Mental Health

Workflow, Pathways and Journeys

Another issue with record transfer messaging is its focuses on the EHR record. Before modern technology (1990's onwards), interactions between practitioners especially in different care settings was via letters. From 1990's we started to see technical splitting this into:

• Systems being used to record EHR data.
• Messaging being used to support the workflow and care coordination between providers. This was mostly around Health Administration and pathology (as HL7 v2).

record transfer messaging has been and continues to be developed. The clinical process shown in the diagram below tends to be a high level view.

This diagram uses Business Process Model and Notation to describe the workflow. BPMN diagrams often show a sequence of interconnected processes. In this diagram we have chosen to represent a high-level process which takes in

• input which is information required to perform the task. In record transfer this is usually a large EHR record extract. For example, a referral letter.
• output which is the information output from the task and is normally used to pass information to the next task. For example, a discharge or outpatient letter.

A practitioner performing this task will also use other resources to help perform the task. For example, a Shared Care Record (SCR). While they are performing the task, they will record what has taken places in local EHR records.

Potential uses of standards are shown alongside these. Note this is showing competing standards on both input and output. PRSB is another standard which applies here.

This view of process is high level, focused around both transfer of care and stays/episodes. In practice, health and care is a collection of many tasks which tend to revolve around individual encounters. For example:

If Dawn had been attending Marge in her NHS role, she would have would retrieve Marge's summary from her NHS Trusts EPR system and/or Yorkshire and Humberside Care Record (YHCR), a Health Information Exchange (HIE) (input). The measurements and evaluation would have been recorded in the EHR (activity). A HL7 v2 ADT_A04 event message would have automatically been generated to inform other practitioners and systems of the event (output). Dawns NHS Trust is Mid Yorkshire and so the encounter notification messages are sent to Marge's GP Practice using NHS England HL7 v2 ADT Messaging standard which the trusts EPR supports. Marge's GP would have been notified of the event and could review the encounter in the YHCR HIE.

YHCR HIE and the EHR records it adhere to the INTEROPen (supported by NHS England) HL7 FHIR STU3 CareConnectAPI standard. This is a vendor neutral open API standard, for FHIR R4 versions see Query API

The separation of records and workflow is a natural pattern. Here the BPMN inputs change definitions.

• input is either responding to an event (e.g. Patient Admitted, High Blood pressure observation) or a request
• output is normally a series of events (e.g. Patient Discharged, Patient demographics updated)
• reviewing patients and recording new EHR data items takes part during the activity. It does not form part of the input or output (unless EHR systems are not available).

However, the big point is where the standards are now applying. openEHR, HL7 v3 and FHIR are no longer competing but complementing each other. We also see the introduction of IHE standards to support the workflow. On shared care records, IHE has been introduced to define how FHIR should be used to help share records, openEHR is both a definition and system which implement health records. HL7 v2 has been reintroduced to provide health administration process support.

Most importantly we have refocused the problem around practitioners, patient and associated clinical processes and not around transferring health records.

This pattern can be repeated again and again on the different stages of a patient's pathway and journey.

ReSPECT notes

All three types of records can be found within the NHS. They all can be found on a single patient pathway.

For example, vital signs observations (resources) collected from a patient PHR or bedside vital signs monitoring equipment can be used to auto complete a template. A completed template may result in vital sign observations being created (resources). When shared with other providers both of these may result in Observation Chart being created and this is stored as a document.

This mix of record types is also present on different stages of Roberts journey. His journey was all about interoperability but this is a very generic term and this can lead to considerable confusion.

From a regional or local perscpective we can break down interoperability into five categories, again all of these apply to Roberts journey.

• Command 'pagelink' could not render: Page not found.
  discusses the systems used within a typical NHS Hospital and electronic communication which is used to syncronise health administration between these systems. (HL7 v2)
• Command 'pagelink' could not render: Page not found.
  discusses the standards for recording health data and standards+systems used to access these records. (HL7 FHIR Profiles (UK Core), DICOM, openEHR and IHE XDS/MHD/QEDM)
• Command 'pagelink' could not render: Page not found.
  discusses standards used to coordinate care between the providers on a patients journey. (IHE and FHIR Workflow)
• Command 'pagelink' could not render: Page not found.
  Looks at template/form data entry and possible options for standardisation. (openEHR and FHIR Structured Data Capture)
• Command 'pagelink' could not render: Page not found.
  Looks at structured clinical documents which are typically used to provide patient summaries and summary of care (also known as transfer of care). (PRSB and FHIR Documents)

From a NHS England perspective which tends to focus on standards, we have:

THIS IS A WORK IN PROGRESS AND HAS NOT BEEN AGREED. THIS IS PURPOSELY NOT USING NHS ENGLAND DIGITAL DEFINITIONS OF

• RECORD
• REQUEST
• EVENT

AND SWAPPING INSTEAD TO NHS ENGLAND CLINICAL AND NHS TERMINOLOGY. I.E. MOVING FROM TECHNICAL TO CLINICAL PATHWAYS (AND ENGLISH NHS VIEW ON TECH)

In addition we have several organisations looking to bring this all together.