Process Automation in Telemedicine - Improving Efficiency

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Process Automation in Telemedicine:
Improving Efficiency
Presented by Baxter SpA
With the participation of Universita Cattolica
Dr. John Svirbely, MD
Chief Medical Informatics Officer (CMIO),
jsvirbely@Trisotech.com
Denis Gagne
Chief Executive Officer (CEO),
dgagne@Trisotech.com

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Abstract
Trisotech Telemedicine Webinars Series
presented with Baxter SpA
Telemedicine is the practice of medicine using technology to deliver care at a distance. While telemedicine and its use are not new,
widespread adoption beyond simple telephone exchanges has been relatively slow. However, the current pandemic has forced
rethinking of how health care is delivered, while, new developments in technology have made remote care more accessible.
In this webinar series we will explore the application of the BPM+ Health set of standards to Telemedicine and the benefits that can
be expected. More specifically, we will explore how automation of telemedicine can improve efficiency, improve care, and reduce
risk.
Webinar 1: Process Automation in Telemedicine: Improving efficiency.
Moving beyond phone banks, this webinar will provide a brief introduction to telemedicine and explore the benefits of automation
applied to telemedicine using the BPM+ Health set of open standards. A demonstration of an automated nurse teletriage pathway
for an ill-appearing infant will be presented.
Presented by:
Dr. John Svribely, CMIO Trisotech
Denis Gagne, CEO & CTO Trisotech
PROCESS AUTOMATION IN TELEMEDICINE: IMPROVING EFFICIENCY

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Introduction to Telemedicine

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What is Telemedicine?
 Telemedicine may use a range of
technologies, depending on the need, use
and sophistication.
 Telemedicine may be stand-alone but is
much more useful when integrated into the
patient’s overall care.
Telemedicine/Telehealth
• Telemedicine is the
delivery health care at a
distance using
telecommunications.

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Technology in Telemedicine
 Technologies that may be used in
Telemedicine have evolved over time:
Telephone
emails
Bidirectional
video
Device
interface for
data exchange
Robotic
control

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Benefits andDisadvantages of Telemedicine
Benefits
 Convenient for people who find it difficult to travel
or who are unable to do so
 Safer in a pandemic
 Potentially more efficient of time and resources
 Can provide access to otherwise unavailable
expertise (teledermatology, telesurgery)
 Able to close blind spots in standard care delivery
and to catch things early before they progress
Disadvantages
 May be limited by poor communication quality
 Disparities between haves and have-nots
 May be difficult to develop rapport
 May have gaps in confidentiality
 Subtleties of body language, etc. may be missed

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Accelerationof
telemedicine
 The global COVID-19 crisis created a pivotal moment
that accelerated the adoption of telemedicine.
 Healthcare providers have increased their telemedicine
use for non-urgent or non-essential care.
 Many in the healthcare industry agree that these
technologies will likely be more widely used than they
were before.
Process Automation in Telemedicine: Improving efficiency

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Introduction to Business Process
Automation

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Marryingtwo sets of standards
www.OMG.org www.HL7.org

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© 2020 Object Management Group
Established to foster the sharing and
promulgation of best-practices around
modeling and sharing:
• shareable pathways,
• clinical pathways,
• automatable clinical guidelines, and
• other healthcare knowledge
A robust and thriving community-of-
practice of healthcare institutions,
professional societies, and vendors
www.BPM-Plus.org

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Setting some BasicTerminology
Workflow
Automation
Decision
Automation
Open Standards
DMN
(DECISION MODEL AND NOTATION)
Decision tables and logical expressions
BPMN
(BUSINESS PROCESS MODEL AND NOTATION)
Prescriptive sequence of activities
CMMN
(CASE MANAGEMENT MODEL AND NOTATION)
Declarative unstructured event-condition-action
Technology enabled
orchestration of activities, able
to react to business events.
Both may have humans in the loop or not.
(Referred to as Knowledge Workers.)
Technology enabled decisions,
returning answers given some
inputs.

