openEHR Process Examples
| Issuer: openEHR Specification Program | |
|---|---|
Release: PROC latest |
Status: DEVELOPMENT |
Revision: [latest_issue] |
Date: [latest_issue_date] |
Keywords: process, task planning, decision logic, examples, workflow |
|
| © 2017 - 2020 The openEHR Foundation | |
|---|---|
The openEHR Foundation is an independent, non-profit foundation, facilitating the sharing of health records by consumers and clinicians via open specifications, clinical models and open platform implementations. |
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Licence |
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Support |
Issues: Problem Reports |
Acknowledgements
1. Preface
1.1. Purpose
This document contains elaborated examples of the openEHR Process framework, including Task Plans and Decision Logic Modules, with diagrams in TP-VML.
The intended audience includes:
-
Plan and Guideline authors;
-
Tool vendors.
1.3. Status
This specification is in the DEVELOPMENT state. The development version of this document can be found at https://specifications.openehr.org/releases/PROC/latest/process_examples.html.
Known omissions or questions are indicated in the text with a 'to be determined' paragraph, as follows:
TBD: (example To Be Determined paragraph)
1.4. Feedback
Feedback may be provided on the process specifications forum.
Issues may be raised on the specifications Problem Report tracker.
To see changes made due to previously reported issues, see the PROC component Change Request tracker.
2. Overview
3. Teamwork
The examples in this section illustrate the use of TP for team-based work plans, including hand-offs, callbacks and other kinds of coordination.
3.1. Out-patient Eye Clinic Encounter
This example is based on the original description of DIPS Eye encounter example.
3.1.1. Plan Overview
As for all Plans defined in the Task Planning formalism, it must be remembered that the Plan definition above is what the TP engine executes. It is the result of the execution (including worker allocation and communication, which is not shown in the definition) that causes workers in the real world to do things. Additionally, what the TP engine knows about the real world is limited to what it is told - many actions and events can occur outside the TP computing environment that will remain unknown to the system unless it is informed (e.g. by Manual notification).
The Work Plan consists of two top-level Task Plans, one for the patient and one for the clinic administrator / reception. The latter has two sub-plans linked by hand-off Tasks.
The purpose of the patient top-level Task Plan is to allow the system to notify the patient of the visit, via a reminder on the day of the visit, or some fixed time beforehand. The driving event is the calendar appointment, which is waited on by both the patient and the clinic admin Task Plans. It is assumed that longer term reminders, opportunities for changing appointments and so on are managed by another system that see the same calendar events, and is responsible for setting the calendar events in the first place. Thus, in the model above, the patient top-level plan is not really necessary (he/she will be notified by the appointment system), and is mainly included for purposes of demonstration.
3.1.2. Detailed Description
The main work of the Work Plan is in the other three Task Plans, which essentially encode the following logic:
Clinic Administrator:
-
clinic has a live Task Plan waiting on appointment A for patient P, at 2019-02-15 09:30:00;
-
when this calendar timepoint is reached, the TP system 'opens' the appointment via a System Request to the clinic appointment system (details not shown);
-
WAIT: the clinic Task Plan enters a new wait state for patient P, for appointment A;
Patient:
-
patient arrives at clinic (modelled as a Manual notification);
Clinic Administrator:
-
receive patient, record presence;
-
Hand-off: pass to consultation (e.g. send to waiting area);
-
WAIT: until manual notification (patient returns)
Nurse:
-
receive patient & check EMR
-
review eye function, decide on whether to send to doc or not:
-
EITHER: return to reception
-
OR: pass to doctor
-
Specialist:
-
receive patient and check EMR
-
perform examination
-
update EMR
-
send patient back to reception.
4. Order Management
The examples in this section illustrate the use of TP for order management, where openEHR Instructions and Actions (or other non-openEHR equivalents) are created and tracked.
4.1. Order Coordination
This example is based on a standard Moscow City clinic protocol, and covers a 12 month period.
