table 10 F t r Process benefits sisestus roris reni tiea een aro gaii 67 Table 11 Process comparison table isi iiiedssieiaacs to edadysagncdetasebeads cashaaes sbedats doealetaesdaataauseans 69 Table 12 Process turnaround time css cot te pctcaarans shaass Wtacaaeucgundescsaumeadangeaesaituasteoneuedeeees 70 LIST OF ABBREVIATIONS AND SYMBOLS AGV Automated Guided Vehicle a laser navigated vehicle that can be used to transport and deliver lab order samples to the lab BPML Business Process Modeling Language an XML based advanced UML language used to develop tasks with certain conditions and guidelines in YAWL BPEL Business Process Execution Language used by process designers programmers or technical analysts in the implementation stage of the life cycle of business process design BPMN Business Process Modeling Notation used by business analysts in designing and improving the business process modeling life cycle CBC Complete blood
109. een healthcare organizations using software applications J2EE A Java Platform Enterprise Edition a platform for developing software JavaScript A computer programming language typically used to control web applications Kardex A medication record or a legal report of the drugs administered to a patient at a hospital or a department used by health care professionals Lab order workflow process or Lab round trip The complete process of all the lab orders performed in all the departments of a hospital from the beginning of placing the order including all the processes concluding with adding the results to the patient record LAN An abbreviation for Local Area Network a computerized network used to connect computers in an institution or a small area like a home or library Medical Laboratory Technologists Sometimes called Technologists a healthcare professionals who perform tests on a laboratory samples and monitor operate laboratory instruments to analyze and provide information to physicians to monitor and prevent disease xii MS Project Microsoft Office Project software tool a timeline tool designed by Microsoft Corporation to set the time tasks roles and resources of any potential project MT An abbreviation for the MT electronic health record platform Used by healthcare professionals to record or update patient health record it supports clinical decision software plugins and is used for writing reports ph
110. efficient for the system when considering the path to follow YAWL Foundation 19 see Figure 6 for sample of the delivering process and Figure 1 for sample delivering cancelation Non Technical Issues Language support The YAWL workflow tool supports XML Schema XPath XQuery and Java YAWL Foundation 19 Use in eHealth Based on YAWL sources the YAWL workflow tool is used in some eHealth studies and designs of some healthcare processes of the Academic Medical Center AMC University hospital in Netherland A healthcare process and YAWL modeling design of 325 82 M Sc Thesis A Kamil McMaster University Computing and Software eHealth activities and patient visiting to the gynecological oncology outpatient clinic of the AMC hospital 19 Tool cost YAWL is open source software and free to download The tool also provides free support and commercial support through the Acclario BPM company Support available The tool provides multiple support methods YAWL workflow tool is free to download and users have access to Java source code the YAWL foundation forum is available for asking and answering questions Other supporting tools the user and technical manual tutorial and teaching videos commercial support contact support and an email address case studies screen shots examples a YAWL book and FAQ s are also available with YAWL workflow 19 Together Workflow Tool Tool overview Together
111. efines that marking assigns to each place a non negative integer For example if we assign a place a a non negative integer k we can say that place a is marked with k tokens K tokens inside the places represent the truth of the condition indicating that k data items or resources are available see Figure 16 ee th a Marking before firing t is enabled p t p eos pos 1 a b Marking after firing t is disabled Figure 16 Illustration of transition firing rule 73 M Sc Thesis A Kamil McMaster University Computing and Software eHealth In mathematical terms we can explain Petri Net as PN P T F W Mo where the finite set of places are represented as P p1 p2 p3 pm Finite sets of transitions are represented as T t1 t2 ts tm The set of arcs are represented as F PxT U TxP the weight function as W F gt 1 2 3 and the initial marking as Mo P gt 0 1 2 3 Note that P N T and TUP Murata 24 YAWL Workflow Tool Tool overview YAWL Yet Another Workflow Language is a new workflow language based on Petri Nets theory with a graphical representation and well known workflow patterns YAWL uses a control flow perspective pattern and manages to extend Petri Net s lack of support for patterns such as cancellation multiple instance and the generalized OR join with dedicated constructs to deal with the data perspective resource pe
112. el as the most important among the rest of the analysis features in Bonitasoft tool This feature detects whether there are errors or problems in the workflow design for example choosing the wrong gateway Join or split between two activities tasks and then proceeds to display it directly on the workflow graphic design where the error or problem takes place as a red X sign Users can display the descriptions of the error by passing the pointer over the X sign and a window with the error description will appear 21 see Figure 21 94 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 1 0 X i T E N problems in the ician Assistant Rysician assis an lt 1 Diva Order From T Q All output transitions from a XOR Gateway must be default or conditional Gatewa If you want to continue on several branches use an Inclusive Gateway Physician Assistant X g Rurse Practitioner X x Busing Medical x gt ee Order 3 Order Directive Gateway3 Gateway4 fd Figure 21 Bonitasoft error message Analysis role Each of the analysis features has its own role They are described below Bonitasoft User Guidance 21 e Check BPMN model role This feature screens the tasks of the process model for any error or missing configuration as you design a process when a task in a process model is incomplete For example when missing an actor or a connector configuration a red
113. encies Metrics Proposed Process Issues Performance Quality Patient safety Technology Ordering Paper based Time consuming Writing Missing CPOE Direct increases the errors records lost entry to MT waiting time tests wrong test Too many Time consuming Require Status board steps to get to human the status resources Duplicated Time consuming Detection orders system Entering Nurse or clerk Time consuming Errors when Increase CPOE Direct orders to MT required entering adverse events entry to MT orders Printing labels Labels printed Possible Confidential Mobile devices in lab or unit labels lose patient info or bar coded tubes Labels design Labels not Major error Missing Mobile labeling designed very when records lost device well for some mother s tests adverse Scanning department labour name is not events verification amp delivery on baby s blood label Receiving lab No specific Delay the service Increase Increase Mobile devices orders informing patient patient amp notification way waiting time diagnostic and system 57 M Sc Thesis A Kamil McMaster University Computing and Software eHealth treatment time Collecting Collection Depend on Delay in Management samples time collection type delivering system the samples Initial on Not always Potential Mobile labeling labels represent the error device person who Scanning collected the verification sa
114. er University Computing and Software eHealth 10 11 12 13 14 15 16 17 18 19 20 21 How do nurse technician identify the patient for sample collection for sample test Verbal two ID check H D O B Is there any difference in flow between different samples No Where normally samples are collected Blood work amp ECG room in P A T T department Where collected samples are normally labeled Blood work amp ECG room in P A T T department How samples delivered to the lab Lab tech when they go to lab How the clinics receive the results All results printed by the end of the day MT How long it will take to receive the results within the normal time What do you do if results not received missing 3 Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT No patient will get activity sheet works as confirmation Any issue with the current system Delay in service between 2PM 3PM when lab tech change shifts Recommendations and suggestions Need lab technician work only for P A T T same as Finch site Do you use blood bank service amp how to order Yes e Physician order paper e Clerk enter to MT 238 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Lab technician collect blood e Blood will be sent to hospital when patient admitted P A T T Observation
115. ernational Conference on 25 28 March 2008 pp 111 120 doi 10 1109 WAINA 2008 131 4 A Fish S George E Terrien A Eccles R Baker O Ogunyemi Workflow Concerns and Workarounds of Readers in an Urban Safety Net Teleretinal Screening Study American Medical Informatics Association pp 417 426 Oct 22 2011 PMCID PMC3243157 Retrieved from http www ncbi nlm nih gov pmc articles PMC3243157 5 Brogi R Popescu M Bravetti M Nunez and G Zavattaro From BPEL Processes to YAWL Workflows Web Services and Formal Methods Springer Berlin Heidelberg 2006 Available at doi 10 1007 11841197_7 6 Together Professional Open Source Together WFMC XPDL and OMG BPMN Java Workflow Editor Available at http www together at prod workflow twe 151 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 7 A Adriansyah B F van Dongen D Piessens M T Wynn M Adams Robust Performance Analysis on YAWL Process Models with Advanced Constructs Journal of Information Technology Theory and Application JITTA Vol 12 Iss 3 2011 Article Available at http aisel aisnet org jitta vol12 iss3 2 8 Mr Miller C Zhan Pediatric Patient Safety in Hospitals A National Picture In 2000 Pediatrics 2004 Jun 113 6 1741 6 Retrieved from http www ncbi nlm nih gov pubmed 15173500 9 D Berwick D R Calkins C J Mccannon A D Hackbarth The 100 000 Lives Ca
116. ersity Computing and Software eHealth A nurse can do a glucometer collection based on the physician s order single collection hourly or daily PICC line collection A nurse can carry out urine and blood collections for patients in the unit blood collections are performed on patients with PICC line only Routine collection Nurses in some units can perform a routine collection based on the order type but this process is mostly done by a lab technician Blood bank test The process of determining the patient blood type is performed before ordering blood from the blood bank This test is done to find out the patient s blood type d Lab technician in unit Lab technicians can perform sample collections in a unit for STAT routine and round trip orders This includes Routine collection The activity of performing a daily round trip to collect samples at different times of the day 7 00 am 10 00 am 1 00 pm Blood bank test The process of determining the patient blood type is performed before ordering blood from the blood bank This test is done to find out the patient s blood type STAT collection This process is performed by lab technicians only when blood test results are required urgently 127 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Lab technician in lab Lab technicians can carry out collections in the lab for patients referred by a physician or for an
117. erview questions Project name Lab order process flow in L amp D Clinic Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Mary Sackeyfio Nurse Genevieve Date July 17 2012 Time 1 30 PM Location Finch site 185 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 What type of samples you collect at these clinics CBC Blood Culture Baby blood in OR Blood gas How many orders normally placed per day About 10 15 day Who is placing the orders Physician How physicians placing an order Paper chart Phone gt Nurse confirm amp enter it to MT What are the methods of adding another test request to a sample Paper Nurse or clerk enter it to MT Where are labels printed or received from In clinic Do the nurse technician confirm the information in labels with the test request Yes How staff notified there will be test needed Known to do Routine Verbal Who is collecting the samples nurse or lab technician Nurse RT How do nurse technician identify the patient for sample collection for sample test Arm band two ID check H D O B Is there any difference in flow between different samples Ne born baby test orders will not be saved in MT but will be kept in medical files Where normally samples are collected Bedside Where collected samples are normally la
118. es rf Bete A j D Figure 24 NOVA quick fix from problem window Ordering cwf D Nursejava 52 m B Outline amp package laborder OrderExample import ca stfx logic cwf mc base uncompensable UncompensableTaskMCImp1 af public class GB extends UncompensableTaskMCImpl t i l aR 8 laborder Ord Nurs Rename compilation unit to Nurs java 0verride Rename type to Nurse public P Rename in file Ctri 2 R i Rename in workspace Alt Shift R Overridg public d SS c Rename compilation unit Nurse java to Nurs java Press Tab from proposal table or click for focus Figure 25 NOVA quick fix from editor window Analysis configurations The available analysis configuration in the NOVA workflow tool was derived from the configuration of eclipse features such as run configuration and debug configuration This tool does not allow users to have much control when trying to change configurations except when choosing to configure run or debug as eclipse requires 103 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Analysis results The NOVA workflow tool offers a problems panel with information for workflow tool users The result of the analysis categorizes the problems as follows e Descriptions to display the error or warning description in detail e Resources to specify the error or warning resource in the project p
119. esses using business rules The study places an emphasis on how to improve business processes in healthcare and illustrates some examples about the use of widely used information systems in healthcare organizations such as Electronic Medical Records EMRs telemedicine and business process management BPM 14 M Sc Thesis A Kamil McMaster University Computing and Software eHealth That study focuses on the business and technical views of the modeling and execution of healthcare BPM systems based on workflows used in health insurance companies The authors investigate two questions for each businesses view What does eHealth in the health insurance industry have to do with process improvement and What are the business rules and why are they important for business agility Two technical questions were also examined Where do business rules reside in traditional information systems and What architecture is enabling eHealth information systems in the insurance industry to be adapted rapidly to the changing political judicial and business environment The paper also presents a short case study concentrating on claims processing and fraud detection in a major private health insurance company It analyzes how to use forms to display rules enhancing the flexibility of their processes and to automate manual tasks 2 9 Related Work Comparing workflow modeling tools is a comprehensive top
120. essfully run on e Windows XP Vista Windows 7 Server e Linux Ubuntu 9 10 sidux Debian Etch e Mac OSX Tiger Leopard Snow Leopard Lion Graphical editor This section describes the YAWL graphical editor version 2 1 The YAWL graphical editor is the first place where the designers should start when designing a new workflow process This tool allows YAWL users to create configure validate edit and analyze the workflow process The YAWL editor is a Java archive file when users click and start YAWL editor they start the YAWLEditor2 2 jar file 14 18 p 41 YAWL editor workspace is designed in an efficient way The graphical editor is designed to make the work easier for the users when working with a workflow design The graphical editor workspace contains the modeling canvas in the middle surrounded from the top with a grouped tool bar specification maintenance specification verification and analysis net maintenance edit options alignment options size options cancellation sets zoom options From the left side users will find workflow elements and tools task icons decorations and join split panel At the bottom the tool has a note and problem panel an engine resource service status and hints and messages The menu bar in YAWL contains an overview of the same components available in YAWL editor Users have the choice of working with components through the tool bar or the menu bar 76 M Sc Thesis A Ka
121. est needed When labels printed Who is collecting the samples nurse or lab technician Lab Technician How do nurse technician identify the patient for sample collection for sample test Patient name and patient hospital number on patient face sheet no arm bracelet Where normally samples are collected Phlebotomy Where collected samples are normally labeled Phlebotomy How samples delivered to the lab Delivered to the lab by the same lab technician How unit receives the results a MT 176 M Sc Thesis A Kamil McMaster University Computing and Software eHealth b Lab sends copy of the result to the department printer 15 How long it will take to receive the results Depend on the type of the test normally within the normal time no delay 16 What do you do if results not received missing Call the lab and ask for the status Check status in MT 17 Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT Yes 18 Why related to question 15 Make sure samples delivered 19 Any issue with the current system a Porter service b Some blood band order cannot be seen in MT c Some test names have been changed with the new MT 20 Recommendations and suggestions a Fix MT bugs Note No patient arm bracelet used in fracture clinic Outpatient Observation Project name Lab order process flow mapping Observer name job title Amm
122. est request to a sample Give paper chart to nurse to confirm amp enter it to MT Figure 11 Sample interview amp questionnaire form The plan targets to capture the current lab order process performance deficiencies and errors and to design a new digital lab order process flow including all the activities surrounding that process in order to eliminate these errors and deficiencies and avoid any process that could lead to these errors Future Process The future process consists mostly of the same main current process stages except the contents of the stages would be more advanced and digitally controlled The plan is to use the following strategy for the future process e Ordering Use of CPOE e Confirmation and Verification 50 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Use of MT system e Collecting samples Use of bar coded tubes or mobile labeling machines e Delivery system Use of a pneumatic system PTT and AGV vehicles e Submitting results Use of MT system e Inventory system Use of the commuter system We analyzed the current data by entering the collected data into two designed tables and categorized it based on the requirement of a new digital system The first table shows the strategy objectives current standings of the process deficiencies and action plan for the new design for more details see Table 6 A second table shows the process type current technology
123. ests gt nurse call to tell For Routine tests gt from the paper request Who is collecting the samples nurse or lab technician Nurse RT Phlebotomist How do nurse technician identify the patient for sample collection for sample test Arm band two ID check H D O B Is there any difference in flow between different samples Stat tests get to lab quickly Banc s and Fluid the order should specify the destination of the sample in the lab Where normally samples are collected Bedside Where collected samples are normally labeled Bedside How samples delivered to the lab Stat gt send by the clerk Routine sent by Porter How the clinics receive the results MT MT amp Fax when critical 184 M Sc Thesis A Kamil McMaster University Computing and Software eHealth If result is up normal it will be highlighted red 17 How long it will take to receive the results Stat gt 5 min Routine 30 min lhour 18 What do you do if results not received missing Call the lab 19 Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT Yes 20 Any issue with the current system Need manual to know where to send bronchioles samples Porter service slow 21 Recommendations and suggestions Need to have tracking system Mobile labelling device seems good idea 22 Do you use blood bank service amp how to order No L amp D Finch int
124. ew heterogeneous applications by providing an approach for semi automated aggregation The intention of this study was to aggregate and deploy a new BPEL service by translating BPEL processes into YAWL workflows The authors chose the YAWL language because of the well defined YAWL formal semantics hence the methodology they recommend outlines a YAWL pattern for each BPEL activity The authors also chose to use YAWL because of its ability to handle complex data transformations and web service integrations as an advanced specification when compared with the other tools For example the Web Service Description Language WSDL interface provides only a syntactic description of the supported operations which could severely affects the process of semi automated service composition as composed services may lock during their interaction 2 5 Use of Workflows in Healthcare The study in this thesis involves choosing the right workflow for designing lab processes in a healthcare setting Workflow languages have been used before to facilitate workflow processes A study by Jenkins and Eckel 2 about analyzing methods for improved 11 M Sc Thesis A Kamil McMaster University Computing and Software eHealth management of workflow in an outpatient pharmacy setting represents work done by the authors as a time motion of workflow analysis at a large central outpatient pharmacy In the case studied here a centr
125. f samples There are no current confirmations of the pickup and delivery of samples in most of the hospital departments therefore making it easy to lose a sample except in Endoscopy and OR departments where they have a signature sheet for nurses porters and lab technicians to sign when they receive the samples Porters carry blood tube by hand No basket or special bag is available Labeling Labeling the samples is done in many ways depending on the type and environment of the collection location In some isolated patients rooms lab technicians apply labels outside the room as part of a precaution procedure Lab technicians need to disinfect the sample tubes from outside by using alcohol which could erase the printing on labels The labeling on a 24 hour urine collection bottle normally done after a patient brings the bottle back to the clinic not before taking it home Some departments delay entering orders or printing labels until after the collecting of the samples 52 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Most of the labels are normally printed in the lab and brought by the lab technician to units A collection will not take place if a label is not available or if there is no identification bracelet ID on patient The collected information that we gathered from the lab technicians shows that there are at least 1 to 2 specimen labeling errors exist in the process every day Accordi
