Meeting with Alan Fekete - Project rescope

Today Hendy and I had a meeting with Alan Fekete and Peter Budd to report our findings for the previous week and discuss how we could divide up the treatise into two meaningful segments.

Investigation into the use of CareVue in G.H.I.M.S ICU

The following segment describes the findings describing whether the G.H.I.M.S ICU system will rely or use CareVue.

CareVue Database Environment

• Data is recorded by CareVue and stored into two separate databases; real time database and an historical database. The difference in both databases is that the real time database records and displays live data for recent ICU patients whereas, the archival database stores data for all ICU patients.
• The historical database is called the Information Support Mart (ISM); a clinical data management information support mart that interfaces with CDA to create a set of approximately 30 tables from 300 tables.
• The real time database is called the Clinical Data Archive (CDA) contains over 300 tables

Extraction of Data from CareVue for the ICU G.H.I.M.S

• Currently, there is code written (from another project called the Ward Round System) to extract data from the historical database. As a result, we envisage that investigation into extracting data from CareVue and inputting it into an ICU G.H.I.M.S would be trival.
• While extracting data from CareVue would be achievable, inputting the data into the database is live or archival database is problematic because:
• We will be manipulating
• There is a resource constraint on the access of the database.
• Furthermore, it is envisaged that the complete ICU G.H.I.M.S would serve as a replacement to the hospitals current information system setup. Instead, de-identified CareVue data could be used as a base for data requirements analysis (as per system analysis completed) and as sample data to enter into a prototyped ICU G.H.I.M.S.

Workflow in the ICU

• CareVue currently does not support a workflow management system.
• There are really no standardised forms that CareVue uses during throughout the workflow in the ICU. There are certain stages and activities (e.g. automated recording of vital signs, recording of nurse discharge summaries) where there are computerised forms which are later printed out. A significant portion of clinician notes a rerecorded in free text, however some entries follow standard template (such as the Ward Round Templates).
• Some paper forms are used during certain ICU workflows. For example, during the discharge process, medication data in CareVue is transferred by the nurse and doctors to standardised forms which are used hospital wide.
  

Conclusions
Considering that the proposed G.H.I.M.S would effectively be a replacement (with greater functionality and support) to any hospitals electronic or non – electronic system, CareVue should be used as a base line for which the minimal type of information could be stored on a G.H.I.M.S ICU IS. CareVue de-identified data coupled with the workflow analysis can be used as a test bed for the prototype (and full) implementation of the G.H.I.M.S. ICU IS.

The Workflow Management System

The workflow management system (shown in diagram above and in previous post) can be divided up into two independent sections - a workflow builder and a workflow manager. The workflow builder will allow users to create abstract workflow representations which then can be instantiated by the workflow manager. The workflow manager will then require to route the workflows to the appropriate users at the appropriate time. The workflow builder and workflow manager becomes the foundation for the proposed workflow management system.

The need for a workflow managment system, workflow builder and workflow manager requires some form of common ground for communication between each segments. Therefore a workflow definition language written in XML would need to be devised. This would be served as a set of rules used to describe workflows in XML much like the FDL (Forms Definition Language).

Task for the following week

For the following week, I plan to do the following:

• Hendy and I are to work on the workflow definition language.
• Investigate requirements and scope for the workflow builder and workflow manager.

Meeting with Jon Patrick & Alan Fekete and Project Scope

Hendy and I had a comprehensive meeting today with our supervisors Jon Patrick, Alan Fekete and Peter Budd (a PhD student who developed G.H.I.M.S and Terminology Server).

Administration

Over the next 6 weeks, Jon Patrick will be away. Temporarily taking his place as thesis supervisor will be Alan Fekete (refer to previous posts). We plan to keep in touch with Jon through regular email and progress updates on the TRAC website. We have also set up weekly meetings with Alan Fekete every Thursday at 12 mid day.

Project as of today

So far, the system analysis phase of the project has been finalised. Only minor changes need to be made which will take no longer than a couple of days. However, we are still perfoming some validation and feedback tests with Angela at the RPA (she has been unavailable this week). With the first half of the project complete, Hendy and I will diverge in our investigations in the remainder of the second phase of the project.

Project Goals for the remainder of the thesis (Project Scope)

Generally, the aim of the project is to develop a working prototype that demonstrates (a proof of concept) a document centric workflow management systems in an ICU environment.

The diagram above depicts the current state of the technology. Essentially, there are two versions of G.H.I.M.S that need to be consolidated. The version of G.H.I.M.S that was developed by Peter Budd contains a form designer with version control using a MySQL database. The second version of G.H.I.M.S, developed by William Chau, contains a workflow management systems (WfMS), written in C#, but does not contain a versioned form designer. The backend operates on an Oracle database.