4.1.1. Plan Overview
The Work Plan shown above defines the tasks for a 'standard health check' that includes a chest x-ray, a full blood panel and a hypertension checkup. The Plan executes over the periof a year, and consists of a health coordinator creating orders for the three items, via UI forms. The result of creating these orders will be the creation of a normal Composition and Instruction in the openEHR EHR for the patient. At some later point in time, the coordinator will action these orders, which will cause the EHR data to be used to create appropriate API calls / messages to the relevant target systems (radiology clinic, pathology lab, consultant) that will further cause appointments and attendances in the normal way by the patient. Each of these 'execute order' Tasks will block and wait for appropriate callbacks resulting from each of the orders being fulfilled and corresponding Actions being committed to the EHR (or else timeouts, if nothing happens). With the received results, the coordinator creates a health summary for the patient and commits that to the EHR.
5. Multi-drug Chemotherapy
This section illustrates multi-drug chemotherapy with complex dosing and timing arrangements.
This example is based on the version of RCHOPS-21 documented by NHS Thames Valley Cancer Network.
5.1. Limitations
The following elements of the plan are not yet included (mainly for brevity of the example):
-
Vincristine dose modification due to hepatic impairment;
-
Concurrent meds only shown in summarised form;
-
Exception pathways to handle patient reactions not shown.
5.2. Plan Definition
The following shows the pre-medication phase.
The following shows the main regime, including conditional addition of Rituximab / methotrexate for high IPI patients.
5.3. RCHOPS21 Decision Logic Module
dlm RCHOPS21
language
original_language = <[ISO_639-1::en]>
description
lifecycle_state = <"unmanaged">
original_author = <
["name"] = <"Dr Spock">
["organisation"] = <"Acme healthcare">
["date"] = <"2020-03-22">
>
details = <
["en"] = <
language = <[ISO_639-1::en]>
purpose = <"NHS CHOPS-21 chemotherapy guideline ....">
>
>
use
BSA: Body_surface_area
preconditions
has_lymphoma_diagnosis
reference
paracetamol_dose: Quantity = 1g
chlorphenamine_dose: Quantity = 10mg
prednisolone_dose_per_m2: Quantity = 40mg
rituximab_dose_per_m2: Quantity = 375mg
doxorubicin_dose_per_m2: Quantity = 50mg
vincristine_dose_per_m2: Quantity = 1.4mg
cyclophosphamide_dose_per_m2: Quantity = 750mg
cycle_period: Duration = 3w
cycle_repeats: Integer = 6
input -- Diagnosis
has_lymphoma_diagnosis: Boolean
time_window = tw_current_episode
staging: Terminology_term «ann_arbor_staging»
currency = 30 days
time_window = tw_current_episode
has_metastases: Boolean
currency = 30 days
time_window = tw_current_episode
input -- Labs
neutrophils: Quantity
currency = 3d
ranges =
----------------------------------
[normal]: |>1 x 10^9/L|,
[low]: |0.5 - 1 x 10^9/L|,
[very_low]: |<0.5 x 10^9/L|;
----------------------------------
platelets: Quantity
currency = 12h
ranges =
----------------------------------
[normal]: |>75 x 10^9/L|,
[low]: |50 - 74 x 10^9/L|,
[very_low]: |<50 x 10^9/L|;
----------------------------------
bilirubin: Quantity
currency = 12h
ranges =
----------------------------------
[normal]: |<20 mmol/L|,
[high]: |20 - 51 mmol/L|,
[very_high]: |51 - 85 mmol/L|,
[crit_high]: |>85 mmol/L|;
----------------------------------
gfr: Quantity
currency = 24h
ranges =
----------------------------------
[normal]: |>20 mL/min|,
[low]: |10 - 20 mL/min|,
[very_low]: |<10 mL/min|;
----------------------------------
ldh: Quantity
currency = 24h
ranges =
----------------------------------
[normal]: |>20 mL/min|,
[low]: |10 - 20 mL/min|,
[very_low]: |<10 mL/min|;
----------------------------------
rules -- Conditions
high_ipi:
Result := ipi_risk ∈ {[ipi_high_risk], [ipi_intermediate_high_risk]}
rules -- Main
|
| patient fit to undertake regime
|
patient_fit:
Result := not
(platelets.in_range ([very_low]) or
neutrophils.in_range ([very_low]))
prednisolone_dose: Quantity
Result := prednisolone_dose_per_m2 * BSA.bsa_m2
rituximab_dose: Quantity
Result := rituximab_dose_per_m2 * BSA.bsa_m2
doxorubicin_dose: Quantity
Result := doxorubicin_dose_per_m2 * BSA.bsa_m2
* case bilirubin.range in {
===================
[high]: 0.5,
[very_high]: 0.25,
[crit_high]: 0.0
===================
}
|
| TODO: hepatic impairment dose modification
|
vincristine_dose: Quantity
Result := vincristine_dose_per_m2 * BSA.bsa_m2
|
| CHECK: is low platelets and GFR dose modification
| cumulative?