126. features such as concurrency role binding and transaction and commitment support in the models Another study by Murray 16 investigates the Strategies for the Successful Implementation of Workflow Systems within Healthcare A Cross Case Comparison a multiple case study to analyze the implementation of a commercially available healthcare workflow system The study researches on how to implement a workflow system successfully in an organization The study presented cross case comparison and implemented a multiple case study design The cases were selected based on five criteria similar environments version of the workflow product purchased stage in the implementation process internal institutional characteristics and potential willingness to participate in the study A study by Kano et al 17 about U Compare A modular NLP workflow construction and evaluation system investigates how workflow comparison and evaluation could help in the development of natural language processing NLP applications by discovering the nature of NLP problems The study concentrated on how to enhance an NLP application Adding a customizable comparison and evaluation system was one of the features the authors used along with other features into their U Compare system 2 10 Summary Through this review of previous studies we found that workflow languages can be used to help develop eHealth application to attain better ser
127. flow users can define more configurations than with the analysis tool of TWE workflow which results in more error detection and better workflow design Analysis configurations The available configuration in TWE sets the design time validation to either true or false Based on the TWE user manual setting the option for design time validation to true will refresh the problem list automatically if the option for design time validation is set to false the problem list will not be refreshed automatically Together User Manual 20 87 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Analysis results The problems tab contains useful information for the workflow tool users about any workflow design problem The analysis categorizes the problems as follows e Problem type to represent a process problem type error or warning by an icon e Error warning type to specify if the problem is an error or warning logic conformance connection or schema e Description to describe the error or warning in details e Element to specify the element involved in error or warning variables activity e Location to show any details the error or warning location in the workflow package process sub process task 20 see Figure 20 Technical Issues Executable model The TWE tool generates XPDL and XML code with its workflow systems to run and execute the workflow process The tool make use of the op
128. following JRE JDK versions are supported e Oracle Java SE Runtime Environment 6 u30 and Oracle Java Runtime Environment 7 u3 available from the Oracle web site and installed according to these instructions e OpenJDK 6 b24 available from the OpenJDK web site 92 M Sc Thesis A Kamil McMaster University Computing and Software eHealth For process deployment you also need a JEE application server The following are supported Tomcast 6 0 35 JBoss 4 2 2 GA JBoss 5 1 0 GA Glassfish 3 1 2 2 and Oracle Weblogic server 10R3 Bonitasoft User Guidance 21 Graphical editor With the Bonitasoft tool graphical interface the whiteboard users can start designing a new workflow diagram by drawing one or more process diagrams or by drawing one or more pools Note that each pool is a complete process The interface consists of six parts The diagram panel whiteboard is in the middle of the screen surrounded from the top by menu bars and the tool bar cool bar and left by the design palette activity task connectors From the bottom it is surrounded by the overview panel and the detail panel general applications appearance and simulation panels The Bonitasoft tool interface is connected directly to the execution engine and the execution engine connects the process to the existing system to deploy or run the process Bonitasoft User Guidance 21 Execution engine The Bonita execution engine is used to execute a
129. ft Open Your Process Bonitasoft User Guidance Bonitasoft Open Your Process Online Available http www Bonitasoft com resources documentation index php 22 Stfx Centre for Logic and Information NOVA Workflow NOVA Workflow Overview Online Available http www logic stfx ca software nova workflow Overview index php 23 Stfx Centre for Logic and Information NOVA Workflow User Manual 2 0 Online Available stfx Centre for Logic and Information http logic stfx ca _files file php Fileid filemaykpgcupr amp filename file_User_M anual_2 0 pdf 24 T Murata Petri nets Properties Analysis and Applications Proceedings of the IEEE 77 4 541 580 1989 25 Bonitasoft Open Your Process Bonita Open Solution Open Source Bonitasoft Overview Online Available http www Bonitasoft com 26 Bpmn2bpel Bpmn2bpel A Tool For Translating BPMN Models Into BPEL Processes Project Information Online Available 154 M Sc Thesis A Kamil McMaster University Computing and Software eHealth http code google com p bpmn2bpel 27 Bpmn2bpel Bpmn2bpel Getting Started Online Available bpmn2bpel http code google com p bpmn2bpel downloads detail Name Getting 20started pdf amp can 2 amp q http www yawlfoundation org pages support more html 28 APACHE AIRAVATA Online Available Http airavata apache org 29 Jbpm The Jbpm Team JBPM User Manual Version 5 4 0 Fina
130. gital process a complete lab order will take 40 minutes to complete A difference of 95 minutes between the two processes highlights the benefits of the new design see Figure 14 Time in minutes 160 140 120 100 80 60 40 e Current process turnaround time in minutes g Future processturnaround time in minutes Figure 14 Current and future process turnaround time 70 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 5 CHAPTER FIVE DISCUSSION We divided the discussion into two parts to encompass all of the content and cover the two parts of the study The first part of the discussion will discuss the work on the workflow tools The second part of discussion is dedicated to talking about current and future lab order process flows 5 1 Introduction to Workflow Tools There are multiple workflow tools available for use in designing a workflow process we selected only 15 open source workflow tools to investigate due to some limitations exist such as duration of the study and pre set criteria We chose the following tools YAWL Together Bonitasoft NOVA bpmn2bpel Apache Airvata jBPM Anduril Kepler nexusBPM Apert joget Process Maker Open Source RunaWFE and Yaogiang BPMN Editor 2 1 21 and filter them to choose the best tool to design a new digital flow for Humber River Hospital s lab order process The study identified th
131. given after contacting the author e There is no substantial difference between the NOVA workflow version 2 0 and version 0 1 though version 2 0 requires adding more codes than with version 0 1 e Running the workflow engine of NOVA workflow version 2 0 still requires configuring the tool database e There are significant errors with the NOVA workflow version 2 0 eclipse file It is described as follows o Torun NOVA workflow version 2 0 the user needs to download the latest SDK package tool files version 21 1 for android The NOVA workflow version 2 0 tool uses the SDK path Cvcliresearch tools android sdk windows to download the package tool for android in eclipse The specified path address is not editable and cannot be reset due to the copyright of the tool In order to be able to run the tool we had to solve this issue by creating a path address with the same address mentioned above to let the eclipse tool work and configure the SDK manager 108 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e All the issues that we mentioned above will not be easy for a regular user to do or follow unless they have some coding knowledge or worked with eclipse before 5 1 1 Overview of Other Workflow Tools bpmn2bpel Workflow Tool The tool source page does not have enough information about the tool features and benefits The plugin tool with eclipse is missing the tool context menu entry what cause the ecl
132. he current system The clinic is consists of two parts away from each other about 7 min when blood work done in one part it need to be carried about 7 min travel time to the other clinic to spin or complete the work 20 Recommendations and suggestions Need lab tech to do the blood work Results sent by outside labs fax and mail need to be entered to MT 21 Do you use blood bank service amp how to order Yes The paper work will be done blood unit will be transferred from Church site to Keele site Kidney Care Observation Project name Lab order process flow mapping Observer name job title Ammar Kamil Project assistant Observation place Kidney Care unit Dorota Jamroz Resource Nurse Date July 26 2012 Time 10 00 AM Site location Keele e Physician telephone order Paper chart or verbal e Nurse confirm amp enter it to MT e Labels printed in unit e Nurse checks two patient IDs verbally H D O B or F L Names e Nurse collect samples e Spin the blood and put in ice in a specimen bag in fridge e Call Carrier for pickup 203 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Note The clinic is consists of two parts away from each other about 7 min when blood work done in one part it need to be carried about 7 min travel time to the other clinic to spin or complete the work Kidney care clinic will be transferred to Finch site State tests w
133. he person who collect the sample e Nurse scan or write patient information in the device e Nurse scan the blood stripe e Perform the test on the patient e Nurse enter result shown on the device screen to the patient record in MT e Nurse place the glucometer on the loading deck results will be sent to the lab Acute care unit 224 M Sc Thesis A Kamil McMaster University Computing and Software eHealth o Usually lab order will be done in triage if another lab order need to be done in the unit it will be as follows e Physician or RN can place an order paper chart and place it in a basket e Nurse or Clerk enter the paper order to MT e Labels will be printed in the unit e Samples will be sent to lab by the pneumatic system e Lab process the samples and submit the results to MT Sub acute care unit o Usually lab order will be done in triage if another lab order need to be done in the unit based on the following order e Physician or RN can place an order paper chart e Nurse collect samples bedside and brought to front desk e Clerk Nurse enter the paper order to MT e Labels printed in the unit front desk and places on tubes at the front desk location e Samples sent to lab by pneumatic system e Lab process the samples and submit the results to MT General information about the ED unit as whole Most lab order will be done by RN or RPN lab technicians do lab order for admitted patients only and orders need
134. he process done inside or outside the hospital Some test processes that require specific instruments are sent outside the hospital for processing and this action could result in delaying the service The plan is to process most of the required tests in the hospital by purchasing the required instruments as part of the new complete lab 29 M Sc Thesis A Kamil McMaster University Computing and Software eHealth equipment To develop a discrete list of business and technical requirements for a long term solution in order to replace the current lab instrument in the main hospital lab and to supply new equipment to other clinics as needed Current lab services cover most of the tests required except for some services where more equipment and instruments are required Increase processing time and as well as the waiting time to get results Doing these tests outside the hospital may add extra costs to the hospital and there is a negative potential to disclose confidential patient information Buy most of the required lab instrument for the new hospital Table 6 Strategic data analysis The data has also been categorized in different tables to identify the processes current technology used proposed technology for the digital process and if change is required see Table 7 Process Current technology Proposed Technology Require
135. he room used by the physician and no labeling machine available there when draw blood from the baby baby need to be registered first then the order and labels can be printed and places on the sample Need result quickly Better timing management Porter service slow 181 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 20 Recommendations and suggestions Need to have mother s name on baby blood label On MT first page has the baby s mother name by default second page mother name need to be entered manually third page has no mother name mother name need to be on the three pages by default to eliminate errors When blood drawn and patient leave home then come back within 24 h why blood need to be drawn again 21 Do you use blood bank service amp how to order Combine care Nursery Observation Project name Lab order process flow mapping Observer name job title Ammar Kamil Project assistant Observation place Combine care Nursery Date Aug 15 2012 Time 11 30 AM Site location Church site Combine carte Physician order Clerk enter it to MT Orders will be sent to lab the day before the test for lab tech to collect Labels printed in lab Next day morning lab tech come to collect blood Lab tech checks two patient IDs and collect samples Result will be submitted to MT If critical a paper copy will be sent to the unit Nursery
136. he tool uses to generate the applications With the Bonitasoft tool users can add a timer event and call activity Users can also define two types of variables global variable for the entire process and local variables for an individual task With the Bonitasoft tool graphical interface users can start designing a new workflow diagram by drawing one or more process diagrams or drawing one or more pools The Bonita execution engine is used to execute or run the process in a development environment for testing purpose only and not for deploying a process in a productive environment The tool provides a simulation option to evaluate the process under multiple conditions resources and load 38 M Sc Thesis A Kamil McMaster University Computing and Software eHealth The tool can be used for simulation run and executed Different process actors can be selected and assigned data Variables can be global local single multiple and can have a list of options The tool modeling capability consists of multiple activities including creating a service task a human task calling an activity gateways transitions events and event sub processes The Bonitasoft workflow tool processes data in multiple formats including Java Objects and XML The applications generated with Bonitasoft use standard html css and Javascript The tool is available as free software or as commercial software for subscription or expertise pack The Boni
137. ial is not well structured for a regular user We couldn t find enough evidence about using the tool in a healthcare setting when searched about the tool in the available sources jBPM Tool Workflow Tool Although the provided information about the tool shows that the tool has useful features and the eclipse plugin graphical editor is easy to use but it is difficult to get to the required download files The instructions are also unclear on how to access these files 29 The tool uses a practical drag and drop graphical editor feature but most of the other operations defining process creating a knowledge base and starting process are to be done through modifying the XML code JBPM User Manual 29 Notably the tool does not have enough support I was not able to download some required plugin files making it impossible to work with this tool 110 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Anduril Workflow Tool This workflow framework was developed at the Computational Systems Biology Laboratory at University of Helsinki for the use of scientific data analysis The tool was intended to be used by developers only it has no graphical editor for regular users to develop a workflow There is also not enough support available for this tool and the overall information is missing a lot of details 30 Kepler Workflow Tool This tool was mostly designed to help programmers de
138. ian Journal of Information Systems pp 103 116 1998 Online Available http ssrn com abstract 2176241 15 Y Lei M Singh A Comparison of Workflow Metamodels 7997 Online Available http osm7 cs byu edu ER97 workshop4 ls html Cas 16 M Murray Strategies for the Successful Implementation of Workflow Systems within Healthcare A Cross Case Comparison Proceedings of the 36th Hawaii International Conference on System Sciences 2003 Online Available http www hicss hawaii edu HICSS36 HICSSpapers HCHCW01 pdf 17 Y Kano M Miwa K Cohen L Hunter S Ananiadou J Tsuji U Compare A modular NLP workflow construction and evaluation system IBM Journal of Research and Development Vol 55 Issue 3 Pages11 1 11 10 2011 Online Available http ieeexplore ieee org xpl articleDetails jsp arnumber 5730625 18 YAWL Foundation YAWL User Manual 2 3 Online Available YA WL Foundation Available at http www yawlfoundation org pages support manuals html 153 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 19 YAWL Foundation YAWL Yet Another Workflow Language Features Of YAWL YAWL Foundation Online Available http www yawlfoundation org 20 Together Teamsolutions Co Together User Manual V 4 7 Available at Together Professional Open Source Online Available http www together at prod workflow twe manual 21 Bonitaso
139. ibe the fundamental steps in IHE profiles This particular paper demonstrates different examples of IHE profiles integration specifying some of the approaches in integration by using a standard interface with two transactions together first outlining the transactions describing the collaboration between the IT systems and second clarifying the workflows describing the real life process There are many IHE profiles and each profile has been designed to fit the business need of the vendor or the enterprise to support different sets of user profiles Yet combining these profiles requires determining the precedence of all the involved transactions manually The same study also defines the stages of grouping IHE actors in order to design the business process automatically The authors considered IHE profiles and used OASIS ebXML machine processable language and the Business Process Specification ebBP Language for the purpose of defining precedence rules in transactions of the IHE Profiles by using a graphical tool to let the users select the actors for grouping IHE uses the standard profiling approaches of business processes describing selected real world use cases to accomplish both effective integration and interoperability in the eHealth domain A study by Hiisemann et al 13 defines how a Health Insurance Company can improve business agility using flexible business processes for Building flexible eHealth proc
140. ic different studies researched different areas of workflow comparisons but none of the available studies compared 15 workflow tools the way we did and recommended the best and more reliable tool to design a fully digital workflow process for a healthcare setting A study by Rosemann and Muehlen 14 about Evaluation of Workflow Management Systems A Meta Model Approach compares two meta models of workflow management systems WorkParty Siemens Nixdorf and FlowMark IBM The research analyzes the usefulness of a meta models in a pre selecting of an appropriate workflow management The authors used Evaluation of the Organisational Meta Models and Evaluation of the Process Meta Models as the methods of evaluation in the research evaluating the process meta models was based on the outcomes of the graphical models and the pre defined process components of the proposed models Another study by Lei and Singh 15 focused of comparing multiple workflow metamodels Task flow based metamodel State transition based metamodels Relationship capturing metamodels and Communication based metamodels The study 15 M Sc Thesis A Kamil McMaster University Computing and Software eHealth identified major categories of workflow metamodels and a list of criteria to use as evaluation dimensions the evaluation was based on how the metamodels handle tasks and control flow as well as the available advanced
141. ient a Registered therapist A registered therapist is able to perform the following types of collections Specimen collection Pathology Cytology amp histology Arterial blood gas ABG collection b Physician Endoscopy collection A physician can carry out a collection of an endoscopy sample in the endoscopy room 135 M Sc Thesis A Kamil McMaster University Computing and Software eHealth OR Collection A physician can carry out a collection in the OR c Nurse in the unit Nurses can perform routine sample collections in a unit for patient with PICC line nurses also give glucometer orders Endoscopy collection Nurse can perform endoscopy collection based on the physician s direction in endoscopy room Glucometer collection Nurses can perform glucometer collection based on the physician s order single collection hourly or daily PICC line collection Nurse can perform urine and blood collection for patients in unit Blood collections are performed on patients with PICC line only Routine collection Nurses in some units can perform routine collections based on the order type but this process is mostly done by a lab technician Blood bank test The process of determining the patient blood type is performed before ordering blood from the blood bank This test is done to find out the patient s blood type d Lab technician in unit Lab technicians can carry out sample collections in a
142. igital process outcomes based on information from lab technician ongoing and future processes digital lab order process plans designed by the lab director and the capabilities of the new digital process lab Pre and Post Analytical Instrument that was planned by Humber River Hospital The new digital process is expected to have a tremendous impact on operations in the Humber River Hospital such as improvement of turnaround time from 135 minutes for the paper based system to 40 minutes for the digital system Other improvements can include reduce human errors caused by wrong sample labeling and providing a more secure environment for patient information when working with patient data M Sc Thesis A Kamil McMaster University Computing and Software eHealth The result of this research ca benefit the future of the healthcare system by recommending the right tool for designing a new process system and providing valuable data for future processes Workflow process designers and users need to have a reliable process modeling tool to design new healthcare process flow systems the research can improve the healthcare system and facilitate developer efforts when designing a new digital lab order process M Sc Thesis A Kamil McMaster University Computing and Software eHealth 2 CHAPTER TWO LITERATURE REVIEW The field of eHealth is evolving quickly many healthcare organizations are switching their daily operations to involve
143. ile devices from inside or outside the hospital e Needing to improve quality of sample taking current sample takers are not following the proper procedure The current lab order process flow has been performed using some old methods that could lead to multiple issues in different areas of the process An explanation for every process will follow Ordering Ordering procedure followed now is represented by e A paper request e Physicians having no access to CPOE e Verbal amp phone orders will be entered into MT by a nurse or clerk Confirmation amp Verifications e There are no current confirmations on the pickup and delivery of the samples in most hospital departments except for Endoscopy and the Operation Room OR which have recently implemented a signature sheet for a nurse porter and lab to sign once they have received the samples e No notification available when results are ready in MT unless results are critical 46 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Most of the time the lab tech or nurse does not confirm the test s information on labels with test request order Collecting Samples Collecting samples can be done by physicians nurses lab technicians and registered therapists Collecting samples could have the following issues e There is no defined way on how to inform nurses in a unit about new lab order requests e In most departments nurses do not have