In order for the system to function, investigation needs to be done to port the WfMS into Perl for it to be compatable with G.H.I.M.S developed by Peter. Open source backend, such as MySQL will also need to be implemented. Using the system and workflow analysis completed in the first half of the thesis, we have to demonstrate the generic generation of an ICU information system. In order to reduce scope, this ICU system will be a component of the ideal system that is complex enough to demonstrate a proof of concept. It is essential that several principals, on which G.H.I.M.S is based upon, are demonstrated. These are (on the top of my head):

• Support for user workflow - adaptive workflow for the main users of an ICU information system; i.e., clinicians, nurses, allied healthcare professionals, administrators, researchers


• Use of terminology (SNOMED-CT)


• Customisation and Interoperability - data transfer between the ICU G.H.I.M.S and a mini (basic) G.H.I.M.S for allied healthcare professionals.


• Extendability - ability for users to effectively define their own systems (and workflow) with the use of the form designer.


• Medical Record storage and retreival.

My Tasks for the next week

For the following week, I plan set up the development environment on my laptop, install Peter's code and experiment with G.H.I.M.S. (I have scheduled a meeting with Peter Budd on Friday). My specific aims is to see what is required in order to make the system (bar the WfMS) to work with CareVue or to be able to mimic CareVue. This requires investigating the paper and electronic document environment surrounding the ICU's workflow and their use with CareVue and possibly, how adaptive their workflow will need to be. I plan to post an entry on adaptive workflows soon as this area is especially useful in the ICU environment.

Draft Treatise Hand In

I have finalised the draft treatised and given a copy to Alan Fekete and Jon Patrick for initial feedback. Over the next two days, I plan to work on the draft treatise extending the system analysis and workflow analysis chapters. I also have to clean up the literature review and continue to add to the literature base as I continue researching.

ICU General Workflow (Meeting with Angela on 25th and 27th July 2007)

On the 25th and 27th of July 2007, Hendy and I had meetings with Angela Ryan of RPA hospital. Briefly, the core purposes of the meeting were to discuss:

• The ICU structure at the Royal Prince Alfred Hospital
• The flow of patient in a general ICU.
• Brief overview of the “Whiteboard”
• Core users of RPA ICU’s information system; CareVue
• Extension of Functional and Non Functional Requirements

ICU Department at RPA

The ICU at the RPA hospital is divided into three/four sub division/department based on the three types of patient that is administered into the ICU. They are:

1.General ICU – The most generalised ICU unit that is designed to deliver the highest of medical and nursing care to the sickest of patients with non-unique conditions.
General ICU High Dependency Unit (HDU)– deals with patients which need constant care. Often up to two nurses can be assigned to each patient in the High Dependency ICU

2.Cardiothoracic Intensive Care Unit (CICU)/High Dependency Unit (CICU-HDU) - CICU cares for patients who need heart (cardiac) and chest (thoracic) surgery. Surgical procedures may include operations on the heart, the heart’s blood vessels, the chest or the lungs.

3. Coronary Care Unit (CCU) - The Coronary Care Unit or CCU cares for patients who have heart disease and occasionally other medical or surgical problems. In RPA, this unit is more or less combined with CICU.

4. Neurosurgical Intensive Care Unit (NICU)/High Dependency Unit (NICU-HDU) - The Neurosurgical Intensive Care Unit cares for patients with brain or spinal cord conditions and occasionally other medical or surgical problems. (Source)

The General ICU and Neurosurgical ICU/HDU patients are cared by specialist doctors relevant to their area whereas the General ICU HDU and Cariotherastic ICU/HDU care is driven by ICU specific doctors.

Flow of patient in a general ICU

Patients who come into ICU often need constant monitoring and medical care. These are usually patients from lengthy surgery, unconscious and/or require ventilation hookup. A new patient administered into the ICU would follow the procedure:

1. Upon arrival (or even before arrival) a new patient is created in CareVue. Given the MRN, a linkage to the hospital’s patient administration system automatically uploads all other administrative (not medically relevant) data.

2. The patient physically arrives to the ICU department, usually accompanied with several nurses and doctors. During the setup procedure, necessary equipment (such as ventilator, machines measuring vital signs) are attached and linked to the patient. Once linked some of these medical equipment automatically update data into CareVue.

3. Nurses and/or doctors then create a care plan for the patient. (Different depending on diagnosis or investigation).

4. Nurses and doctors perform their duty in caring for the patient (To be investigated next week).

ICU Whiteboard

In almost all hospital departments, exist a whiteboard used to record and keep track of patients, nurses and doctors on shift. The RPA’s ICU uses a whiteboard as a tool to map patients to nurses and to record which doctors are on shift.

Core Users of CareVue

• Doctors – heavy user
• Nurses – heavy user
• Physios – medium user
• Dieticcian – heavy user
• Social workers – light users
• Visiting Medical Teams – medium users
• Speech Pathologist – medium users

Note: Physios, Dieticians, Speech Pathologists and Pharmacists are usually referred to as Allied Healthcare professionals. These set of users have limited use in CareVue. They often view CareVue information and only enter notes compared to Doctors or Nurses whom extensively use CareVue.