Extending UML Activity Diagrams for Workflow Modelling with Clinical Documents in Regional Health Information Systems

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1 1160 Extending UML Activity Diagrams for Workflow Modelling with Clinical Documents in Regional Health Information Systems Stergiani Spyrou, Panagiotis Bamidis, Kostas Pappas, Nikos Maglaveras Lab of Medical Informatics, The Medical School, University of Thessaloniki, Central Macedonia, Greece Abstract Healthcare organizations are sufficiently rich in their infrastructure to handle the internal administrative and clinical processes, but the need to integrate the processes of geographically distributed and organizationally independent organizations is evident. Building business processes in the health care sector from a local process is a new challenge. We propose an extension of UML Language to model processes in the health care domain using workflow modelling techniques and examining interoperability concepts among heterogeneous environments. We extend the UML Activity Diagram to HWADD 1 diagram- to support workflow topics as well as standardized Clinical Documents that are handled by the processes. The diagram can be used to identify the activities in the processes in health care and also the resources for the execution of the activities. Adding also the concept of clinical documents the diagram can represent, in a sound way, the processes in a regional health network and the required resources in a homogenized way. A use case is described through the use of the HWADD and detailed work on the documents to be assigned in the diagram should be scheduled. Keywords: UML Activity Diagram; Regional Health Network Information System 1. Introduction There is currently an urgent need for Regional Health Authorities to deploy integrated healthcare information system, based on secure networks. The integration of existing information systems represents one of the most urgent priorities in order to meet the increasing clinical, organisational and managerial needs. The current approaches to achieve interoperability and integration are the adoption and implementation of (1) message oriented middleware and (2) workflow management systems in health care organizations. Combination of the two approaches can be summarized in the design of an interorganizational workflow management in healthcare enterprises, which is a subset of a framework for enterprise operation management. In order to be competitive in the dynamic marketplace hospitals in a regional health system need to deploy information technology solutions that internally automate the paper- 1 HWADD stands for Health Workflow Activity Document Diagram

2 1161 based medical record systems and externally create connections to achieve management of shared/distributed provision of health care services. This challenge leads the design of architecture of health information systems to combine the principles of Workflow Management Systems (WfMSs), and Middleware approaches to interoperability such as Message Oriented Middleware. We propose an extension of UML Language to model processes in the health care domain using workflow modeling techniques and examining interoperability concepts among heterogeneous environments. We extend the UML Activity Diagram to support workflow topics, as well as, standardized Clinical Documents that are handled by the processes. The diagram can be used to identify the activities in the processes in health care and also the resources for the execution of the activities. Adding also the concept of clinical documents the diagram can represent, in a sound way, the processes in a regional health network and the required resources in a homogenized way through the use of standards to represent the data to be exchanged (via clinical documents). Workflow management techniques are aiming at supporting business process across organization boundaries. Several approaches to modeling workflows have been proposed based on different workflow languages, methods and tools, some mentioned are the Object Coordination Nets, Workflow Graphs, Workflow Nets [1]. The Unified Modelling Language (UML), as the de facto standard in object-oriented modeling, is also used for workflow modeling. The importance of UML for workflow modeling is due to the fact that analysis and design of modern software engineering is closer to the area of business process modeling than to that of programming. The process of transmitting patient medical information between the departments of a health care organization in a Regional Health Network involves dealing with interoperability issues within a hospital information system infrastructure (HIS) as well as harmonizing documents to be exchanged in a regional level [2]. The processes that involve documents for patient care can be standardized and represented with workflow modelling concepts. A methodology to sort and achieve a common understanding in handling clinical documents between different healthcare practitioners and institutions in Regional Health Networks by using the Clinical Document Architecture (CDA) proposed by HL7 standards organization [3] was proposed in [4]. In this proposal the document identification is included in the CDA header and the CDA level attributes describe the content of the clinical documents to be exchanged. The structure of HL7 CDA document should be added in the proposed diagram. 2. Materials and Methods Activity diagrams describe the workflow behavior of a system. The diagrams describe the state of activities by showing the sequence of activities performed. The main reason to use activity diagrams is to model the workflow behind the system being designed, to analyze a use case by describing what actions need to take place and when they should occur, to describe a complicated sequential algorithm, to model applications with parallel processes without giving detail about how objects behave or how objects collaborate. The main concepts of Activity Diagrams, extracted from [5] are shown in Table 1:

3 1162 Table 1 Activity Diagram Concepts Concept Description Activity Ongoing non-atomic execution within a state machine. Activities ultimately results in some actions. Action An executable atomic computation that results in a change in state of the system or the return of a value. Transition Represents the flow of control between two activities. Object [State] A condition or situation during the life of the object. [guard] The conditions to implement a transition path. Event Reception A state that represents the execution of an atomic action, typically the invocation of an operation. SwimLane A partition of organizing responsibilities for activities. They often correspond to organizational units in a business-model. Stereotypes UML extension mechanism that allows the creation of new kind of building blocks and are specific for a particular problem. Not so many works using Activity Diagrams for workflow modeling can be found in the literature. In order to make the use of Activity Diagrams feasible with workflow modeling and increase its application in health business use-case model, we propose an extension of the diagram for Health Care Sector the HWADD - based on the proposed extension of Workflow Activity Diagram (WAD) presented in [5] and associated with the Workflow Management System (WfMS) concepts [6], [7]. The main concepts for workflow modeling as presented in [8] are summarized in Table 2. Concept Package Business Process Activity Workflow Relevant Data Role or Workflow Participant Invoked Applications Work Items Work List Transition Transition Condition Table 2 Workflow Management Concepts Description A formalized view of a business process, represented as a coordinated set of process activities. A set of one or more linked procedures or activities which collectively realize a business objective, normally within the context of an organizational structure defining functional roles and relationships. A description of a piece of work that forms one logical step within a process. An activity may be a manual activity, which does not support computer automation, or a workflow (automated) activity. Includes Data name and path, Data types A resource, which performs the work of a workflow activity instance. This work is normally manifested as one or more work items assigned to the workflow participant via the worklist. Computer tools/applications used to support an activity The representation of the work to be processed (by a workflow participant) in the context of an activity within a process instance. A list of work items associated with a given workflow participant. A point during the execution of a process instance where one activity completes and the thread of control passes to another. A logical expression to decide the sequence of activity execution

4 1163 The main contribution of the extended diagram is the integration of both enterprise and workflow modeling concepts. In order to ease the use of Activity Diagrams with the WfMS concepts and Clinical documents, the HWADD includes concepts from the association of Activity Diagram elements with WfMS classes using stereotypes and defining some new properties. Each element in the new Diagram is represented by a stereotype in order to establish the relationship with a WfMS class as shown in Table 3. The set of workflows and the set of documents data to be recorded- are required to be added in specific points in the workflow. The associated documents in the workflow should be added as shaded rectangles to represent documents involved in the workflow. The clinical document is represented as a stereotype with the notation { HL7 CDA Doc } and using a specific shape as shown in the diagram in figure 1. Table 3 Main elements of Activity Diagrams and the related classes Activity Diagram WfMS Element Comments Element SwimLane Domain,Package The organizational unit where the business process or activities that compose a domain process are executed. Activity Business Process Activity (Automated Activities) The main components of the Diagram Transition Pre- and post- activity Behavioral Rules conditions /Transition [guard] Transition Conditions Represents the Business Process Rule Object Workflow Relevant Data The data, represented by classes. Not include in the Diagram, except for the clinical Document Object Flow Event, Functional Entity Is specialized in three classes: Application, Workflow Participant <<New Stereotype>> Role/ Entity / Workflow New stereotype for these Participant elements <<New Stereotype>> Invoked Applications New stereotype for these elements The objects are represented through the stereotype name showed as text strings surrounded by guillements (<< >>) placed in the object symbol. Thus the main stereotyped classes are: (1)<<Event>>: Events are triggering Domain Processes. An event is an external input generated by an actor to a use case, (2)<<Workflow Participant>>: Represent the Participant or the Role involved with the Functional Operations execution, (3): Represents software application identified by UML Packages and the respective object related with the workflow activity. The representation of an object with the related Application is as follows: <Object Name>: <Application Name (package)>:: <Class Name> for example d: ADTSystem:: discharge, where ADT stands for the Admission-Discharge- Transfer application. An Enterprise Activity has the same representation as the activity in UML Activity Diagram. For the execution of an Enterprise Activity it is necessary to have one or more Functional Entities. The objects represents the objects of the information system that are produced or destroyed by an Enterprise Activity [5]. In order to represent the object flow special notation shown in the diagram in figure 1 is used, where