144. ill be sent to church site by taxi patient or ambulance There are 2 time of collection 10 00 AM amp 2 00 PM If patient live more than 10 KM away from the hospital the blood work will be done in lab outside the hospital result will be faxed or mailed to hospital Result from outside labs will not be entered to MT Mental Health Church interview questions Project name Lab order process flow in Mental Health Clinic Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Jasent Resource Nurse Date July 26 2012 Time 11 00 AM Location Keele site 1 What type of samples you collect at these clinics Blood Urine 2 How many orders normally placed per day 10 day 3 Who is placing the orders Physician phone order Verbal 4 How physicians placing an order Paper chart verbal gt Nurse or Clerk enter it to MT 204 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 15 16 17 What are the methods of adding another test request to a sample Paper telephone order gt Nurse or clerk enter it to MT Where are labels printed or received from In clinic Do the nurse technician confirm the information in labels with the test request Yes How staff notified there will be test needed By communication board Labels will be printed the night before and will be Who is collect
145. in advance collection for a patient with upcoming appointments Physician referrals collection This process occurs once a test is referred by a physician from one of the hospitals units and not an outside clinic In advance collection This process is for patients where results should be ready for the physician at the time of the appointment primarily for oncology patients 6 Delivering samples Delivering the samples is done in four ways a Porter service A hospital porter service personal collect the lab samples from a basket in a hospital department and deliver them to the lab this process is the main methods of delivering samples to the lab in the current lab order process flow b Lab technician The lab technicians take the collected samples with them to the lab when they finish their round trips or routine collections c Staff A staff of a department delivers the urgent collections to the lab d Courier In Humber River Hospital Keele site they send samples to the lab with a commercial courier services or a taxi cab 128 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 7 Processing samples After the lab receives samples technicians start categorizing them based on the required test Processing samples occurs as follows a In hospital process Samples are normally processed in the hospital lab except for some samples where a required instrument is not available in the lab
146. in the study collecting qualitative data supported by quantitative data For the qualitative methodology we used following procedure analyzing each tool independently investigating all the tools designing capabilities exploring all the tools features reviewing and studying the tools This was done by following the qualitative parameters below Qualitative Parameters e Flexibility of the tool of change move delete re design e Reliability of the design and analysis to meet the goal e Quality of the process whether it was easy or difficult to read and understand the workflow joins tasks e Performance of the tool simulation analysis resource needed e What information is available to the users downloading installation user guide examples troubleshooting e Ease of tool use and information access The study also included quantitative methodology to support the results gathered earlier from the qualitative methodology This happened by providing statistical data collected from analyzing the workflow tools the design of a workflow samples and a list of the tools technical features non technical features designing time and workflow components used in each design This was all done by following the quantitative parameters below Quantitative Parameters e Total cost including user time tool cost support and other sources e Workflow process designing time including additional time for fixing errors e Types of
147. ing system human or configure a role resource and resource sets The graphical editor has easy access to graph and XPDL views for package and process a navigator and tree area property problem and WFXML components The Together Tool supports XPDL XML Java Languages and is available as open source software It also offers free and commercial support 6 The study we performed on TWE and the examination of the tool revealed that the Together Workflow Tool has 19 technical workflow features and 10 non technical features The tool took 75 minutes to complete the design of the designated sample 36 M Sc Thesis A Kamil McMaster University Computing and Software eHealth workflow process Future lab ordering and used 57 workflow components tasks and branches see Figure 8 The TWE uses swim lanes to specify the sub process under the main process platform these swim lanes specify the type or actor in the sub process The elements of the process is arranged in the lanes to clarify the tasks of each process path starting the process in the starting order lane or the types of orders a physician can order in the physician lane are some examples of these elements and tasks see Figure 8 mS Future Lab Process W Starting Order amp Physician Nurse amp Physician Assistant stgrt Physician Assistant Order z End task O Transition Nurse Practitioner pei
148. ing the samples nurse or lab technician Nurse How do nurse technician identify the patient for sample collection for sample test Safety check will be performed by the patient responsible nurse Arm band two ID check H D O B then sample collection will be done by another nurse Is there any difference in flow between different samples No Where normally samples are collected Patient room Where collected samples are normally labeled Patient room How samples delivered to the lab Carrier come for pickup at 10 00 AM 2 00 PM 6 00 PM How the clinics receive the results MT How long it will take to receive the results Within the normal time about 2 hour What do you do if results not received missing Call the lab and make sure that the lab received the samples 205 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 18 Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT No find it not necessary because they don t have any issue of missing samples within the last 4 years 19 Any issue with the current system When placing an order in MT labels will not be printed when order status is to be collected unless you change the status to collected 20 Recommendations and suggestions On the result page in MT regular parameter need to be beside the results 21 Do you use blood bank service a
149. inics Urine Blood blood culture tissue fluid spinal specimen 2 How many orders normally placed per day 30 day 3 Who is placing the orders Physician 213 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 15 16 How physicians placing an order Paper chart gt Nurse confirm amp enter it to MT What are the methods of adding another test request to a sample Paper Nurse or clerk enter it to MT Where are labels printed or received from In clinic Do the nurse technician confirm the information in labels with the test request yes How staff notified there will be test needed Paper request when changing shifts Who is collecting the samples nurse or lab technician Nurse if CVAD otherwise collection will be done by lab tech How do nurse technician identify the patient for sample collection for sample test Arm band two ID check H D O B Is there any difference in flow between different samples No Where normally samples are collected Bedside Where collected samples are normally labeled Bedside How samples delivered to the lab Porter How the clinics receive the results MT Phone call if critical How long it will take to receive the results Stat takes 1 2 hour Routine takes 2 hours 214 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 17 What do you do if resul
150. ipse plugin to produce errors Searching about this tool results in following 26 e Not enough information for installing the tool e No workflow examples or screenshots e No user manual available e No support available The file for getting started provided by the tool source page specifies some of the disadvantages of the bpmn2bpel tool It shows that the current implementation still has the following issues 27 e There are still some bugs with the translation of arbitrary cycles with a single entry point e The translation of REPEAT WHILE patterns is still unimplemented e Some other problems might be present because this is the first version of the Plugin The current layout algorithms are not well suited to deal with highly nested models 109 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Apache Airavata Workflow Tool Apache Airavata is a workflow software tool used to build science gateways providing software modules to construct execute manage and monitor applications and workflows This tool is mostly intended for developers and most of the provided information is about code The download page of the tool does not provide clear information about the required files It describes a lot of files with no instruction on how to use these files This can be highly confusing for users 28 The tool has not enough support available no user manual and the provided tutor
151. ironment Information about the chosen tools was collected by studying each workflow tool individually We analyzed and filtered the 15 tools and eliminated 11 tools that don t have specified criteria as the Availability of an analysis tool tool features vendor support graphical editor execution engine and simulation see Table 1 We chose four tools which have the mentioned criteria and examined them by using these tools separately to design a sample workflow process then we evaluated each tool based on the outcome of the workflow sample design The work also involved studying all tool design capabilities by referring to related studies tool user manuals and web pages to gather and learn more information about these tools Such effort included evaluating the tools based on certain quantitative and qualitative criteria Part two of the study consists of studying the lab order process flow and was made up of four phases Phase one involve collecting information about the current lab order process including observing the workflow process for all the departments of the three Humber River Hospital s sites Church site Keele site and Finch site as well as the hospital laboratory The work included designing the information form to collect data through interviews and observation It also included writing step by step the lab orders process Each observation and interview had the following components unit name project name intervie
152. iscover infinite loop 1 0 0 0 Unreachable states 1 0 0 0 Probability of failure 1 1 0 0 Access to graph l 1 1 1 Access to XPDL 0 1 0 0 Activities 1 1 1 1 Process parameters 1 1 1 1 Create variables 1 1 1 1 Manage property 1 1 1 1 Sub process 1 l 1 1 Timer event 1 1 1 0 25 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Message event 0 0 1 0 Call event 0 0 1 0 Total Score 23 19 17 13 Table 2 Workflow tools technical features Workflow Tools Non Technical Features YAWL Together Bonitasoft Nova Number of programming 4 3 3 2 languages the tool supports Use in eHealth 1 1 0 1 Free tool download amp install 1 1 1 1 Open source software 1 1 1 0 Access to source code 1 1 0 0 Support available 1 1 1 1 User amp Technical Manual 1 1 1 1 Training 1 1 1 0 Total Score 11 10 8 6 Table 3 Workflow tools non technical features The work includes not only defining the features but also making sure the features are useful when designing a new process We collected other data from designing a designated Future lab ordering workflow process see Figure 7 Figure 8 Figure 9 Figure 26 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 this data was used to compare the workflow process designing time by measuring the time of designing the workflow process sample using the
153. ital lab order process see Figure 6 and Figure 1 Delivering_Samples gt Brakedown _ Operation D Porter Service Pneumatic pte Operation Tube System Hoo Start task ee p End Task H al Confirmations Cancellation sign 3 an ER Varifications Split sign gt i Figure 6 Delivering sample process YAWL is an open source software and provides a variety of support for the users including free tool download access to Java source code the YAWL foundation forum where one can ask and answer questions user and technical manual tutorials teaching videos commercial support contact support and email address case studies examples screen shots a YAWL book and FAQ s YAWL Foundation 19 The results of the tool evaluation reveal that the tool is a reliable workflow tool and an easy to use tool containing all the necessary aspects of a dependable workflow tool The tool gained the highest ranking in our measurements scales among the four workflow tools YAWL Together Bonitasoft NOVA based on the evaluation we performed The YAWL workflow tool has 23 technical workflow features and 11 non technical features When designing the designated workflow process Future lab ordering the YAWL tool 34 M Sc Thesis A Kamil McMaster University Computing and Software eHealth took 45 minutes to complete the desig
154. iversity Computing and Software eHealth Moreover TWE provides composing transition condition help Users can click on an arrow in the text box of entering condition to get a list of possible variables which can be used within the condition Together User Manual 20 Requirements The only prerequisite to be able to run TWE on Windows or Linux system is Java JRE 1 7 installed on the machine There are several binary packages for Windows and Linux operating systems that can be used to install TWE 20 e TWE for Windows uses twe x y z exe package e TWE for Linux uses twe x y z noarch rpm package Graphical editors Together Graphic Editor also referred to as the TWE user interface is the most essential section in the workflow tool The user interface is configured to provide comprehensive access to designing a workflow process TWE users use the graphical editor to create manage edit and review graphical workflow and XPDL process files The graphical editor is designed in such a way that it allows users to see all of the required features at once The user interface consists of four main parts The first two are the graphic and XPDL panels located at the center of the user interface surrounded from the top side by the tool menu and info bars From the left side it is surrounded with a special area containing the external package relation workflow overview and transient package pool The left side also contains navigation
155. kes editing more difficult what let the nurse to wait for the collection to be completed before entering patient information to avoid any changing in the order in case the physician decided to collect different type of specimen Observing the lab technician work in PATT Pre Operations Department Lab tech paged for lab order in PATT Labels already printed in the phlebotomy room 200 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Lab tech arrives collect samples and affix labels e Lab tech take samples to lab Observing the OR In OR they have their own labeling machine Round trip 6 AM 10AM 1PM 3 30PM 6PM After 6PM there will be no collection unless it s STAT amp Tim Test Kidney Care Church interview questions Project name Lab order process flow in the kidney care Clinic Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Saverina Sanchez Manager Dorota Jamroz Resource Nurse Date July 26 2012 Time 9 00 AM Location Keele site 1 What type of samples you collect at these clinics everything 2 How many orders normally placed per day 5 day 3 Who is placing the orders Physician 4 How physicians placing an order Physician telephone order Paper chart or verbal Nurse confirm amp enter it to MT 5 What are the methods of adding another test request to a sample Physicia
156. kflow challenges that other researchers have missed Their study focuses on how to identify certain fundamental factors that need to be considered when performing teleretinal readings by specialists This study also used a qualitative descriptive method to collect data through interviews with all of the following the project s reviewers clinical staff and patient focus groups Data was also collected through observation of clinic workflows The authors defined some key issues that could arise when evolving workflow protocols for the safety net and their broader applicability in telemedicine Another part of this same study shows that telemedicine could be a means of improving care services if used for safety in clinics or in a resource poor setting or in an area where the population of uninsured patients is expanding At the same time the authors suggested that adoption of telemedicine in a healthcare workflow setting is not an easy switch and could become another problem in developing standardized workflows and patient care protocols 13 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 2 8 The Use of Business Process Languages and Business Rules Business process languages are used for a variety of purposes Among them a study by Dogac et al 12 about integrating healthcare enterprise IHE profiles by using ebXML Business Process Specification Language the study descr
157. kflow tools available but not every tool has the necessary and required workflow analysis feature that a workflow designer needs when designing a reliable workflow process 2 3 Workflow Tools A study by Van Der Aalst et al 10 defines the implementation of system supporting YAWL and creates a tool that would be able to provide direct support for a multiple pattern concept YAWL is based on an accurate analysis of existing workflow management systems and related standards using an inclusive set of workflow patterns 10 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Another study by Adriansyah et al 7 investigates the design and implementation of performance tools these tools help to analyze a variety of performance metrics using information from existing process model logs These tools also help in making more effective improvements and decisions These authors chose the YAWL process model language to apply their techniques and compare performance of process instances YAWL process models and performance characteristics obtained from replaying the log in the model which are projected onto the model The same paper demonstrates the use of this approach in an insurance company s activities where activities were kept for auditing purposes These activities were mostly used for analysis 2 4 Workflow Languages A study by Brogi et al 5 investigates the adaptation of web services into n
158. l This tool is open source software based on the JBOSS JBPM workflow core Even though the tool has a user web interface it consumes a large amount of computer memory and resources which in turn causes the server to take a long time to launch and thus slows down the performance of other software on the computer This ultimately makes the work progress slow and complex The tool is also missing an analysis tool simulation execution engine components and features 38 39 Yaoqiang BPMN Editor 2 1 21 Workflow Tool This tool is a BPMN graphical editor for business process diagrams the webpage of the tool does not have any information available except some screen shots and a download link Even though the screenshots show a strong design graphical editor but this is not enough to select the tool for designing a workflow process 40 The tool is also missing the analysis tool and the ability to generate code in addition to other modeling capabilities such as declaring variables and setting parameters 5 1 2 Workflow Tool Evaluations Procedure In this section of the study we discuss how we chose to evaluate the selected 15 workflow tools We will examine the parameters and what influenced the decision of identifying the best workflow tool among the 15 tools To evaluate the tools we followed a mixed 113 M Sc Thesis A Kamil McMaster University Computing and Software eHealth qualitative and quantitative methodology
159. l Online Available http docs jboss org jbpm v5 4 userguide 30 Anduril Online Available http csbl fimm fi anduril site 31 Kepler Kepler Documentation Kepler 2 3 Getting Started Guide Online Available Kepler Https code kepler project org code kepler docs trunk outreach documentation shipping 2 3 getting started guide pdf 32 Kepler Online Available https kepler project org 33 Nexusbpm Online Available http nexusbpm sourceforge net 34 Aperte Workflow Aperte Quick Start Guide Online Availableat Aperte Workflow https github com bluesoft rnd aperte workflow core wiki Quick start guide wiki Setup_using other_application_server 35 Aperte Workflow Online Available 155 M Sc Thesis A Kamil McMaster University Computing and Software eHealth http www aperteworkflow org 36 Joget Workflow Online Available http www joget org 37 Processmaker Open Source online Available http www processmaker com 38 Runawfe Online Available http wf runa ru About 39 Runawfe Runawfe User Guide Version 3 0 Online Available Runawfe http wf runa ru doc WF system_User_guide 40 Yaogiang BPMN Editor 2 1 21 Online Available http bpmn sourceforge net 41 J P Brian Workflow Associated With the Collection of Clinical Lab Data at the Point of Care M Sc Health Informatics Thesis Indiana University 2007 Available
160. l waste the time many collections waiting to be done while technicians running to the lab technicians should stay in floors to collect blood 3 Need an electronic board for technologists in the lab to display a Number of samples collected received incase collected amp not received b Number of samples in progress C Number of samples completed to determine if sample is missing 160 M Sc Thesis A Kamil McMaster University Computing and Software eHealth d Real time turnaround to manage work in the lab number of technicians and technologists needed 4 Need to show correct processing time in MT 5 Need to determine better priority and clinic identification for example by printing a colored square on the label for etc 6 Need for auto release auto verification to confirm the completion of work by technologist 7 Need for confirmation system for receiving the order and sample and for distributing the result 8 Blood specimen stool samples will be stored after work completed urine samples will not be stored but will be kept for 4 hours only Laboratory Additional Questions Project name Lab order process flow in lab department Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Terry Calabrese DIRECTOR LABORATORY SERVICES Date Thursday June 21 2012 Time 11 00 AM Location Church site Lab 1 Where
161. linic a physician could do a sample collection and verbally request another sample at the same time 123 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Phone Physicians can also place an order by calling the hospital department A nurse or clerk can answer and enter the order details on a paper request or directly input it into MT as a new order or ad on a test order Referred to lab Physicians can refer patients to the lab for a new order only This occurs when test results take several days to be completed and need to be ready in advance when a physician sees a patient Glucometer order Physicians can place a glucometer order only as a new order Blood bank order Physicians can place an order for a blood bank as a new order only Pathology order Physicians can place a pathology order as a new order or as an add on test order Pathology orders can include cytology or histology orders b Physician assistant In the current process a Physician assistant has the following options to place an order Using medical directive Physician assistant with a medical directive can use a paper request or access the MT electronic health record to begin a new lab order or pathology order o Pathology order A Physician assistant can place a pathology order as a new order or add on test order Pathology orders can include cytology or histology orders o Verbal order from the physician 124 M Sc
