Dr. John Svirbely's blog post - Going from Zero to Success using BPM+ for Healthcare. 
                Part I: Learning Modeling and Notation Tools
Dr. John Svirbely, MD
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Going from Zero to Success using BPM+ for Healthcare.

Part I:
Learning Modeling and Notation Tools

By Dr. John Svirbely, MD

Read Time: 3 Minutes

Welcome to the first installment of this informative three-part series providing an overview of the resources and the success factors required to develop innovative, interoperable healthcare workflow and decision applications using the BPM+ family of open standards. This series will unravel the complexities and necessities for achieving success with your first clinical guideline automation project. Part I focuses on how long it will take you to reach cruising speed for creating BPM+ visual models.

When starting something new, people often ask some common questions. One is how long will it take to learn the new skills required. This impacts how long it will take to complete a project and therefore costs. Learning something new can also be somewhat painful when we are set in our old ways.

Asking such questions is important, since there is often a disconnect between what is promoted online and the reality. I can give my perspective based on using the Trisotech tools for several years, starting essentially from scratch.

How long does it take to learn?

The simple answer – it depends. A small project can be tackled by a single person quite rapidly. That is how I got started. Major projects using these tools should be approached as team projects rather than something an individual can do. Sure, there are people who can master a wide range of skills, but in general most people are better at some things than others. Focusing on a few things is more productive than trying to do everything. A person can become familiar with the range of tools, but they need to realize that they may only be able to unlock a part of what is needed to automate a clinical guideline.

The roles that need to be filled to automate a clinical guideline with BPM+ include:

1 subject matter expert (SME)

2 medical informaticist

3 visual model builder

4 hospital programmer/system integrator

5 project manager

6 and of course, tester

A team may need to be composed of various people who bring a range of skills and fill various roles. A larger project may need more than one person in some of these roles.

The amount of time needed to bring a subject matter expert (SME) up to speed is relatively short. Most modeling diagrams can be understood and followed after a few days. I personally use a tool called the Knowledge Entity Modeler (KEM) to document domain knowledge; this allows specification of term definitions, clinical coding, concepts maps and rule definitions. The KEM is based on the SVBR standard, but its visual interface makes everything simple to grasp. Other comparable visual tools are available. The time spent is quickly compensated for by greater efficiency in knowledge transfer.

The medical informaticist has a number of essential tasks such as controlling terminology, standardizing data, and assigning code terms. The person must understand the nuances of how clinical data is acquired including FHIR. These services cannot be underestimated since failures here can cause many problems later as the number of models increase or as models from different sources are installed.

The model builder uses the various visual modelling languages (DMN, BPMN, CMMN) according to the processes and decisions specified by the SME. These tools can be learned quickly to some extent, but there are nuances that may take years to master. While some people can teach themselves from books or videos, the benefits of taking a formal course vastly outweigh the cost and time spent. Trsiotech offers eLearning modules that you can learn from at your own pace.

When building models, there is a world of difference between a notional model and one that is automatable. Notional models are good for knowledge capture and transfer. A notional model may look good on paper only to fail when one tries to automate it. The reasons for this will be discussed in Part 3 of this blog series.

The hospital programmer or system integrator is the person who connects the models with the local EHR or FHIR server so that the necessary data is available. Tools based on CDS Hooks or SMART on FHIR can integrate the models into the clinical workflow so that they can be used by clinicians. This person may not need to learn the modeling tools to perform these tasks.

The job of the project manager is primarily standard project management. Some knowledge of the technologies is helpful for understanding the problems that arise. This person’s main task is to orchestrate the entire project so that it keeps focused and on schedule. In addition, the person keeps chief administrators up to date and tries to get adequate resources.

The final player is the tester. Testing prior to release is best done independently of other team members to maintain objectivity. There is potential for liability with any medical software, and these tools are no exception. This person also oversees other quality measures such as bug reports and complaints. Knowing the modeling languages is helpful but understanding how to test software is more important.

My journey

I am a retired pathologist and not a programmer. While having used computers for many years, my career was spent working in community hospitals. When I first encountered the BPM+ standards, it took several months and a lot of prodding before I was convinced to take formal training. I have never regretted that decision and wish that I had taken training sooner.