5 1164 each Functional Entity and mainly the concludes in their representation the Object State since this represents the state of the object during its execution. The object state is optional. Since the objects belong to a software application, the Operations are implemented by methods of these objects at the information system. Objects can be output of one activity and input of many other activities except for the <<WorkFlowParticipant>>, which always are input objects for the activities. Those are the main elements of the new type of Activity Diagram. 3. Results In 2001 a reform of the Greek National Healthcare System was introduced and one of the main changes was the division of the country in seventeen Healthcare Regions namely the Regional Healthcare Authorities (RHA). In order to support this reform an Information System for each RHA was designed which consists of a series of subsystems covering the information and data workflow management in a regional healthcare system. The processes and the related documents of the Regional Health Network have already been recorded for the health units and the next step is to be homogenized to achieve interoperability in RHA. HWADD can be used to model the use cases of the above information system. In figure 1, a use case of Patient Transfers among health units especially hospitals is represented. The use case of Patient Transfer chosen as it constitutes a multi-process example, where many participants (Human, Application, Machine etc) are involved and finally it is a general example of a cross-organisational need for communication Hospital Regional Health Authority Remote Hospital <<Event>> ev: RequestTransportation Update RHS for patient transfer r: RIS::SychronizePIDs [request PID] Request Admission to remote Hospital <<Role-System>> r:requestadmission d: ADTsystem::Discharge [in progress] Request Transportation Call patient lookup service to sychronize pids r: RIS::SychronizePIDs [PID created] [No] [Doctor approved admission] a: ADTSystem::Admission d: ADTsystem::Discharge [scheduling] h: HL7System::CDAHL7Msg [sending] [Head of clinic approved?] Discharge patient [No] [Patient exists in the RHS database (according to the profile)] Update Patient Data in RIS [No] Add New Patient in RIS Admit patient h: HL7System::ReceiveHL7Msg Import Patient Data (HL7 CDA msg) { HL7 CDA Doc} Export Patient Data (HL7 CDA msg) { HL7 CDA Doc} h: HL7System::HandleHL7Msg h: HL7System::ReceiveHL7Msg [query for acknowelge] { HL7 CDA Doc} Update HIS for transfer h: HL7System::SendHL7Msg [PID imported in HL7msg] [Caller is the remote hospital] Update remote HIS for transfer Return PID to the chosen Patient profile h: HL7System::ReceiveHL7Msg Cancel Transportation h: ADTsystem:::Admission [canceled] End of Transportation Figure 1 - The use case: Patient Transfers in a Regional Health System The application of the diagram to other scenarios on the phase of design of the information system will help in identifying the requirements of the system. Moreover elaborating the diagram may be useful in the identification of the documents that are exchanged through the health units.

6 Conclusions The main goal of HWADD is to help designers and analysts of an Information System for the Regional Health Authority to: describe the workflow model as a set of use cases using the Workflow modelling concepts represent graphically the association of resources need to implement an activity improve the Activity Diagram applying the principles of workflow modelling describe the exchange of documents and especially the clinical documents to achieve a satisfying level of integration even among legacy systems on a regional level associate the software applications with the activities that composes each use case Each use case identified at the business-model can be described by a HWADD. The diagram can help the efforts to implement a Regional Heath Network dealing of course with the need to interoperate among health units. Our next steps are to describe the clinical documents in a more detailed way and combine the use of HWADD with the class diagram for documents. In this way one may obtain a clear picture of the nodes that provide or use information in the health network. 5. References [1] Wil M.P. van der Aalst, Mathias Weske, Guido Wirtz, Advanced Topics in Workflow Management: issues, requirements, and solutions, Transactions of the SDPS, Journal of Integrated Design and Process Science, March 2003, Vol.7, No. 1, pp [2] S. Spyrou, A. Berler, P. Bamidis, Information System Interoperability in a Regional healthcare System Infrastructure: a pilot study using healthcare Information standards, Proc. Of MIE 2003, Saint Malo, France, pp , IOS Press, [3] HL7 Internet sources: site visited [4] S.S. Spyrou, A.Berler, P.Aggelidis, Integration of Healthcare Information Systems: steps towards common clinical documents, 2nd International Conference on Information Communication Technologies in Health, 8-9 June 2003, Samos Island,Creece [5] Ricardo M. Bastos, Duncan Dubugras A.Ruiz, Extending UML Activity Diagram for Workflow Modeling in Production Systems, Proceedings of the 35th Hawaii International Conference on System Sciences 2002 [6] S.C. Cheung, Dickson K.W. Chiu, Sven Till, Data-driven Methodology to Extending Workflows to E-Services over the Internet, Proceedings of the 36th Hawaii International Conference on System Sciences (HICSS 03) [7] Sistine A. Barretto, BIT (hons), Jim Warren, Andrew Goodchild, Designing Guideline-based Workflow-enabled Electronic Health Records, Proceedings of the 37th Hawaii International Conference on System Sciences 2004 [8] Workflow Management Coalition, The Workflow Reference Model, Document Number TC , Document Status - Issue 1.1, 19-Jan-95, David Hollingsworth Address for correspondence Stergiani Spyrou, Phd Student, Lab of Medical Informatics, The Medical School, Aristotelean University of Thessaloniki, Tel: , Fax: spirou@med.auth.gr,

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