162. ll be printed Nurse or technician collect sample Sample sent to lab through chute tube Process sample Q Godge dgdgd Report results o If critical result will be sent to physician s cell phone o If normal result will be entered to MT Physician screen Physician MT screen show the results of lab orders status as one of the following depend on the status order active taken or received If order missing Check order in MT and confirm e s still not received notify the nurse to follow up 167 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Call the lab to find out Suggestions and comment e Concern about future e CPOE takes 14 steps to place an order e Need more specification in MT about the types of orders prefer to have list of the available tests shows up when physician enter the test ex UA shows Urine Analysis Add or change test Physician fills new paper order e Nurse enter it to MT Questions 1 Do enter lab order under your login or the physician login Nurse log in Emergency Department ED interview Church site Project name Lab order process flow in Emergency department Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Mayda Timberlake EMERGENCY SERVICES MANAGER Date Monday June 11 2012 Time 2 00 PM Location Church site ED 1 What type of samples ED send to lab B
163. ll type 2 How many orders normally placed per day About 10 day two shifts a day 3 Who is placing the orders Physician 4 How physicians placing an order Paper chart gt Nurse confirm amp enter it to MT 5 What are the methods of adding another test request to a sample Paper telephone order Nurse or clerk enter it to MT 6 Where are labels printed or received from In clinic 7 Do the nurse technician confirm the information in labels with the test request Yes 8 How staff notified there will be test needed On care plan or at the time 9 Who is collecting the samples nurse or lab technician Nurse 188 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 15 16 17 18 19 20 21 How do nurse technician identify the patient for sample collection for sample test Arm band two ID check H D O B Is there any difference in flow between different samples No Where normally samples are collected Bedside Where collected samples are normally labeled Bedside How samples delivered to the lab Porter How the clinics receive the results MT Printed if critical How long it will take to receive the results Over hour What do you do if results not received missing Call the lab re process Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT
164. lood urine swaps tissues rarely happened biopsy specimen 2 How many orders normally placed per day 168 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 Around 140 patients Who is placing the orders Physician or nurse How physicians placing an order Physician write a paper request and a clerk or a nurse enter the order to MT 6 0 What are the methods of adding another test request to a sample Physician submit a paper request and a clerk or a nurse enter the order to MT 6 using ad on test feature in MT Where are labels printed or received from In clinic 4 places Do the nurse technician confirm the information in labels with the test request No How staff notified there will be test needed Physicians give paper request to nurse or put it in the requests box Who is collecting the samples nurse or lab technician a Nurse b If difficult gt call Technician How do nurse technician identify the patient for sample collection for sample test Patient name and patient hospital number on patient arm Where normally samples are collected Bed site location anywhere in the department Where collected samples are normally labeled Bed site location How samples delivered to the lab Tube chute nurse deliver it How ED receives the results a MT with paper copy printed in ED printers 169 M Sc Thesis A Kamil McMaster University Computing an
165. looked at the tools examination results and chose four tools YAWL Together Bonitasoft and NOVA that have the declared criteria We used these four selected workflow tools separately to design the workflows process sample and to evaluate each tool based on the outcome of the new workflow design To evaluate the tools more intensively we followed a mixed qualitative and quantitative methodology This entailed collecting qualitative data of the tools supported by quantitative data of the tools The qualitative methodology we followed to evaluate the tools included in depth analysis of each tool investigating all of the tools designing capabilities exploring all of the tools features and finally reviewing and studying the tools The study also included quantitative methodology to support the results gathered earlier from the qualitative methodology through statistical data collected from analyzing the workflow tools and the design of workflow samples A list of the tools technical features non technical features designing time and workflow components were used in each design We chose the best workflow tool based on different factors We put the perspective of users into consideration as one of these factors Workflow tool users prefer reliable fast and controllable tools they prefer to use the tool that provides the most designing power with the minimum time required 146 M Sc Thesis A Kamil McMaster University
166. low in XML format The graphical editor is the eclipse SDK Java tool plugin it contains the graph panel in the middle surrounded by the tool bar and the menu bar from the top to the left is the package explorer at the bottom are the workflow components and problem panel and from the right is the outline panel Execution engine The NOVA workflow engine was developed using the Hibernate amp Spring framework It is little bit different from other workflow tools the engine and the client application need a certain configuration in order to be ready to run 100 M Sc Thesis A Kamil McMaster University Computing and Software eHealth The NOVA workflow component panel has a useful feature which can help users to configure the workflow engine and the client application by entering the following information container location workflow name file name and prefix base and database URL database name and password to the workflow setting panel After configuring the workflow engine users need to generate service classes by using the create service classes feature in the component panel this feature will generate Hibernate mapping files and application context xml files which are required for the execution of the engine The create service classes feature will also configure the client application Execution will be ready after that Simulation The NOVA workflow tool uses the DeVinE model checker to simulate and verify the
167. low version 0 1 and version 2 0 general information a phone number and an email address NOVA Workflow Overview 22 General Issues Although the tool uses a unique language the compensable workflow modeling language CWML and has some workflow features but it is not easy to use when compared with the other tools We experienced some general issues when working with NOVA tool that we haven t experienced with the other tools YAWL Together and Bonitasoft and will express it as follows The tool user manual steps are not clear especially the installation part which is missing a lot of detailed steps including how to get to some of the required installation files finding the specific or exact address for some needed files and relying on vague information for some required files In addition some installation files are not compatible with all computers operating systems The workflow engine services instructions are mostly for programmers only and the available instructions only outline how to modify the code Even the steps in the user manual are intended for developers or for users who are familiars with eclipse SDK not for first time eclipse users The graphical editor is complex and has limited features inserting a task is a complex operation compared to other available modeling tools NOVA Workflow User Manual 2 0 23 106 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Designing tes
168. lowing placing an order printing labels receiving the order collecting the samples delivering the samples to the lab processing the sample and analyzing and submitting the results These work process orders were paper based and required manual procedures The current process affects numerous M Sc Thesis A Kamil McMaster University Computing and Software eHealth aspects of the healthcare system the paper based system uses more resources requires more time to complete and has more possibility for errors The second part of the study is to determine the main design steps of the new lab order process and then start designing the new process based on the requirements of a new digital system The main design steps include designing the new lab order process work tasks drawing the process workflow diagrams and defining the roles of the staff involved in the lab orders The analysis of the collected data shows that the current paper based order has multiple issues lab orders take a long time to be completed they contain mislabeled sample errors the processing cost of samples increases due to the long processing time there is a lack in mobility with current order placement and blood sample collection process needs major improvement in its stages After gathering all the required information described before for the current lab order process the next step was to analyze this information to design the new digital process
169. m that used the Business Process Modeling BPM software tool selected in the second part of the thesis During the research we collected lab order process data and used a qualitative methodology to analyze the data and find the critical phases in the current process in order to improve the new digital lab order process flow design The results of this research will help in the development of future eHealth system processes by providing valuable data and recommending the right tool for designing a new process system The new digital lab order process flow design will save healthcare time and money in addition to contributing to patient satisfaction It will also provide more security to patient information than the old paper based system Notably the chosen workflow tool has unique design features and components which allow tool users to manage control and finish a successful workflow design efficiently resulting in reliable digital lab order process flow design ACKNOWLEDGEMENTS Sincere gratitude to Dr Emil Sekerinski for his supervision throughout this work his contributions in stimulating suggestions and encouragement has helped me to improve my thesis I would also like to thank Dr Peter Bak for his assistance and involvement in directing the collection of lab order process information Both individuals were extraordinarily significant at several phases of this work vi TABLE OF CONTENTS PSR Ws ue Se ctieeaal ech n asia
170. ma and also to check if there is a validation problem in the workflow design The analysis option includes using the WofYAWL analysis algorithm use the reset net analysis algorithm check for unnecessary cancelation regions and check for unnecessary or joins different analysis options allows broader examination of the process design more information is in Chapter 5 The verification and the analysis options use the note and problem panel to display a description of any note or problem The engine and resource service status panel is to display the status when running the execution engine and also to display the status of the resource service available The YAWL workflow tool captures the data perspective by using XML Schema XPath and XQuery The tool has multiple modeling capabilities mapping tasks to human participants or use web services and external applications The tool is also capable of using split and joins tasks or assigns task as manual or automated routing tasks atomic composite tasks multiple instance and set conditions to a process path 33 M Sc Thesis A Kamil McMaster University Computing and Software eHealth The tool has the powerful modeling feature concurrent duration of activities However the most significant feature that the YAWL tool has is the cancellation feature this feature is not available in any other tool except YAWL and is useful when designing the sample delivery process of the new dig
171. mil McMaster University Computing and Software eHealth Execution engine The work of the YAWL engine starts after completing the workflow process design in YAWL editor The YAWL tool saves the workflow process specifications in an XML file and this file contains the information of the control flow data and resources The role of the YAWL engine is to interpret the control flow and data files then pass the contents of the resource file to a dedicated custom service resource service YAWL User Manual 2 3 14 18 Users can configure the YAWL engine based on several parameters such as enable persistence default work list enable login allow generic admin ID enable hibernate statistic gathering initialization announcement timeout interface X listener and observer gateway Simulation Simulation in YAWL is used for operational and technical decision making YAWL tool create simulation model that precisely reflect the designated real world process supported by workflow management system YWAL workflow system creates event log every time an activity is enabled started completed or cancelled the system also record the event enacted time with who has enacted it so the system will have all specifications historical data that has been executed before In simulation YAWL system creates function to extract the historical data of a specification from the YAWL engine and export it in an XML mining log format YAWL workflow system e
172. mp how to order NO Mental Health_ Outpatient Church interview questions Project name Lab order process flow in Mental Health Outpatient Clinic Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Joan Citulski Resource Nurse Date July 26 2012 Time 1 00 PM Location Keele site e Physician order lab order e Patient do the lab order outside the hospital in private lab e Results bill be faxed or mailed to the hospital e Neither order nor results will be entered to MT but it will be kept in a paper file 206 M Sc Thesis A Kamil McMaster University Computing and Software eHealth If patient chose to go to Life Lab the result will be accessed by the hospital through a lab link system used by the lab a password provided from the lab to the hospital to enable the hospital staff of accessing the lab patients spread sheet o Physician order lab order o Patient do the lab order outside the hospital in Life Lab o Lab process the samples and send the results to the lab database o Nurses amp Physicians can check patients results by accessing the lab database using the password provided Dialysis Nephrology clinic interview questions Project name Lab order process flow in Dialysis Nephrology Clinic Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Jennifer Duteau
173. mpaign Setting A Goal And A Deadline For Improving Health Care Quality The Journal Of The American Medical Association 295 3 324 327 2006 10 W M P Van Der Aalst L Aldred M Dumas A H M Hofstede Design And Implementation Of The YAWL System doi 10 1007 b98058 1011388 Retrieved from http eprints qut edu au 379 11 K Geebelen E Kulikowski E Truyen W Joosen A MVC Framework for Policy Based Adaptation of Workflow Processes A Case Study on Confidentiality Web Services ICWS 2010 IEEE International Conference on vol no pp 401 408 5 10 July 2010 doi 10 1109 ICWS 2010 81 Retrieved from http ieeexplore ieee org stamp stamp jsp Tp amp arnumber 5552759 amp isnumber 5552704 12 A Dogac Y Kabak T Namli A Okcan Collaborative Business Process Support in eHealth Integrating IHE Profiles through ebXML Business Process 152 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Specification Language IEEE Trans Inf Technol Biomed Vol 12 Iss 6 pp 754 62 2008 13 S Hisemann M Schafer H Stormer A Meier M Schumacher Building Flexible Ehealth Processes Using Business Rules Presented At European Conference On Health pp 12 13 2006 Retrieved from http subs emis de LNI Proceedings Proceedings9 1 GI Proceedings 91 3 pdf 14 M Rosemann M Muehlen Evaluation of Workflow Management Systems A Meta Model Approach Austral
174. mples Filling up cart Delay the Increase Possibility of Carts contain supplies collection process patient losing labels supplies on waiting time during this board set rules action Labeling Possible Delay the Critical on Mobile devices mislabeling service patient safety or bar coded tubes Delivering Manual Time consuming Depend on Pneumatic samples process human delivery system resources availability Processing Processing Some process Vary Critical in Pre Post samples time requires human between test some cases if Analytical interaction types delayed Instrument Process Possible delay if Delay the Increase Implement the location sample sent result patient required outside diagnostic and instruments treatment time Analyzing Manual Required previous Space for Critical on Automated results process patient record in error patient health Instrument some cases if miss judged 58 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Submitting No Keep staff busy Notification results notification checking all time system available when results are submitted into MT Unnecessary Printer resource Wasting staff MT 6 0 update paper copy wasting time Storing Manual Serious if sample Require time Automated samples mis stored and resource storing system Confirmation Not available No prove of Missing or Increase Confirmation in most action losing patient s
175. n Lab technicians collect samples on their floors unless the collection is a PICC line collection peripherally inserted central catheter a flexible blood collection tube inserted into the patient s vein in the upper arm in this case a sample will be collected by the nurse and not the lab technician The indication is that the lab technicians roam the hospital halls and go from patient to patient to collect samples In the current state they always go back to the lab to deliver samples and get work orders and pick up tubes On the other hand with the new digital system lab technicians receive work orders electronically from their devices so they know what they need to do and can go back to their base lab when their work is complete Lab technicians do labeling and bedside verification using their mobile labeling device a wireless portable label printer placed on the cart 63 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Pre bar coded sample tubes The other proposed ideal states for labeling are pre bar coded sample tubes With this proposed technology the tech would grab tubes and other specimen bottles while with the patient and scan the bar code on the tube They would then scan the patient and confirm that the order has been used Finally the lab technician would scan himself herself so the system can capture all of the required information and send it to the white board Delivery
176. n telephone order Paper chart or verbal Nurse confirm amp enter it to MT 201 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 15 16 17 18 Where are labels printed or received from In clinic Do the nurse technician confirm the information in labels with the test request Yes How staff notified there will be test needed Labels or patient s chart Who is collecting the samples nurse or lab technician Nurse How do nurse technician identify the patient for sample collection for sample test Patient chart two ID check H D O B no arm band used in this clinic Is there any difference in flow between different samples No Where normally samples are collected Test room Where collected samples are normally labeled Test room How samples delivered to the lab Spin the blood put in ice in a specimen bag fridge gt Carrier How the clinics receive the results MT Faxed or mailed to hospital if blood work done in lab outside the hospital How long it will take to receive the results Within the normal time What do you do if results not received missing Check MT Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT Yes some missing samples 202 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 19 Any issue with t
177. n and used 47 workflow components tasks and branches see Figure 7 Ordering Sample Start task Physician A Assistant L Nurse Practitioner Order Physician Order Verbal order From The o Physician Using Medic Directive i End Task Split sign Join sign Cancellation sign co C 1 od Bank Order lucometer f Order Referred to pee Lab ar gt ee ee Nurse Or A E Phone n Clerk Eanes 7 Verbal ee aS eet Add on Test CPOE Figure 7 YAWL workflow ordering design Together Workflow Tools Results Together Workflow Editor TWE is a Java workflow editor for creating editing managing and reviewing workflows The tool relies on Workflow Management Coalition WfMC and XML Process Description Language XPDL Specifications V2 1 using the Business Process Modeling Notation BPMN graphical notation process definition files 6 The variety of functions in the graphical editor helps the user to find activities participants applications or errors in the model By using the standardized Wf MC XPDL schema the editor produces a final output in an XML file which makes it easy to be executed by all Wf MC XPDL compliant workflow engines In TWE users can
178. n the first part of the study we selected 15 open source workflow tools and filtered them based on certain criteria which include the availability of analysis done by the tool tool features support a graphical editor an execution engine and simulation We chose four tools YAWL Together Bonitasoft and NOVA that satisfied these criteria We evaluated each tool based on the outcome of the new workflow design by using the four selected workflow tools separately to design the new workflow process We evaluated the tools by following a mixed qualitative and quantitative methodology by collecting qualitative data supported by the quantitative data generated by the tools Based on results from following the mixed methodology as well as the results that were derived from studying the designated workflow process future lab ordering designing outcomes we recommend YAWL Yet Another Workflow Language as the best workflow tool to use in the design of the new digital lab order process flow design In the second part of the study we examined the current paper based lab order process at Humber River Hospital this included analyzing the process information to define the iv crucial points of errors in the process bottlenecks of the process most time consuming process tasks and the main process points where improvements could be applied The last part of part two was the design of a new fast and reliable digital lab order process syste
179. nd run the process in a development environment for testing purpose only not for a deploying process in a productive environment Clicking the run button installs the process on a test application server jetty by default Bonitasoft User Guidance 21 The execution engine can run a process for a test when it is fully defined and configured Pools are saved as an individual Bonita archive file but can be deployed together or separately Users need to define all the parameters dependencies define organizations and define and map actors to the organizations to be able to run the process Bonitasoft User Guidance 21 93 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Simulation The Bonitasoft workflow tool provides simulation option to evaluate the process under multiple conditions resources and load To run successful simulation on a process users should define the simulation parameters of the process tasks and define simulation resource and load the tool will generate a report to show the results of the simulation Bonitasoft User Guidance 21 Analysis the Tool Can Perform Analysis definition The Bonitasoft analysis tool consists of different useful features in Bonitasoft workflow editor The process problems are detected directly or indirectly throughout checking BMPN models running debugging testing a connector and processing simulations We can identify Check BPMN mod