I started with DMN. On-line training takes about a month. After an additional month I had enough familiarity to become productive. In the following 12 months I was able to generate over 1,000 DMN models while doing many other things. It was not uncommon to generate 4 models in one day.

I learned BPMN next. Training online again took a month. This takes a bit longer to learn because it requires an appreciation of how to design a process so that it executes optimally. Initially a model would take me 2-3 days to complete, but later this dropped to less than a day. Complex models can take longer, especially when multiple people need to be orchestrated and exception handling is introduced.

CMMN, although offering great promise for healthcare, is a tough nut to crack. Training is harder to arrange, and few vendors offer automatable versions. This standard is better saved until the other standards have been mastered.

What are the barriers?

Most of the difficulties that I have encountered have not been related to using the standards. They usually arise from organizational or operational issues. Some common barriers that I have encountered include:

1 lack of clear objectives, or objectives that constantly change.

2 lack of commitment from management, with insufficient resources.

3 unrealistic expectations.

4 rushing into models before adequate preparations are made.

If these can be avoided, then most projects can be completed in a satisfactory manner. How long it takes to implement a clinical guideline will be discussed in the next blog.

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What is SMART on FHIR®?

SMART on FHIR®, an abbreviation for Substitutable Medical Applications and Reusable Technologies (SMART) on Fast Healthcare Interoperability Resources (FHIR), is an open, standards-based technology that enables innovators to create apps that seamlessly and securely integrate with Electronic Health Records (EHRs).

It combines the Fast Healthcare Interoperability Resources (FHIR) standard with an authorization protocol based on OAuth 2.0 to provide access to data in a standardized format with granular access controls.

HL7 Fast Healthcare Interoperability Resources (FHIR) Logo

Note: HL7®, and FHIR® are the registered trademarks of Health Level Seven International and the use of these trademarks does not constitute an endorsement by HL7. CDS Hooks™, the CDS Hooks logos, SMART™ and the SMART logos are trademarks of The Children’s Medical Center Corporation.

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SMART on FHIR has revolutionized the way Electronic Health Records (EHRs) are accessed and utilized in the healthcare industry. This innovation is the product of the collaboration between technology and healthcare, aiming to improve the interoperability and delivery of healthcare services. It has the potential to unlock health data and drive innovation across the healthcare ecosystem.

By leveraging the SMART on FHIR specification, healthcare innovators can develop apps that query, update, and analyze a patient’s EHR data without custom integration or interference to EHR system operations. Apps can offer clinical decision support, customized patient education, interoperability bridges, Population Health Management, and more.

SMART on FHIR enables an iPhone-like app platform for healthcare.”

Who Uses SMART on FHIR?

SMART on FHIR is used by major companies like Epic, Cerner, Allscripts, Meditech, athenahealth, Microsoft Azure, and Apple, showcasing its widespread adoption and importance in the healthcare sector. Epic and Cerner, which account for over half the U.S. EHR market, both integrated SMART capabilities into their systems in 2018. The SMART on FHIR specifications allow organizations to use plug-in applications and run them inside any EHR that complies with HIPAA.

In the United States, SMART™ support is specifically referenced in the 21st Century Cures Act of 2016. The 21st Century Cures Act requires a universal API for health information technology, providing access to all elements of a patient’s record accessible across the SMART API, with no special effort.

SMART on FHIR is widely adopted because it delivers many benefits. Here are just a few:

What is SMART on FHIR used for?

SMART on FHIR apps, both publicly available and custom-created, are demonstrating major healthcare benefits in care coordination, clinical decision support, clinical research, data visualization, disease management, genomics, medication, patient engagement and education, Population Health Management, risk calculation, telehealth, interoperability bridges, and many more areas.

For example, an app called CORSI helps emergency physicians safely prescribe opioids by analyzing FHIR resources against state PDMPs (Prescription Drug Monitoring Program) data. Another app identifies EHR data inconsistencies in under one second compared to traditional manual review methods that take weeks. SMART and SMART on FHIR apps are creating an ecosystem of medical apps that are reducing costs and improving health on a major scale.