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Overview

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Benefits of BPM+ Health
Automatable ClinicalDecisionsandWorkflows
Rapid access
to evidence-
based best
practices
Standardized
clinical
pathways
Better
coordination
of patient
care
Visual story
of the
patient's
progress
Better
decisions at
point of care
Provides
data in
context
Better
clinical and
financial
outcomes
Improved
organizational
and operational
efficiency

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Nurse Teletriage of the
Ill-Appearing Infant
Bringing Telemedecine and Business Process Automation
Together

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Nurse Teletriageof the Ill-AppearingInfant
Current operationalissues
Personnel requirements:
• licensed nurses
Access:
• by telephone at a call center
Scheduling:
• need to have sufficient nurses to
ensure an acceptable response time
Challenges:
• need to be able to adapt to variable
call volumes, including surge
handling
Duties:
• The nurse typically performs all
tasks (information collection,
assessment, triage, referral).
Decision-making:
• often prescribed by evidence-based
protocols which may be printed or
on-line

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Nurse Teletriageof the Ill-AppearingInfant
With automation
Need to go beyond the phone bank where
nurses perform all of the required tasks……
 Can some tasks be done by non-nurses? Or
by bots?
 Can you provide the same or better service
with fewer nurses?
 Can you use remote patient monitoring to
collect reliable data?
 Can existing data on the patient be
automatically collated from various EHRs?
 Can the patient provide much of the required
information before talking to a nurse?

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Narrative:
Nurse TriageProtocol: Ill-Appearing Infant (Age1-12 Months)
Findings Critical Acute Urgent Nonurgent
Respiratory distress Severe Moderate Mild None
Dehydration Severe Moderate Mild None
Temperature Hypothermia >= 41°C any age; >=
38°C if < 10 weeks old
>= 38°C in infant 10-12
weeks old
Normal; 38-40.9°C in
infant > 12 weeks old
Level of consciousness Stupor or coma Listless or lethargic;
inconsolable
Irritable but consolable Awake, alert, consolable
Vital signs Any critical All stable
Vomiting Bilious or ”coffee
grounds”
Profuse None or intermittent
Diarrhea Bloody or currant jelly None or intermittent
Other Severe pallor; petechial
rash with fever
Recent seizure; jaundice;
distended abdomen; stiff
neck; generalized edema
Unexplained bruising;
failure to thrive

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Methodology:ModelingBest Practices
Computational
Independent Model
(CIM)
Platform Independent
Model
(PIM)
Platform Specific
Model
(PSM)
Narrative
FHIR® enabled
BPMN, CMMN, DMN
Services
Add data types and
logical expressions
SME
Capture Narrative into
Models
Add bindings to
specific data source
(Create FHIR
wrapper)

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ComputationalIndependent Model(CIM)
Nurse TriageProtocol: Ill-Appearing Infant (Age1-12 Months)

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Platform Independent Model (PIM)
NurseTriage Protocol:Ill-Appearing Infant(Age 1-12 Months)

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Nurse Teletriage of
the Ill-Appearing Infant
Demo

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How can we improve efficiency?
Task Historical Approach Automated Approach
Collect pertinent information Nurse takes down verbally Initial information taken by automated digital assistant
Record current vital signs Nurse takes down verbally, may be unreliable Remote device monitoring
Contacting pediatrician on call Call Secure text message for asynchronous communication
Scheduling office visit Parents to call office next day Scheduling app
Recommendation to go to ED Verbal "go to ED" by nurse Program determines appropriate setting based on
distance, insurance, wait times and expertise
Recommendation for emergency transport “Call 911” Direct message to squad with required information
Transmission of episode findings to point of care Call point of care and verbally give information Digital transmission in a FHIR format
Follow-up Manual Digital tracking of episode
Quality assurance Retrospective Real-time

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Conclusions
 We introduced some telemedicine concepts
o Well-structured protocols are ideal for automation
 We introduced the BPM+ Health open standards
o Introduced a methodology to go from a protocol narrative to an executable model
o BPM+ Health models are both human readable and machine automatable
 Presented and demoed a model that improves efficiency
o Not giving up control for the sake of efficiency using attended tasks

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Any questions?
THANKS!
Dr. John Svirbely, MD
Chief Medical Informatics Officer (CMIO),
jsvirbely@Trisotech.com
Denis Gagne
Chief Executive Officer (CEO),
dgagne@Trisotech.com

Process Automation in Telemedicine - Improving Efficiency

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