180. ner to identify the most time consuming event or task of the process and fix it as a result if we design a process with a tool that has this feature we will get a less time consuming process than any other process designed with a tool doesn t have this feature Table 2 shows the best scoring tool in these features among the other tools Cancellation is also one of the important features that affect the process time A process designed with the cancellation feature can save more time compared to any other process designed without this feature For example by using the cancellation in the delivery process of the new digital lab order the system can determine the order of the tasks and cancel the other paths see Figure 1 and Figure 6 While with any other process without cancellation the path of the process is determined manually which normally takes more time than the automated system Evaluation Summary This study starts by selecting 15 open source workflow tools and filtering them based on certain criteria These include Availability of an analysis tool tools features support graphical editor execution engine and simulation We looked at the tool s examination results and chose four tools YAWL Together Bonitasoft and NOVA that have the declared criteria We used these four selected workflow tools separately to design the workflows process sample and to evaluate each tool based on the outcome of the new workflow design T
181. nets are broadly used in the workflow analysis to detect errors in a workflow model at design time A Petri Net is a directed graph consisting of two types of nodes In graphical representation places were drawn as circles and transitions were drawn as rectangles The places and transitions are connected by arrows which show the direction the components flow The arrows are called arcs where arcs could represent directions from places to transactions or from transactions to places Arcs are labeled with their weight token w p t from P to T or w t p from T to P Places and transitions are used in modeling as conditions and events where places represent conditions and transitions represent events In modeling the input and output places for transition event are denoted as pre and post conditions of the event see Figure 15 72 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Input Place Transition Output Place PETI 3 Fi Fi Pre condition Event Post condition Figure 15 The interpretation of Places amp Transitions The Petri Net theory has rules for transition enabling and firing represented by the activity of the transitions The transition acts as a key to enabling the firing and transferring of data or action between two or more places The firing rules determine the state or marking in Petri Nets to simulate the dynamic behavior of a system The study by Murata 24 d
182. ng the samples nurse or lab technician Lab Tech Stat and routine Nurse PICC line 190 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 15 16 17 18 19 20 How do nurse technician identify the patient for sample collection for sample test Arm band two ID check H D O B New bracelet has barcode now Is there any difference in flow between different samples No Where normally samples are collected Bedside Where collected samples are normally labeled Bedside in observation libels carried in to the room to identify the patient then the labels carried out again to be placed on the blood sample How samples delivered to the lab Porter Clerk or Nurse How the clinics receive the results MT if critical lab will phone How long it will take to receive the results Routine 2 hour Stat 1 2 hour What do you do if results not received missing Check if porter pick it up Call the lab Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT Yes Any issue with the current system Turnaround time need to be shorter Porter doesn t check if there is a sample in the fridge to pick up Recommendations and suggestions No 191 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 21 Do you use blood bank service amp how to
183. ng to the collected information from lab technicians nurses and department s administrators labels are not designed well priority of test is not well visible labels are printed every other row leaving one row of labels empty and print on the other one in labour and deliver department the baby s mother name is not on the baby s blood sample label General The current system is unable to determine duplicated orders Lab technicians need to go back to the lab to get supplies every time supplies run out Lab carts are not designed sufficiently and specifically for lab use could delay the process of collecting samples There is no place on the cart to write on the labels A sample s tubes are not being isolated or protected from the surrounding environment cleaning materials containing alcohol could erase the printing on labels Lab technicians having difficulties carrying more than one collection tube technicians sometimes need to collect 8 samples from one patient in which case they do not have the proper basket or container to put in these tubes this would result in the lab tech having to going back and forth many times to the cart outside the room 53 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Departments noticed a delay in service between 2 00PM 3 00PM when lab technicians changed shifts e The available set of lab instruments is missing the post analyzer e No automa
184. niversity Computing and Software eHealth The following information is considered a description for the current lab order flow process diagram and the current process flow is explained as follows 1 Ordering Lab order process starts with placing an order either by a physician physician assistant or nurse practitioner The main method of entering orders by a physician is a paper based requisition then a nurse or clerk will enter it into the MT electronic health record The current process starts either by placing new order or request additional test on sample Add on test The Add on test is a process of adding another test on a recently collected sample the Add on test request will go directly to the lab and a lab technician will enter it to MT then process the sample based on the request of the physician The new order process will proceed as follow a Physician order This process consists of seven sub processes all these processes will lead to one of two tasks New order or Add on a test Paper based requisition This process is the primary method of entering an order by a physician in the current flow Physicians do not have direct access to write an electronic requisition using CPOE Instead physicians make a paper based request then a nurse or clerk will enter it into MT directly Verbal This process is typically used in units where physicians are busy and unable to write orders For example in the endoscopy c
185. niversity Computing and Software eHealth b Out of hospital process The processes of sending samples require an unavailable instrument to outside the hospital for processing in future process less samples will be sent outside the hospital due to the availability of the new lab instrument 7 Analyzing Results Lab technologists analyze the samples and watch for cases where samples are out of the expected results and treat it as abnormal results Some lab samples show concerning results due to abnormal patient situation and will be processed as follows a Abnormal results This process will take place if the results have abnormal expectations The technologist analyzes samples as follows Abnormal that meet repeat criteria o Repeat Process Analyze the result as abnormal or critical if it meets or does not meet repeat criteria If the sample results in meet repeat criteria it will be reprocessed again If the samples results in doesn t meet repeat criteria they will proceed as Critical then to results submission and sample storing Critical o Calling the unit In this process the lab will call the unit and inform them directly about the result for faster action o Submitting to physician phone or device In this process the lab will call the physicians on their phone or device and inform them about the results o Submit to MT 140 M Sc Thesis A Kamil McMaster University Computing and Software eHealth
186. normal or critical by the laboratory technologists Submitting results to MT automatically by the laboratory instrument system Storing the samples based on the sample type For example blood samples are stored for days while urine samples are stored for hours only We performed a data analysis on the collected information from the questionnaire and observation of the current process The recorded data shows multiple deficiencies and issues in the current lab process see Table 8 and Table 9 We also collected future process data based on the information from the questionnaires and proposed equipment features and capabilities and compared the future process data with the current process data see Table 11 to show the benefits of the future process see Table 10 and the difference in the turnaround time of both current and future process see Table 12 The data analysis showed that the current lab process described above is not satisfactory for many reasons 45 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Lab order takes a long time to be completed based on the observation of the process e Lab orders contain mislabeling errors of samples based on the information collected from the hospital laboratory e Long processing time causing an increase in processing cost of samples due to increase the time of using the resources e No mobility with the current order placing cannot place order using mob
187. nual and introduction tutorials The subscription support pack includes phone support online resources for an unlimited number of issues training paid online or in Bonita facilities as well as open sessions available for different types of training and in 6 human languages Additional expertise support includes an expertise monitor talking with a mentor 1 day proof of concept 1 5 days set up jumpstart 2 days deployment jumpstart 2 days remote development guidance and inquiries Bonitasoft Overview 25 NOVA Workflow Tool Tool overview Our study shows that the NOVA workflow tool was developed in consideration of compensable transaction and formal verification This workflow model framework uses a 98 M Sc Thesis A Kamil McMaster University Computing and Software eHealth formal graphical language proposed by StFX University Antigonish Nova Scotia Centre of Logic and Information CLI It is called the Compensable Workflow Modeling Language CWML 22 The framework includes a graphical editor a translator and a workflow engine The graphical editor of the tool is an eclipse plugin The role of the translator consists of transferring a workflow model language to the language of the model checker DeVinE for simulation and verification The workflow engine uses Spring and Hibernate J2EE framework to execute the verified workflow model The tool needs multiple plugins Hibernate and Spring Framework wo
188. o evaluate the tools more intensively we followed a mixed qualitative and quantitative methodology This entailed collecting a qualitative data of the tools supported by quantitative data of the tools We chose the best workflow tool based on different factors We put the perspective of users into consideration as one of these facts Workflow tool users prefer reliable fast 120 M Sc Thesis A Kamil McMaster University Computing and Software eHealth and controllable tools they prefer to use the tool that provides the most designing power with the minimum time required Based on the information we gathered from tools examination and evaluation following the mixed qualitative and quantitative methodology analysis and evaluation of the four selected workflow tools revealed results of the designated workflow process sample Future lab ordering designing outcomes We can recommend YAWL as the best workflow tool to design the new digital lab order workflow process TWE as the second choice Bonitasoft as the third choice and NOVA as the last tool among the four selected workflow tools 5 2 Introduction to Current and Future Lab order Process Flows Current process flow The current lab process flow consists of ten main tasks ordering entering orders into the MT electronic health record printing labels receiving lab orders collecting samples delivering samples processing samples analyzing results submitting results
189. o Split sign fered vo ibez A Join sign ae Sat _ Ne __ ae Blood Urin Ax ina A and ANis Be i a 2 _MEDITECH oe 00 r1r J aa Submitting A 5 Paper Copy I Q d 4 k 7 gt al 2 K Ye to Units 0 Ordering EDITECH Receiving Collecting Delivering Processing Analyzing Submitting BloodBank a Storing EHR Orders Samples Samples Samples Results Results Results Samples See BEEE N Basedon NN Se Rn Se Z Submitting A Type ater real to Physic NAET ysician NS Glucometer Phoneor Results Device A AY pest y Confirmations 5 a and awe Varifications Calling The ese EAn Unit Figure 5 Future lab process using YAWL 3 4 Data analysis The intention at the beginning of the study was to analyze the data from the workflow tools and categorize them to assess and choose the workflow tool with the best easiest most useful features across all 15 tools The study categorized the tools based on certain criteria filtering the tools based on the Availability of an analysis tool tools features support graphical editor execution engine and simulation see Table 1 23 M Sc Thesis A Kamil McMaster University Computing and Software eHealth We used the collected data to evaluate the tools by following mixed qualitative and quantitative methodology collecting qualitative data supported by quantitative data
190. ocessing the samples as follows a In hospital process In future process most samples will be processed in the hospital lab except for some samples where a required instrument is not available in 138 M Sc Thesis A Kamil McMaster University Computing and Software eHealth the lab In hospital process will be done using pre and post analytical instruments The process starts by placing the received samples in the pre analytical processing instrument one by one then the lab instrument will process the samples and write the results in MT and finally the samples will proceed to the post analytical instrument to be stored The process in hospital will include Add on test A process of adding another test on a recently collected sample order where a physician can request the add on test and the lab technologist makes sure to add the new test in the system and rerun the test on the sample to get the required result Urine process o Manual A process of analyzing urine samples manually o Automated A process of analyzing urine samples by pre post urine analytical instruments this process is available in future process only Blood and specimens o Manual A process of analyzing blood samples manually o Automated A process of analyzing blood samples by an analyzer instrument o Pathology amp Micro Pathology A process of analyzing pathology samples Cytology amp Histology 139 M Sc Thesis A Kamil McMaster U
191. od collected if not nurse do blood collection e Order blood on MT or by calling the lab e Send the face sheet with porter to lab e Receive the blood B 300 Cardiology Respiratory interview questions Project name Lab order process flow in B 300 Cardiology Respiratory Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Kahisay Resource nurse Date Aug 14 2012 Time 12 30 PM Location Church site 1 What type of samples you collect at these clinics Blood Urine Sputum 2 How many orders normally placed per day 3 Who is placing the orders Physician 228 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 15 How physicians placing an order Paper chart Nurse enter it to MT What are the methods of adding another test request to a sample Paper Nurse or clerk enter it to MT Where are labels printed or received from In clinic Routine In lab stat Do the nurse technician confirm the information in labels with the test request Yes How staff notified there will be test needed By MT Who is collecting the samples nurse or lab technician Lab tech Nurse if there is a PICC line How do nurse technician identify the patient for sample collection for sample test Arm band two ID check H D O B Is there any difference in flow between different samples No Where n
192. of the tools The evaluation criteria of the tools were set to compare the scoring of the tool s features We gave to an available feature and 0 to a non available feature in the tool we then calculated the total scores of each tool and compared them with other tools to define which tool has the most features among the rest of the workflow tools We specified two types of features in the tools technical and non technical Technical features are the analysis tool split and join and cancellation features which used directly in the tool for the purpose of designing a workflow process While non technical features are the free tool download support available and training which used for general purpose of the tool See Table 2 Table 3 Workflow Tools Evaluation Technical Features YAWL Together Bonitasoft Nova Executable model 1 1 1 1 Generate code 1 1 1 1 Can be simulated 1 1 1 1 Analysis tool 1 0 0 0 Define workflow designing 1 1 1 1 problems Identifying bottlenecks 1 1 0 0 Can declare participants and their 1 1 1 0 type system human etc 24 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Split and join 1 1 l 1 Manual automated and routing 1 1 0 0 tasks Multiple instance atomic amp 1 0 0 1 composite tasks Conditions 1 1 1 1 Cancellation 1 0 0 0 Duration of activity 1 1 1 0 D
193. of a pneumatic tube network running between all of the hospital s units and labs It uses pneumatic capsules to deliver collected samples from units to the 137 M Sc Thesis A Kamil McMaster University Computing and Software eHealth lab Based on the capsule s size this pneumatic tube system could also be used to deliver blood bags from a lab to units when needed if the pneumatic capsules are large enough to carry blood The system could also be used by pharmacy b Breakdown operations This process will take place during the abnormal running operation when it is unable to use the pneumatic tube transport system for any reason The alternative method of delivering samples during the breakdown operations could be one of the following Staff The lab technician who collects the samples or one of the unit members can deliver the samples to the lab Porter service A porter service arrangement can be used to deliver the samples to the lab AGV system Automated guided vehicle AGV is a laser navigated vehicle that can be used to transport and deliver lab order samples to the lab The method of sample delivery will be determined in the breakdown operations based on the priority of the orders 6 Processing the samples After the lab receives the samples technicians start to place them on the pre analyzer instrument track The instrument will specify the samples based on the required test and start pr
194. ollect samples Go outside the patient room initial the labels and affix the labels on tubes the technician excuse for affixing the labels outside the patient room is there is no place inside the room where technician can write their initials on the labels Samples will be left in the department for porter to pick up Lab technician will go to a different department 212 M Sc Thesis A Kamil McMaster University Computing and Software eHealth In some cases lab technician take stat samples with them when they going back to lab after collection Note o Lab technician round trip at 6AM 10AM 1 30PM 3 30PM 8PM 10PM o Lab technician has to do other duties when they go to lab o Lab cart are not sufficient to help technicians doing the work and has no place for writing o Lab tech suggest using pneumatic system for delivery o Itis preferred by the lab tech if there is a lab cart for every department so lab tech don t have to take them back to lab or have to fill up the tubes Medicine B 6CD amp 6W interview questions Project name Lab order process flow in Medicine B 6CD amp 6W Clinic Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Shohreh Mahdavi Manager Medicine B 6CD amp 6W Sarbdeed Resource nurse Date July 27 2012 Time 12 00 PM Location Finch site 1 What type of samples you collect at these cl
195. on labels given to lab tech directly when they are at the unit for routine blood collection e Lab tech collect samples and affix labels e Lab tech deliver to lab Glucometer e Physician order blood sugar test on paper only no MT available e Nurse get the order from the patient chart or from the nurse sheet e Nurse start by scanning their badges so the system writes the name of the person who collect the sample e Nurse scan patient arm band or write patient information in the device e Nurse scan the blood stripe e Complete the test for the patient e Write the result on a paper sheet e Nurse place the glucometer on the loading deck results will be sent to the lab e Nurse could enter result shown on the device screen to the patient record in MT directly Notes Lab technician has to cancel one of the orders when go back to lab patient has passed away after placing the order 166 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Physician order in ER Project name Lab order process flow in lab department Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Laura Copeland PHYSICIAN Date Thursday June 7 2012 Time 12 30 PM Location Church site Church Dr Copeland s Office Lab order flow Physicians in ER order a test by filling a paper request Nurse or clerk to enter it to MT under their login Label wi
196. or a lab technician If a lab tech is required then the software works out who the best technician is to do the job This dispatching is performed based on the location of a lab technician priority of orders for that patient or department and current backlog of orders based on priority The software then will notify the person who needs to do the collection by sending a message to their device the person needs to accept the request within a certain time so that everybody knows that the job has been assigned The suggested dispatching software is also responsible for creating a proposed dashboard status board of jobs that managers can review on a hand held and on a status board placed in the hospital lab see Figure 12 for a status board proposed prototype with the data supposed to be displayed in it 62 M Sc Thesis A Kamil McMaster University Computing and Software eHealth A geass fe eee hara Name Nara David Martin Dr Smith Routine blood 24 08 2012 9 02 AM Ordered Andria Sheen Dr John Routine Blood TA Unit 24 08 2012 8 30 AM Accepted 3 Bob Tailor Dr Smith i i 24 08 2012 8 13 AM Delivered mC 24 08 2012 8 00 AM In Process 24 08 2012 7 13 AM Completed 2 Dr Broun l 24 08 2012 7 22 AM in Process 24 08 2012 7 32 AM Completed 24 08 2012 7 45 AM Completed Nadia Sheen Dr Broun Stat Blood T S Lab 24 08 2012 6 30 AM Completed Figure 12 Status board Collectio