A well-recognized and significant usage of SMART on FHIR is for Clinical Decision Support.

The SMART on FHIR Standard

In 2009, in a New England Journal of Medicine article, the Computational Health Informatics Program, Boston Children’s Hospital, introduced the idea of an API to promote an apps-based health information economy. The SMART team focused on leveraging web standards, presenting predictable data payloads, and abstracting away many details of enterprise health information technology systems while marshaling data sources and presenting data simply, reliably, and consistently to apps. Since 2013, through co-development and close collaboration, SMART and FHIR have evolved together. SMART enables FHIR to work as an apps platform today referred to as “SMART on FHIR.” The SMART authorization layer complements the FHIR specification by allowing patients to authorize trusted third-party apps to securely access select FHIR resources relevant to the apps.

Here are the HL/7 Standards and Specifications related to SMART:

Trisotech and SMART on FHIR

Trisotech provides support for SMART on FHIR through the Healthcare Feature Set (HFS)

via features and functions that allow healthcare organizations to model and automate their decisions and workflows.

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Healthcare Feature Set (HFS)

Access is provided to FHIR®, CDS Hooks™, and SMART™ on FHIR, as well as AI and Machine Learning (ML) capabilities. The Healthcare Feature set makes understanding and using the latest interoperability standards in healthcare technology available in a modern, easy-to-use way that is compatible with existing software systems in any healthcare setting.

Autogenerated SMART on FHIR webapps

How to develop SMART on FHIR apps? With the Healthcare Feature Set, SMART on FHIR web applications can be created from decision, workflow, and case models using one-click deployment. Links to those SMART on FHIR applications are automatically generated and are suitable for inclusion on CDS Hooks “App Link Card” or in any SMART compatible environments.

FHIR Support

Trisotech’s Healthcare Feature Set allows for data storage, retrieval, and patient data exchange using the FHIR (HL-7®) interoperability standard. Re-useable FHIR data types and drag and drop FHIR resources are available for all FHIR Resource structures including Foundation, Base, Clinical, Financial, and Specialized resource structures.

Predefined FHIR Data types

Trisotech provides out-of-the box FHIR data types that can be assigned with one click to elements in Decision models (DMN), Workflow models (BPMN), and Case models (CMMN).

CDS Hooks Support

CDS Hooks is one of the most common ways to embed Clinical Decision Support (CDS) automation functionality in a clinician’s workflow. When an EHR system notifies external services that a specific activity occurred within an EHR user session, a CDS service can gather needed data elements through FHIR services and return information to the clinician in the form of a “card.” As part of the Healthcare Feature Set, Trisotech provides a CDS Hooks server to accept decision support requests and generate customizable CDS Cards in return. Where CDS Services require specific FHIR Resources to compute the decisions the CDS Client requests, CDS Hooks support will provide the interface to acquire those resources.

Connection to a FHIR Terminology Server

The Healthcare Feature Set allows concepts used in Workflow, Decision and Case models to be healthcare coded using healthcare coding systems (SNOMED CT, LOINC, RxNorm, ICD, etc.) and ValueSets through a connection to a terminology server of choice that adheres to the FHIR Terminology Sever specification.

Discover the complete set of feature of the Digital Automation Suite.

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Trisotech Telemedicine Webinars Series
Process Automation in Telemedicine: Improving Efficiency

Presented at FHIR North 2021 by
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Dr. John Svribely, CMIO at Trisotech

Denis Gagne, CEO & CTO at Trisotech

Informed Consent (also known as Consent for Medical Treatment) is required prior to most medical procedures. It allows the patient to actively participate in decisions about what his or her own care. Informed Consent is therefore an integral part of Patient-Centered Care.

FHIR defines a Consent resource that is meant to cover four different uses cases: Privacy Consent, Medical Treatment Consent, Research Consent, and Advance Care Directives. Currently, only the Privacy Consent use case has been elaborated.

In this session we will explore the usage of the FHIR Consent Resource for the purpose of Informed Consent. This process will be captured using the BPM+ set of standards and combined with the usage of the FHIR Consent resource.

Attendees will learn about:

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