197. order Surgical department A300 North observation Project name Lab order process flow mapping Observer name job title Ammar Kamil Project assistant Observation place Surgical department Date July 18 2012 Time 10 30 AM Site location Church site 10 45 AM Physician ordered blood test 10 50 AM Clerk entered the order to MT 11 00 AM Clerk called the lab to send technician 11 15 AM Technician arrived O O Tech went to the patient room and identify the patient by the armband Tech take the labels to the room and collect the blood sample and take it with the labels outside the patient room Tech initials the labels with time and date and place the labels on the blood samples Sample left in the clinic to the porter to pick it up and send to lad 11 25 AM Nurse called porter for pickup 11 45 AM Porter arrive and pick up the sample 12 15 PM Lab submitted the result to MT Note 192 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Lab technician labeled the sample with extra stat red label plus the stat on the original label Mother amp Baby Pediatric interview questions Project name Lab order process flow in Mother amp Baby Pediatric Clinic Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Mary Sackeyfio Manager Joan Willis Clinical Practice Leader
198. order process flow mapping Observer name job title Ammar Kamil Project assistant Observation place Endoscopy unit Nurse Valeria Date Aug 01 2012 Time 10 00AM Site location Finch site e Collection start by a verbal order from the physician e Nurse collect the sample and write the information on the specimen container e Then the same nurse take the specimen container to another desk and leave it there e Another Nurse come and enter the order information of the specimens one by one to the patients record on MT based on the information on the container 198 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Nurse print the labels initial the labels with nurse initial and affix the labels on the containers Notice now the initial on the samples labels represents the Nurse who e All specimens from 8AM 12PM will be placed in one basket e Nurse or Clerk call porter to pick up the specimen e Lab process the specimen and put the results on MT Endoscopy unit Observation Project name Lab order process flow mapping Observer name job title Ammar Kamil Project assistant Observation place Endoscopy unit Date Aug 14 2012 Time 2 54 PM Site location Church site Two nurses working in the clinic at the time of the observation e Nurse review the information with patient and ask the patient to sign consent e Nurse got labels with patient name from
199. ordered but incomplete tests this new feature will assist the physicians with the meaningfulness of the test Mobility One of the important features of the new digital design is Mobility physicians can place orders on line from their mobile devices anywhere in the hospital outside the hospital and anytime during their duties or out of duties in case of emergencies Voice command The new process design provides voice command technology to allow the physician to place the order verbally this will be something like SIRI the voice command function featured in iPhones or iPads This feature is a voice version of the touch interface to the mobile device so the physicians can see the actions of the voice command However this is not speech transcription 61 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Receiving orders dispatching Lab orders in the current lab order system is dispatched manually between lab technicians When the lab technicians receive paper copies of the new orders lab technicians divide the orders among themselves based on the current available technicians in the lab regardless of whether there are some technicians on the hospital floors Dispatch software The new digital lab order system will have dispatch software to dispatch jobs previously done by the lab technicians this software works out who should collect the specimen if this order is for a nurse or if it is f
200. orkflow errors in a workflow model A number of functions in the graphical editor help the user find activities participants applications or errors in the model By using the standardized Wf MC XPDL schema the editor produces a final output in an XML file which makes it easy to be executed by all WfMC XPDL compliant workflow engines TWE is a tool for process definition modeling It has three main goals defining the process through graphical representation exporting process definitions to XPDL and importing any valid XPDL and its graphical representation In TWE users can determine the responsibilities of the participants in the package or the process by selecting the Redefinable header tab from the package property Workflow variables can also be declared in the package property by selecting the workflow variables tab then specifying the properties of workflow variables 20 pp 40 42 In TWE users have the ability to specify a public access level where a process could be invoked by an external system or application Users can also specify a private access level of a process where a process may only be invoked from a SubFlow Activity Declaring a data type as Basic in the TWE tool could mean one of the following data types string integer reference float date time boolean or performer The user of the tool is also able to set an activity to start or end automatically or manually 84 M Sc Thesis A Kamil McMaster Un
201. orkflow tool when designing a new workflow process Using this tool requires coding background or a user who has used eclipse before We do not recommend using the NOVA workflow tool for design a workflow process at this time The tool needs more powerful user interface and need further studies to determine more areas of improvements The results of this research will have tremendous effects on eHealth and the future of the healthcare system it has provided valuable data and recommends the most advantageous tool for designing a new process system workflow Demand is increasing to switch to 147 M Sc Thesis A Kamil McMaster University Computing and Software eHealth using eHealth and health informatics applications and as a consequence there is increasing need for developers to have access to a reliable process modeling tool Thus research can be an extremely helpful tool to improve the healthcare system and facilitate the developers efforts when designing a future healthcare process flow system 6 2 Current Lab order Process Study Conclusion The work in this part of the study investigates one of the essential developmental barriers to eHealth and the healthcare system The old paper based system was being used in healthcare settings though most of the new equipment requires a new digital system able to comply with the new rise of technology in the healthcare This study explored the benefits of transferring the paper b
202. ormally samples are collected Bedside Where collected samples are normally labeled Bedside How samples delivered to the lab Porter stat Lab tech routine How the clinics receive the results MT paper copy Abnormal results gt lab call the nurse 229 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 16 17 18 19 20 21 How long it will take to receive the results 3 4 hours gt blood Stool gt 48 hours Urine gt next day What do you do if results not received missing Call the lab look for it Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT Yes Any issue with the current system Porters Recommendations and suggestions Tube system Do you use blood bank service amp how to order Yes a Physician order b Patient sign consent c Order blood on MT or by calling the blood bank d Nurse collect samples Send the face sheet with porter to lab for blood pick up f Two nurses check the blood and do transfusion 230 M Sc Thesis A Kamil McMaster University Computing and Software eHealth B 300 Cardio Respiratory Observation Project name Lab order process flow mapping Observer name job title Ammar Kamil Project assistant Observation place B 300 Cardio Respiratory unit Kahisay Resource Nurse Date Aug 14 2012 Time 12 30 AM Site location
203. patient chart e Collection start by a verbal order from the physician to nurse e Physician collect specimen e Nurse write the information on the specimen container and leave the container on the desk for the other nurse to affix the labels e At this time another nurse enters the order information to patients record on MT based on the information from physician 199 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Notes Nurse print the labels initial the labels with nurse initial and affix the labels on the containers Notice now the initial on the samples labels represents the Nurse who entered the order later in MT while the initial should be of the Nurse who collects the labels All specimens from 8AM 12PM will be placed in one basket and sign the tracking sheet Nurse or Clerk call porter to pick up the specimen Porter pickup samples and sign the tracking sheet Lab receives the samples and sign the tracking sheet then process the specimen and put the results on MT Tracking sheet contain signatures of nurse porter and lab track the samples when missing Swaps and specimen collection are in different pages and in order for the nurse to enter the patient information for both types nurse has to switch between two pages on MT and login for both this act is a time consuming for nurses Always need for more than one nurse in the room MT specimen collection order has no cancel button ma
204. proper training for blood collection e The current system is unable to determine duplicated orders e Sample collectors do not always following collection procedures e Using insufficient lab carts can delay the process e Departments have noticed a delay in service between 2 00PM 3 00PM when lab technicians change shifts Labeling issues Labeling the samples in the current system is done by using paper labels and performed in many ways depending on the type and environment of the collection location and has the following issues e Labeling errors e Labeling normally takes place outside the room e Lab technicians prints labels in the lab and bring them to the units e Dates on labels represent the printing date not the test date e Initial of the sample collector on the label does not always represent the person who collects the samples especially in the endoscopy department 47 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Delivering Samples In the current system delivering samples depends on a manual process and no automated delivery system is available at this time except in the Emergency department of the Finch site and the Emergency department at the Church site The former site uses a pneumatic tube system the latter a chute tube for delivery Delivering samples also has the following issues e In some departments samples stay for 4 hours before pick up e g the endoscopy
205. r add on test order Pathology orders can include cytology or histology orders b Physician assistant In future processes a Physician assistant will have the following options to place an order 133 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Using medical directive Physician assistant with a medical directive can access the MT electronic health records and begin a new lab order or pathology order o Pathology order A Physician assistant can place a pathology order as a new order or add on test order Pathology orders can include cytology or histology orders o Verbal order from the physician This process is typically used in units where physicians are busy and unable to write an order The Physician assistant will receive the order and either write a paper request or directly order it with MT c Nurse practitioner order In future processes nurses have two options when placing a lab order Using medical directive Nurses with medical directive can access the MT Electronic Health Record and begin a new lab order or pathology order Verbal order from the physician This process is typically used in units where physicians are busy and unable to write an order like in the endoscopy clinic A physician can perform a sample collection and verbally request for a sample at the same time Pathology order A nurse in the OR Day Surgery Radiology Endoscopy respiratory technicians or
206. r of patients they come to clinic for delivery 3 Who is placing the orders Physician 4 How physicians placing an order Paper Nurse or clerk enter it to MT 5 What are the methods of adding another test request to a sample Papers Nurse or clerk enter it to MT 6 Where are labels printed or received from In clinic 7 Do the nurse technician confirm the information in labels with the test request Yes they double check 8 How staff notified there will be test needed Nurse to Nurse 9 Who is collecting the samples nurse or lab technician Nurses 180 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 15 16 17 18 19 How do nurse technician identify the patient for sample collection for sample test Arm band two ID check Is there any difference in flow between different samples No Where normally samples are collected Patient room Where collected samples are normally labeled Bedside How samples delivered to the lab Porter Nurse when critical How the clinics receive the results MT By fax when critical How long it will take to receive the results 1 2 hours What do you do if results not received missing Call the lab Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT Yes Any issue with the current system In C section only one computer in t
207. r process from the time of placing lab order to the receiving of the test results The study included comparing the workflow process designing time by measuring the time of designing a sample workflow process using the four selected workflow tools YAWL Together Bonitasoft and NOVA individually Process design and development time vary between different tools the time depends on many factors which are number of workflow components used in the design property configurations number of parameters variables joins conditions loading time analysis time To measure the needed time with each tool to design a process we created a workflow design called the Future lab ordering process The proposed process workflow process sample consisted of two required start and end tasks and 15 other tasks Physician assistant Nurse practitioner order Physician order Using medical directive Verbal order from the physician Pathology order Blood bank order Glucometer order Referred to lab Phone Verbal CPOE Nurse or clerk Add on test and New order The design included defining one variable of type double order number one date and time type variable date time and twelve main variables comprised of ten variables of type string as follows Order type Order status Blood type Blood test id Physician name Nurse name Patient name Lab technician name Physician assistant name and Clerk name Measuring the Model Design Time
208. r two important questions First which workflow modeling tool is the best to use when designing a new digital lab order process system in a healthcare system Second why should we switch from using a paper based lab order system to using digital based lab order system The research goal is to investigate two essential problems in eHealth and the healthcare system First the need for reliable workflow tools that can be used to design a new digital process in the healthcare system by examining and comparing different workflow tool and choose the best tool for the new design Second the need for switching from the old paper based system used in the healthcare setting as in Humber River Hospital to a new electronic system capable of adhering to digital technology in the healthcare system by exploring the benefits of saving lab order processing time managing the flow of lab orders controlling lab processes and securing patient information To reach the first goal of the study successfully we examine 15 workflow tools and recommend the best tool based on certain criteria then use the selected tool to help in designing the new digital lab order process Workflow tools can play a crucial role in designing a successful process and providing secure environments for developers or users when working with patient data We collected current lab orders data from all process stages and found that current lab order process orders consisted of the fol
209. re 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Figure 16 Figure 17 F FIGURES Sample Delivery Cancelauonscnisinda disk atone i Ea 7 Model of interview information esessseesesssesessesstssesressessresressersresreesressesereses 20 Sample interview questionnaire used to collect data ee eeeesseeeseeeeeeeees 21 Current lab order process design y lt sccssccaccasatanesscasareseusasgdeassenuuaseeionscadeanqeaaieea 22 Future lab process using YAWL ssssseesesesssessessissresresseseresressersresresseeeresresseese 23 Delivering sample process a 35504 565 EIA A 34 YAWL workflow ordering design xcagssecestievevencsiesaceansstwaaiens Sargsasebcyssasesoeheedebahenee 35 Together workflow ordering design ssssesesssesssesessseessressessseeesseessseesseesseessee 37 Bonitasoft workflow ordering design essssssssssesserssessseersseessseesseesseesseeesssee 40 NOVA workflow ordering design sssesssessesssessseeesseeesseessressersseesssressseesseese 44 Sample interview amp questionnaire form sessssesssssessessersseresseessseesseesseessee 50 Stat s DO ath inienn iris ace a E A E a a Ra 63 Draft of future workflow analysis and submission of results eee 65 Current and future process turnaround time eeeeecesseeceeneeceeeeeceeeeeceneeeesaes 70 The interpretation of Places amp Transitions ee eesceeeeeseceeseesesecsseeeee
210. re required to configure the project first They then need to get Spring and Hibernate jar files and include them in the tool with the project files The instructions on how to get these files are vague and intended for J2EE experts as described in the user manual 23 e There are two versions of the NOVA workflow tool version 0 1 and version 2 0 107 M Sc Thesis A Kamil McMaster University Computing and Software eHealth We couldn t complete the work with Version 0 1 due to some missing packages and classes entity beans classes interface classes and no information is available in the tool user manual or the source demo on how to get these packages what prevent the tool engine from running successfully and complete the process design Version 2 0 also does not run due to significant errors listed in the coming bullets e With version 0 1 in order to run the workflow engine users developers will have to write the business logic inside the business components However in version 2 0 users are not required to write the business logic in the J2EE code e The NOVA workflow tool is free to download and use but it is not an open source tool e The available NOVA workflow version 2 0 downloadable file is not compatible with all computer operating systems The author s suggestion was to download eclipse separately then transfer the feature and plugin files to the features and plugin files of eclipse This suggestion was
211. resents a lab M Sc Thesis A Kamil McMaster University Computing and Software eHealth order process more details will follow in the coming chapters The work also involved studying all the tool design capabilities by referring to related studies user manuals and web pages to gather and learn more about these tools This included using quantitative and qualitative methodologies to evaluate the tools based on certain criteria see Table 1 We followed a quantitative methodology to collect workflow tools information results by filtering examining and comparing the workflow tools then followed by a qualitative methodology for an in depth analysis of the workflow tools We recommend YAWL Yet Another Workflow Language as the best workflow tool to design the new digital lab order workflow process for the Humber River Hospital The YAWL workflow tool has unique features and components that allow users to manage control and design a successful workflow process We chose the best workflow tool based on different factors We considered user perspectives to be of fundamental importance Workflow tool users prefer reliable fast workflow tools they also prefer to use tools that give the designer the ability to control the flow of process and provide design options that will support finishing a workflow design within a minimum time The tool that was chosen to help design the tasks of the digital lab order process workflow and direct
212. results In the current process submitting the results contain some unnecessary steps of submitting results on a paper to the department and no notification available when results are ready while in the future process the paper use will be eliminated and results will be submitted automatically to MT and the system will notify the physician if the results are critical with confirming and updating the sample status on the status board 144 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 6 CHAPTER SIX CONCLUSION This study consisted of two main parts The first part of the study consists of examining 15 BPM tools and defining the best tool for designing the new lab order process flow The chosen tool helped to design a new digital flow for Humber River Hospital s lab order process in a very advanced way the new workflow tool enables the workflow process developer to control and automate the process tasks based on the need of the process flow The second part examined the current paper based lab order process in a healthcare setting It then went on to analyze the process information to define the major points of errors in the process bottleneck of the process most time consumable process tasks and the main process points where improvement could be applied The last point of part one was to use the selected Business Process Modeling BPM software tool to help in designing the new digital based lab
213. rkflow components and DeVinE model checker in order to complete the required workflow design NOVA Workflow User Manual 2 0 23 Requirements To run NOVA workflow tool a user need to have the following NOVA Workflow User Manual 2 0 23 One of these operating systems e SUN Solaris 2 6 7 8 9 or 10 sparc e Linux Red Hat Enterprise Linux Fedora Debian etc e Windows 2000 2003 Server Advanced Server e Windows 2000 XP V ista 2007 Any of these application servers e BEA Weblogic Server 8 1 9 e Resin 3 0 x e Apache Tomcat 5 0 x Any of these database servers Oracle 9i Release 9 2 MySQL 5 Sybase 12 5 or higher 99 M Sc Thesis A Kamil McMaster University Computing and Software eHealth PostgreSQL 8 Java Devleopment Kit SUN JDK 1 6 Open source software s Spring Framework 1 2 Hibernate 3 5 4 Eclipse Indigo 3 7 Android SDK Graphical editor The NOVA workflow tool uses the eclipse user interface as the tool graphical editor plus some extra workflow features workflow components plugin The workflow components plugin panel contains all of the necessary features for designing a workflow process including tasks joins property setting selecting or deleting tasks making composites creating Java script classes opening subnet workflow detaching subnet workflow setting deleting workflow and selecting elements The NOVA workflow tool graphical editor produces a structured workflow and stores the workf
214. rspective and exception handling patterns YAWL User Manual 2 3 14 18 Developers of the YAWL workflow tool stated that their analysis showed that other XPDL BPML and BPEL4WS workflow systems and theoretical models like Petri nets have problems supporting essential patterns as a proof of concept they have developed a workflow management system supporting YAWL It should be noted though that YAWL is not simply a set of macros defined on top of Petri nets Its semantics is not defined in terms of Petri nets but rather in terms of a transition system Van Der Aalst et al 10 The authors also present the design and implementation of the YAWL system which fully supports the YAWL language They clarified the creation of the YAWL system as a result of analyzing more than 30 workflows and standards 74 M Sc Thesis A Kamil McMaster University Computing and Software eHealth We chose the YAWL workflow tool in the design of the digital lab process design for its support and use of multiple patterns and particularly cancellations which are not supported by other workflow tools YAWL uses Petri nets which provide a more theoretical approach Petri nets form a model for concurrency with a formal foundation an associated graphical representation and a collection of analysis techniques Van Der Aalst et al 10 The YAWL tool offers comprehensive support for control flow patterns resource patterns and exceptional h
215. s Physician PN 4 How physicians placing an order Paper chart verbal gt Nurse confirm amp enter it to MT 5 What are the methods of adding another test request to a sample Paper telephone order Nurse or clerk enter it to MT 219 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 15 16 Where are labels printed or received from In ED Do the nurse technician confirm the information in labels with the test request Yes How staff notified there will be test needed MT Verbal Patient sheet Who is collecting the samples nurse or lab technician Nurse for most patients lab tech for admitted only How do nurse technician identify the patient for sample collection for sample test Arm band two ID check H D O B By chart and labels Is there any difference in the process flow between different samples No blood or fluid on ice products of conception should go directly to lab Where normally samples are collected Bedside triage Where collected samples are normally labeled Bedside triage How samples delivered to the lab Pneumatic tube system If pneumatic system malfunction nurse or volunteer take the samples to lab How the clinics receive the results MT paper copy Critical call physician or unit How long it will take to receive the results 1 hour 220 M Sc Thesis A Kamil McMaster University Computing
216. s shortage in supply could cause delay Is there any automated system for ordering lab supplies when run out No automated inventory system all done manually 162 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Oncology Interview Project name Lab order process flow in lab department Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Jane Sanders MANAGER ONCOLOGY Date Thursday June 7 2012 Time 11 00 AM Location Church site Oncology 22 23 24 25 26 21 28 What type of samples you send to lab blood urine tissue and fluid lung etc Are samples taken by nurse or lab technician Clinic staff department management prefer not to have technician perform the work because there are not enough work for the technician and they have to sit all day waiting for work to do What are the methods of placing an order Paper request filled by the physician and given to the clerk to enter the information to MT Who do place the orders Physicians or Nurse Practitioner How do you receive the results MT Where normally samples withdrawn Phlebotomy patient room or any other place where required What are the methods of sample delivery Volunteer or nurse deliver samples to lab porter service rarely used due to the slow in response and sometimes sample lost 163 M Sc
217. s a workflow tool consisting of two major parts First Bonita BPM Studio which is the graphical environment for creating a process and contains the designing tools the whiteboard and the form builder Second Bonita BPM platform which is the deployment and testing platform for the processes Bonita BPM platform contains the web portal the engine and the database The graphical interface of Bonita studio called the whiteboard allows the user to draw processes directly by using notation compatible with the Business Process Modeling Notation BPMN standards The Bonita execution engine runs behind the graphical interface which connects the processes to the existing system to deploy and run the process Bonitasoft User Guidance 21 90 M Sc Thesis A Kamil McMaster University Computing and Software eHealth The Bonita tool has a variety of workflow designing options conditions decision tables add and test connectors multi instantiations and timer configuration The Bonita tool uses the Hibernate lightweight relational database with the Bonita execution engine 21 Although the tool has a lot of useful features the tool does not generate code for users to modify and users will have no excess to the html css and Javascript codes that the tool uses to generate the applications The tool can be useful for developers end users and management users and also for human resources IT management quality management and corpora
218. s applied to certain conditions and rules in a work flow task that needs to perform multiple activities by different users for different purposes based on the path required This study includes specifying four requirements for the adoption of the framework The first requirement focuses on providing reusability and avoiding complexity by separating the modularization of workflow tasks and functional workflows from the adoption logic in 12 M Sc Thesis A Kamil McMaster University Computing and Software eHealth order to support reusability The second requirement concentrates on providing a flexible policy implementation The third requirement provides for workflow implementation using extensible and flexible solutions to enforce any type of policy The fourth requirement demonstrates that the designated workflow should be able to handle a Separation of Duty SoD type of policy where two tasks can be performed separately by two different users 2 7 Workflow Limitations Designing an appropriate workflow system is not without difficulty the research in this paper aims to facilitate this work by using appropriate workflow tools Significantly some previous studies have focused on finding and analyzing Workflow Concerns and Workarounds of Readers in an Urban Safety Net Teleretinal Screening Study For example Fish et al 4 discuss workflow concerns and difficulties that have been found by researchers These authors examine wor
219. s to find the best practice and tools to use for designing the new digital lab process environment of the new Humber River Hospital as its healthcare system continues to develop Confidentiality in eHealth is an important aspect when designing a new process this drives many healthcare developers towards looking for reliable tools when designing a new process The work in this thesis will help process developers to choose the right workflow tools for their designs and to create reliable eHealth applications to carry out necessary tasks with maximum security The study by Russello Dong and Dulay 3 defines the process of designing an access right framework that can provide controllable entities capable of fulfilling their duties The authors chose an eHealth application due to its direct involvement with flexibility and security when they designed their framework Some studies shown that workflow tools are advantageous tools and can be used to design different systems The study by Pappas et al 1 presents the idea of using 1 M Sc Thesis A Kamil McMaster University Computing and Software eHealth workflow automation tools to create Ward In Hand a patient management tool This tool allows the hospital ward staff to access patient records wirelessly and permits physicians and nurses to use these records for day to day activities through PDA devices through an IEEE 802 11 wireless LAN This research aims to answe
220. se the labels e Collect blood and affix labels Notes Some of the duplicated orders are different than the other orders by one test only for example a single order for glucose could be cancelled and entered manually at the time of the collection with other orders the tech will put a reminder so when go back to lab can enter the test and added to the order An error could happened in this case 236 M Sc Thesis A Kamil McMaster University Computing and Software eHealth P A T T interview questions Project name Lab order process flow in P A T T unit Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Angelina Leblanc Resource nurse Date Aug 15 2012 Time 12 00 PM Location Church site 1 What type of samples you collect at these clinics Everything 2 How many orders normally placed per day 30 day 3 Who is placing the orders Physician 4 How physicians placing an order Paper chart Nurse amp enter it to MT 5 What are the methods of adding another test request to a sample Add on if possible 6 Where are labels printed or received from In clinic or lab by lab tech only 7 Do the nurse technician confirm the information in labels with the test request 8 How staff notified there will be test needed pager 9 Who is collecting the samples nurse or lab technician Lab Technician 237 M Sc Thesis A Kamil McMast
221. sed in each workflow tool to examine the usability of each tool and determine which tool is the easiest when designing a digital system see Table 5 Workflow Tools Workflow YAWL Together Bonitasoft Nova Components used in the design of the designated Future lab ordering Tasks needed 15 15 15 49 Start tasks 1 1 1 1 End tasks 1 1 1 1 Branches flows 30 40 4 60 Total components used 47 57 58 111 Table 5 Workflow components used in the sample design The information we gathered from analyzing the current process plus choosing a reliable workflow tool would help in designing a better process and avoid unnecessary workflow steps being used in the current flow Comparing and examining the workflow tools helped us to choose a tool that contains the required features for analyzing and designing a new electronic process that satisfy the needs of the new lab order digital process The second part of the study consists of collecting the current paper based lab order information number of orders who can place orders how to place an order what form of requisition to use and where labels are printed see Figure 3 28 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Analyzing the data consists of two parts The first part was to investigate the current lab order process technology to determine the process performance deficiencies and errors The second part w
222. selected four workflow tools individually see Table 4 Workflow Tools YAWL Together Bonitasoft Nova Design time in 30 minute 60 minute 40 minute 90 minute minutes Error fixing time in 15 minute 15 minute 15 minute 30 minute minutes Total time in minutes 45 minute 75 minute 55 minute 120 minute Table 4 Workflow sample designing time We analyzed the data which we collected from following a qualitative methodology and performed an in depth analysis of each tool to investigate all tool designing capabilities we explored all tool features then reviewed and studied the tools by following the following qualitative parameter flexibility of the tool reliability of the design quality of the process performance of the tool information available to the users ease of tool use and information access The study also collected data from following a quantitative methodology in order to support the results gathered earlier from the qualitative methodology by providing Statistical data collected from analyzing the workflow tools In the designs of the lab order workflow sample we listed the workflow components used in each design such as tasks needed start tasks end tasks and number of branches used based on the capability of each workflow tool and used it in a table to calculate the 27 M Sc Thesis A Kamil McMaster University Computing and Software eHealth total number of components u
223. take value from end user and return outputs data back to Bonita solution Connectors can be configured by adding or creating a connector and can be tested while in the development mode Tool modeling capability The tool modeling capability consists of multiple activities such as creating service task human task call an activity gateways transitions events event sub process Modeling features The Bonitasoft workflow tool has the following modeling features define and configure tasks data actors priority type connectors set the validation define transitions conditions and decision table The tool also has useful features timer events message events generating process documentation multi instantiation and changing the appearance of design elements 21 97 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Non Technical issues Language support The Bonitasoft workflow tool processes data in multiple formats including Java Objects and XML The applications generated with Bonitasoft use standard html css and Javascript for Bonitasoft Overview 25 Use in eHealth There is no indication or proof that the tool is used for healthcare or eHealth study Tool cost The tool is available as free software or as commercial software requiring subscription or an expertise pack Support available The free support available consists of a free download and install free user ma
224. tasoft workflow tool has 17 technical workflow features and 8 non technical features It took 55 minutes to complete the design of the designated workflow process sample Future lab ordering by using the Bonitasoft tool and used 58 workflow components tasks and branches see Figure 9 39 M Sc Thesis A Kamil McMaster University Computing and Software eHealth j 6 t sician Assistant 4 Riana al Pos onerFom c r i Physician Gateway Start task Q a hat C s Rre traction gt Sing Medica Lee b Transition gt 3 Order Directive pa Gateway Gateway4 GatewayS Activity task t XOR Gateway o riood Bank Order x Qevcomete AND Gateway i gt Order u 0 A Ria Q ee 4s ne cay 2 u e 5 Gateway6 H y Persoa 4 Gateway id Phone Y Gateway a 8 Verbal n CPOE D Gateway 5 y y ee 2 g O SO D gt Add on Test CAT Q E E amp a Gatewayl End Figure 9 Bonitasoft workflow ordering design The designing time of this tool is reasonable for users when designing a new workflow process see Table 5 40 M Sc Thesis A Kamil McMaster University Computing and Software eHealth NOVA Workflow Tool Results This tool was developed with consideration of compensable transaction and formal verification This workflow model framework uses a formal graphical language proposed by StFX University Antigonish Nova Scotia Centre of Logic and Information CLI an
225. te finance organizations However there is no mentioning of its use by healthcare organizations or if the tool is used in any of the studies concerning eHealth applications Bonitasoft Overview 25 With the Bonitasoft tool we can add a timer event this feature would be useful when designing the digital lab order process and could be assigned to the event of assigning order to available lab techs or nurses Additionally the tool has message flow and call activity features Examples of message flow include throw catch start end and boundary messages The message feature is different from send email feature and the message flow event would also be useful when designing the digital lab order process by using it when sending messages to a physician or a department when lab results are critical Bonitasoft Overview 25 Messages can be sent between pools process and used to send information from one process to another but it cannot be sent within one pool Sending information between pools or to multiple receivers requires using signals Sending messages requires a data mapping which is sometimes called message configurations the procedure of transferring data between parent process and sub process variables and back The other feature is the call activity it is a sub process can be set to run automatically When the main process reaches it and when this sub process ends the main process will 91 M Sc Thesis A Kamil McMaster
226. te location Church site The ED unit in Church site consists of the following subunits 1 Triage 2 O Zone 3 Miner treatment 4 Acute 5 Critical acute 6 CDU Clinical Decision Unit Triage o if blood work need to be done in triage Nurses will decide what type of blood work need to be done according to the medical directive they have from the physicians they order blood work directly on MT Labels will be printed in triage room label printer Triage or of load nurse will collect the blood in triage room Samples labeled in the same room Samples sent to lab chute Results will be submitted by lab to patient record in MT amp a paper copy will be sent to the department printer 171 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Ifresults are critical lab will call physician or unit nurse Glucometer e Nurse start by scanning their badges so the system writes the name of the person who collect the sample e Nurse scan or write patient information in the device e Nurse scan the blood stripe e Perform the test on the patient e Nurse enters the result directly to patient record in MT Notes Nurse suggested result should flash in MT when ready ICU Department Church Project name Lab order process flow in ICU Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Mitchell Claudia MANAGER CLINICAL
227. ted inventory system it is all done manually Ordering e The ordering procedure followed now is represented by e A paper request is filled by the physician and given to the clerk for entering the information into MT e Adding another test on a sample is performed by submitting a paper request by the physician then a clerk or a nurse enters the order using the Add on Test feature in MT e Physicians have no access to CPOE e Blood bank orders are done on paper e Glucometer orders are done on paper e Nurses or clerks enter verbal and phone orders into MT e Nurses with a medical directory can place an order e No notification is available when results are ready in MT unless results are critical e To check the order status a nurse or clerk is needed to login and check the order page in MT e In some departments lab order needs to be done a day before the appointment to guarantee the receipt of the results due to the delay in the process flow or the nature of the test needed e MT electronic health record has a lot of issues that need to be fixed e Needs more order terms specification to be available to physicians 54 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Physicians prefer to have a list of the available tests show up when a physician enters the test short name For example entering UA should show Urine Analysis e The implementation of the new MT 6 0 changed some test names
228. teria Samples that result in meet repeat criteria will be reprocessed again A sample that results in doesn t meet repeat criteria will then proceed as Critical then to result submission and sample storing Critical o Calling the unit In this process the lab will call the unit and inform them directly about the result for faster action o Submitting to physician phone or device In this process the lab calls the physicians on their phone or device and informs them of the results o Submit to MT All the critical results will be submitted into the MT regardless of any other method of result notification 130 M Sc Thesis A Kamil McMaster University Computing and Software eHealth b Normal results This process will take place if the results have normal expectations and will proceed to submitting result directly e Blood bank operations The process of all the blood bank activities and contains the following three sub processes a Blood preparations A process of Defining the patient blood type Analyzing and preparing the blood bags by the lab Getting blood from the blood bank b Blood supply A process of providing blood bags to the unit a nurse or porter can obtain the samples of blood and deliver them to the units c Analytical Instrument A process of analyzing blood samples by an analyzer instrument for the purpose of the blood bank activity 9 Submission of results The system will submit
229. the IV line for patients not related to lab e Lab tech noticed that there is a duplicated order tech has to do one of the orders amp go and cancel the other order on MT e There is no initial on the label about who places the order it could be different or same nurse e No need for a written order to cancel the duplicated order the written order needed if the physician Nurse want to cancel a regular order only e Lab tech have difficulties carrying more than one tube for patients need many samples they don t have the proper basket or container to put in 8 tubes Glucometer Flow in the Medicine F 6CD unit e Information and specification about the patient diabetes comes from Emergency Department e Physician order blood sugar test on paper only no MT available e Order could be 4 or 2 times day 8AM 12PM 5PM 10PM or could be before eating at 6 AM e Nurse get the order from the patient chart or from the nurse sheet e Nurse start by scanning their badges so the system writes the name of the person who collect the sample e Nurse scan or write patient information in the device 216 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Nurse scan the blood stripe e Perform the test on the patient e Nurse place the glucometer on the loading deck results will be sent to the lab e Nurse could enter result shown on the device screen to the patient record in MT OR amp Surgery unit inter
230. the information obtained from analyzing the current and proposed processes to develop a process comparison table comparing current and future processes making it easier for the reader to see the differences between the two processes see Table 11 for more details 67 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Process Current Process Future Process Activity Ordering Paper based transferring physician s paper based test CPOE order to MT order The current system is unable to determine duplicated orders Confirmation No current confirmations on pickup and delivery Easy to access sample except in Endoscopy and in OR specimens where they use a signature sheet for the nurse porter and lab tech to sign when they receive the samples tracking and confirmation system Receiving order In the MT lab there is no specific way to inform nurses in the unit about new lab order requests Nurses only sometimes know due to the following order sheet patient chart MT page verbally from the physician or from the nurse checking the Kardex Confirmation system MT Status board Mobile devices Collecting Technicians run between the lab and clinics delivering Computerized specimen samples samples or to get supplies collection process mobile Using insufficient lab carts labeling or coded tubes Labeling Technicians carry labels from lab Mobile labeling devices or La
231. the process or deactivate the feature if the users want to share or print a clean diagram For the run feature users need to define the process parameters and define the organization and actors The Test a connector feature requires database connections extra configurations To configure the process simulation feature users need to define simulation parameters on individual tasks as well as define simulation resources 21 Analysis results The different problem detection features have different results as follows Bonitasoft User Guidance 21 o Check BPMN detect if the tasks or connections in the workflow design needs any corrections like misconfiguration o Runa process to diagnose the process execution problems o Debug to rerun any connectors that cannot run successfully o Test a connector to test a connector in a design mode o Process simulation to evaluate the process running under different conditions resources loads 96 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Technical Issues Executable model The Bonitasoft workflow tool can run simulation and execution to evaluate a process Different actors can be selected and assigned data Variables may include global local single multiple and list of options The Bonitasoft tool uses connectors to connect a task or process to the external information system by taking input from users and execute Java code Some connectors
232. the sample workflow process ease of component use and fixing the errors An explanation about the evaluation supported with the information and data collected will follow Process Design and Development Time This part of the study includes qualitative analysis of the tools and measurement parameters This section also discusses the process design parameters and strategies of how we evaluated the tools and what influenced our decisions The evaluation criteria of the tools are to set a comparison based on scoring the features of the tools A 1 was given to the available feature a 0 to non available features in the tool Then the total scores of each tool was calculated in order to compare them with other tools and to determine which tool had the most features among the rest of the workflow tools see Table 2 and Table 3 The work includes not only determining the features but also making sure that the features were useful when designing a new process We will expose the results concerning the helpfulness of these features in the succeeding chapters 116 M Sc Thesis A Kamil McMaster University Computing and Software eHealth We have to mention here that process designing time is different than the new digital lab order processing time Process designing time is the time the tool takes to complete designing a workflow process while the new digital lab order processing time is the duration time of complete digital lab orde
233. tient ID Eliminate error Prevents n amp verification adverse events Verification Confirmation system Prove of action Update the status Receiving Mobile device amp Speed up the process Staff management decrease orders notification system control treatment time Management system Send orders based on Speed up the Eliminate errors 66 M Sc Thesis A Kamil McMaster University Computing and Software eHealth specified parameters process Collecting Scanning system Identify patients and Update the status Eliminate errors samples associate their records prepare labels Mobile device or Efficient labeling prevent Prevents bar coded tubes mislabeling adverse events Carts contain Speed up the collection Decrease patient supplies on board process waiting time Delivering Pneumatic Tube Time saving Speed up the samples Transport process Processing Pre Post Analytical Cut down processing Time saving samples Instrument time Analyzing Automated Cut down processing Eliminate errors Eliminate results Instrument time diagnostic misjudging Submitting Automated MT Quick result submission Efficient results update system Notification system Results notification Allow quick Could prevents response by adverse events physicians or staff Storing Automated storing Better sample Quick sample samples system management location Table 10 Future process benefits Process comparison We use
234. ting process using the NOVA workflow tool took almost a week of work With the other tools YAWL Together and Bonita it took no more than a day to do the same process Designing a process resulted in the following issues e With NOVA workflow tool users do not have the control to design the splits and joins in the way that they want The same issue arises with the transactions branches in which users cannot move or redirect the connection from task to task e Local variables should be declared in the task property class as class attributes in order to use them in the workflow e Users should have knowledge of eclipse when working with NOVA tool For example a project s name should start with small letters A project with a name starting with a capital letter will have a problem when trying to run the project in eclipse Changing the name later is not permissible and a new project needs to be created from scratch e When creating new tasks in the editor the tool will not create the task s property files automatically property files needs to be created manually one by one e Designing the workflow requires a user with some coding knowledge For example all the join and split code in the design is mostly inherited abstract methods and should be created manually There is also a need to export some files and any change to the task property should be done by changing the code of these properties e To run the workflow engine users a
235. tions whether the activity is instantiated once or multiple times cost waiting and working times and duration in a simulation information tab for defined different simulation information Together Professional Open Source 6 Tool modeling capability The tool has multiple modeling capabilities including declaring participants and their type system human configuring a role resource and resource sets The tool also has different types of activities such as normal activity task application sub flow block and 88 M Sc Thesis A Kamil McMaster University Computing and Software eHealth route It can also work as packages and a package could contain multiple processes too Together Professional Open Source 6 Modeling features The graphical editor has easy access to graph and XPDL views for package and process a navigator and tree area property problem and WFXML components Variables of the workflow and tasks can be created initiated edited and deleted through manage variables and process or package properties The sub processes can be done as a new lane for existing participants The tool defines the transitions type and color based on the BPMN specification and offers uncontrolled flow condition flow default flow exception flow and default exception flow TWE offers start end normal task application sub flow and block activity It also provides access to manage process parameters and exten
236. to be entered to MT by 6 AM O If the result is critical lab will call the physician if the physician is not available the lab then call the unit and talk to the team leader or the primary Nurse about the result Most of the time lab have hard time finding the right unit or to be directed to the right person 225 M Sc Thesis A Kamil McMaster University Computing and Software eHealth O If result is not critical the result will be submitted to MT and paper copy will be sent to the unit printer except the O Zone there will be no paper copy Inpatient surgical unit interview questions Project name Lab order process flow in Inpatient surgical unit Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Rose Resource nurse Date Aug 01 2012 Time 10 00 AM Location Finch site 1 What type of samples you collect at these clinics Routine blood work specimen Routine collection could be in one of these times 6 AM 10 AM 1 30 PM 3 30 PM 6PM 2 How many orders normally placed per day 45 day 3 Who is placing the orders Physician 4 How physicians placing an order Paper chart verbal Nurse confirm amp enter it to MT 5 What are the methods of adding another test request to a sample Paper telephone order Nurse or clerk enter it to MT 6 Where are labels printed or received from Routine In clinic Stat In lab 226 M Sc
237. ts not received missing Use add on 18 Do you prefer to have confirmation on sample when lab receives the samples and when clinic receives result on MT Yes the current porter uses confirmation 19 Any issue with the current system 20 Recommendations and suggestions Need status board with color ID 21 Do you use blood bank service amp how to order Yes e Lab tech Nurse take sample e Porter take face sheet to lab e Porter pick up the blood Medicine F 6CD unit Observation Project name Lab order process flow mapping Observer name job title Ammar Kamil Project assistant Observation place Medicine F 6CD unit Date July 31 2012 Time 7 30 AM Site location Finch e 7 45 Lab tech come to floor based on paged call from the department e Lab tech take the labels from the department because the lab tech was in a round trip when she get paged in the 4 floor e Lab tech confirm the information on the label with MT 215 M Sc Thesis A Kamil McMaster University Computing and Software eHealth o Lab tech still struggle with placing the tubes and the equipments on a place there is no place to put or write on the labels e Lab tech toke the samples amp went outside the room to put the labels amp write on them the initials e Lab tech place the samples in cart o Noticed that lab tech follow the proper precautions signs Contact Droplet and Airborne o IV Nurse come amp check
238. ture workflow analysis and submission of results Results Submission The MT system will store the results automatically If they are critical the system will send a notification to the ordering physician as well as the floor staff or nurse 65 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Confirmation and Verification With the new digital lab order design a confirmation system will confirm the receipt or submission of the sample and update the order page on MT and the status board in the lab A verification system will verify the patient s ID by scanning the patient bracelet and then interact with the patient s EHR record before finally placing the order Dispatch software will determine to whom to send the order based on priority of the order location of the technicians and the technician work list Future process benefits The new process will have more benefits to the healthcare organization than the old process We illustrate these benefits in a table containing the benefits and metrics for each related process Please see Table 10 for more details Benefits Metrics Process Technology Performance Quality Patient safety Ordering CPOE Time saving decreases Reduce errors the waiting time Status board Time saving Reduce patient care time Entering Automated entry to Time saving orders to MT MT Confirmatio Scanning amp Confirm pa
239. unit for STAT routine and round trip orders and will include Routine collection The activity of performing a daily round trip to collect samples at different times of the day 7 00 am 10 00 am 1 00 pm 136 M Sc Thesis A Kamil McMaster University Computing and Software eHealth e Blood bank test The process of determining the patient blood type is performed before ordering blood from the blood bank This test is done to find out the patient s blood type STAT collection This process is performed by lab technicians only when blood tests are required urgently Lab technician in lab Lab technicians can carry out collections in the lab for patients referred by a physician or for in advance collections for patients with upcoming appointments Physician referrals collection This process involves a test referred by a physician from one of the hospitals units and not an outside clinic In advance collection This process is for patients where results should be ready for the physician at the time of the appointment primarily for oncology patients 5 Delivering samples Delivering the collected samples to the hospital s lab could be done in two ways a Normal operation This process will happen during the normal running operation and will be the main methods of delivering lab order samples to the lab Pneumatic Tube Transport or PTT system This delivery system will consists
240. urrent and Future Order Processes This section contains descriptions of the lab order process and results of studying current and future lab order processes Current Situation Summary The current paper based lab order process starts with placing lab order either by a physician physician assistant or nurse practitioner in all departments where blood samples or specimens need to be collected emergency intensive care unit nephrology 44 M Sc Thesis A Kamil McMaster University Computing and Software eHealth etc The main method of placing a lab order is a paper based method and the process consists of the following steps Ordering placed as paper requisition only by physician physician assistant or nurse practitioner A nurse or clerk enters it into a MT electronic health record later Printing labels by the MT system automatically after completing and entering the order Receiving the order by the person who performs the collection of the sample and managed by the lab technicians Collecting samples can be assigned based on the order type or the status of the patient Delivering the sample can be done in four ways porter service lab technician staff or courier Processing the sample in the hospital laboratory done based on the required test Samples can be processed either in the hospital or outside the hospital based on the equipment available and type of test Analyzing the results specified as normal ab
241. users can define multiple or individual instantiation cost waiting time working time and duration Together User Manual 20 Analysis the Tool Can Perform Analysis definition The tool has a check validity feature which can produce a problem list by checking the XPDL model s validity based on the WfMC specification to check if the workflow performs as designed and results as expected 86 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Analysis role The role of the problem tab is to spot workflow problems errors and warnings as a list of the workflow problems This problem list of errors or warnings are designed to display all of the necessary information in order to fix any errors or warnings that could potentially affect a workflow design Together User Manual 20 see Figure 20 Properties Search Problems wae DAP k Workflow process Future Lab Process 3 errors 13 warnings Type Description Element Location amp LUGG Unused variable blood esti wi variable bod lest pacae e Worktiow pen FutureLabero 1 boat le Pha i Freres sn poes trl i i 1 LOG Led varade ae es i hloat foie ctrbe er Poa ears Vooges ar i CN arene ea higie Para tr Rt o i i Figure 20 Together problem tab The analysis of the TWE workflow tool is different than that of the YAWL workflow tool With the analysis tool of YAWL work
242. velopers and scientists to create execute and share models This tool does not have enough features to design a workflow model like the other workflow tools the available information about this tool is vague and confusing for a regular workflow designer 31 32 31 The graphical editor of this tool is missing a lot of the regular workflow components and features such as tasks transitions and splits This makes it uncomfortable for the workflow designer when working with the tool nexusBPM Workflow Tool This tool is a JBoss s jBPM product suite It uses eclipse and the eclipse plugin as a workflow platform The tool s web page lacks of information except for a download link and a screenshot Although the tool has a user manual but it has not enough workflow features to develop a workflow model like the other workflow tools This tool is considered as unreliable when comparing it with the other tools when designing a workflow 33 111 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Aperte Workflow Tool This tool is web based workflow software The tool source provides some information about the functionality and the use of the tool but when we used the tool to create a workflow process sample we found following issues The tool interface is very basic and has no advanced components to create a powerful process what makes it difficult to create our digital lab order process The
243. vice and to facilitate the design of new systems in which workflow processes can be controlled and managed based on the required work environments We also found that the healthcare system is changing from the old paper based systems to new digital systems The old systems have had many issues that led to errors or have 16 M Sc Thesis A Kamil McMaster University Computing and Software eHealth affected patient safety Thus designing a new system based on a reliable workflow tool is an effective way of reducing or eliminating these errors In both issues we found that in comparison to related work the problems of this thesis have not been solved in any of the studies no such paper is exists that compares examines and tests workflow modeling tools or analyzes the current paper based system and recommends a new design of a digital system 17 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 3 CHAPTER THREE METHODOLOGY 3 1 Design It is necessary to have the most reliable workflow process tool to improve the current paper based workflow process in a healthcare setting and develop a new digital lab order workflow process We conducted an in depth study and used a mixed qualitative and quantitative methodology in part one and two of the study 3 2 Participants and Setting The first part of the study involves examining 15 open source workflow tools YAWL Together Bonitasoft NOV
244. view questions Project name Lab order process flow in OR amp Surgery Clinics Interviewer name job title Ammar Kamil Project assistant Interviewee name job title Judy Chadwick Director of Surgery Date July 31 2012 Time 10 00 AM Location Church site 1 What type of samples you collect at these clinics All types 2 How many orders normally placed per day 150 day 3 Who is placing the orders Physician 4 How physicians placing an order Verbal 5 What are the methods of adding another test request to a sample Verbal 6 Where are labels printed or received from OR room center core 7 Do the nurse technician confirm the information in labels with the test request Yes with chart nurse surgeon 217 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 10 11 12 13 14 15 16 17 18 19 20 How staff notified there will be test needed Verbal Who is collecting the samples nurse or lab technician Surgeon collect samples gt then Nurse prepare to send to lab How do nurse technician identify the patient for sample collection for sample test Patient already identified before entering the OR Is there any difference in flow between different samples No Where normally samples are collected OR Where collected samples are normally labeled OR How samples delivered to the lab Stat Porter Nurse
245. wer name and job title interviewee name and job title date time and location refer to the model in Figure 2 for the recording tool used to capture 29 interviews and 19 observations data see Figure 2 for a sample form and see interviews questions and answers in Appendix B for complete interview questions and answers 19 M Sc Thesis A Kamil McMaster University Computing and Software eHealth coeeeceneeennncneeceenennen Unit interview questions Interviewer name job tite o Tnterviewee name 7 jobie SSCS Eate E SCCSCSSS S e Figure 2 Model of interview information We designed a questionnaire form to record the required answers based on the available processing information and the needs of the new digital lab order process We used the form to capture data through 29 interviews see Figure 3 Unit interview questions Project name in Clinic Interviewer name job title Interviewee name job title Date Time Location 1 What type of samples do you collect at these clinics 2 How many orders normally placed per day 3 Who is placing the orders 4 How are physicians placing an order 5 What are the methods of adding another test request to a sample 20 M Sc Thesis A Kamil McMaster University Computing and Software eHealth 6 Where are labels printed or receiv
246. xposes the model data through an interface using ProMImport interface The YAWL tool provides simulation support by Process mining environment ProM through the link www processmining org ProM is an open source framework for Windows Mac OSX and UNIX platforms YAWL Foundation 19 77 M Sc Thesis A Kamil McMaster University Computing and Software eHealth Analysis the Tool Can Perform Definitions YAWL provides several options to help users define the workflow specification problems The available options consist of verification option analysis option note and problem panel engine and resource service status hint and message panel and data type validation Analysis role The analysis role is to spot the deadlock situations unnecessary cancellation set members and unnecessary or join decorators at run time discover infinite loops unreachable states and probability of failure workflow problems YAWL User Manual 2 3 18 pp 91 The verification role is to allow users to validate the specifications against YAWL syntax and semantics YAWL User Manual 2 3 18 pp 43 The verification and the analysis options use a note and problem panel to display a description of any note or problem The engine and resource service status panel displays the status when running the execution engine and also displays the status of the resource service available The hint and message panel provides any hints
247. y focuses on how to identify some fundamental factors that need to be considered when performing teleretinal readings by specialists Another Study by Brogi et al 5 explains the approaches used for translating Business Process Execution Language BPEL processes into YAWL workflows The authors chose the YAWL language because of its well defined formal semantics hence the methodology they recommend outlines a YAWL pattern for each BPEL activity the authors chose YAWL for its ability of handling complex data transformations and Web service integrations as an advanced specification when compared with other tools However our study is the first to identify and examine multiple open source workflow tools and assess them based on preset criteria to choose the best easiest and most useful features across all the tools an essential first step toward the ultimate goal of developing a digital flow process The intention of the first goal of the study is to find the most accurate workflow tool and use it to accomplish the second goal of designing the new digital lab order process The information about tool descriptions and evaluations is collected by studying each workflow tool individually We use the workflow process testing model to evaluate the capability of the selected tools and categorize the tools based on certain criteria such the availability of an analysis tool tool features support graphical editor execution engin
248. ysician notes and computerized physician orders the software comes in different versions 6 0 is the latest Order sets A set of lab or pharmacy orders preset by physicians using a specified feature in MT health record software PDA Personal Digital Assistant or Personal Data Assistant a mobile device used as a note or information organizer Processing time The time from when lab order samples originating in the lab are placed in the process analyzer to the completion of the test and the submission of the results into patient health records PTT An abbreviation for Pneumatic Tube Transport system a lab order sample delivery system consisting of a pneumatic tube network running between all of the hospital s units and labs using pneumatic capsules to deliver collected samples from these units to the lab STAT An abbreviation used in lab orders to specify a lab test as urgent Turnaround Time The completion time of a lab order including all process stages starting from the time the order is placed through all the processes and steps to the end of the process when the results of the test are submitted to the MT system WFMC Workflow Management Coalition WSDL Web Service Description Language xiii XML Extensible Markup Language which expresses a set of rules to form a readable language by machines and humans XPath and XQuery A data model based on the XML information set allowing a user to select data from
249. ystem departments samples diagnostic and treatment time Table 8 Current process deficiencies We used the same collected data to create a second table and outlook the main issues in the current process to specify the performance quality and patient safety in the lab order process for more details please see Table 9 n Nurse or clerk Entering orders to MT Printing labels Receiving lab orders required Labels printed in lab or unit No specific way of informing Time consuming increasing waiting time Time consuming Delay the service Writing errors Errors when entering orders Possible labels lost Increase patient waiting time Missing records lost tests wrong tests Increase adverse events Confidential patient info Increase patient diagnostic and treatment time M Sc Thesis A Kamil McMaster University Computing and Software eHealth Collecting Collection time samples Delivering Manual process samples Processing Processing time samples Analyzing results Manual process Submitting No notification results available when results are submitted to MT Storing samples Confirmation Not available in most departments Table 9 Current process issues Depend on collection type Time consuming Some processes require human interaction Required previous patient record in some cases Keeps staff busy

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