|
cyclophosphamide_dose: Quantity
Result := cyclophosphamide_dose_per_m2 * BSA.bsa_m2
* case platelets.range in {
===================
[normal]: 1,
[low]: 0.75
===================
}
* case gfr.range in {
===================
[normal]: 1,
[low]: 0.75,
[very_low]: 0.5
===================
}
|
| International Prognostic Index
| ref: https:|en.wikipedia.org/wiki/International_Prognostic_Index
|
| One point is assigned for each of the following risk factors:
| Age greater than 60 years
| Stage III or IV disease
| Elevated serum LDH
| ECOG/Zubrod performance status of 2, 3, or 4
| More than 1 extranodal site
|
| The sum of the points allotted correlates with the following risk groups:
| Low risk (0-1 points) - 5-year survival of 73%
| Low-intermediate risk (2 points) - 5-year survival of 51%
| High-intermediate risk (3 points) - 5-year survival of 43%
| High risk (4-5 points) - 5-year survival of 26%
|
ipi_raw_score: Integer
Result.add (
---------------------------------------------
age > 60 ? 1 : 0,
staging ∈ {[stage_III], [stage_IV]} ? 1 : 0,
ldh.in_range ([normal]) ? 1 : 0,
ecog > 1 ? 1 : 0,
extranodal_sites > 1 ? 1 : 0
---------------------------------------------
)
ipi_risk: Terminology_code
Result :=
case ipi_raw_score in {
=======================================
|0..1| : [ipi_low_risk],
|2| : [ipi_intermediate_low_risk],
|3| : [ipi_intermediate_high_risk],
|4..5| : [ipi_high_risk];
=======================================
}
terminology
term_definitions = <
["en"] = <
["paracetamol_dose"] = <
text = <"paracetamol dose">
description = <"paracetamol base dose level per sq. m of BSA">
>
["chlorphenamine_dose"] = <
text = <"chlorphenamine dose">
description = <"chlorphenamine base dose level per sq. m of BSA">
>
...
["staging"] = <
text = <"Cancer staging">
description = <"Cancer staging (Ann Arbor system)">
>
["has_metastases"] = <
text = <"Metastatic status">
description = <"Status of metastasis of cancer">
>
...
["neutrophils"] = <
text = <"neutrophils">
description = <"neutrophils level">
>
["platelets"] = <
text = <"platelets">
description = <"platelets level">
>
...
["ipi_low_risk"] = <
text = <"low risk: 5y survival - 73%">
description = <"..">
>
["ipi_intermediate_low_risk"] = <
text = <"intermediate-low risk: 5y survival - 51%">
description = <"..">
>
["ipi_intermediate_high_risk"] = <
text = <"intermediate-high risk: 5y survival - 43%">
description = <"...">
>
["ipi_high_risk"] = <
text = <"high risk: 5y survival - 26%">
description = <"...">
>
>
>
6. Antenatal Care
6.1. Pregnancy Risk Assessment DLM
dlm ruleset Obstetric_pregnancy
preconditions
is_pregnant
input
is_type1_diabetic: Boolean
previous_obstetric_hypertension: Boolean
previous_pre_eclampsia: Boolean
previous_eclampsia: Boolean
previous_gestational_diabetes: Boolean
family_history_of_diabetes: Boolean
race_related_diabetes_risk: Boolean
input -- <time_window = tw_previous_episode>
previous_macrosomic_baby: Boolean
input -- <time_window = tw_current_episode>
is_pregnant: Boolean
has_gestational_diabetes: Boolean
has_pregnancy_hypertension: Boolean
has_pre_eclampsia: Boolean
has_eclampsia: Boolean
has_anaemia_of_pregnancy: Boolean
bmi: Quantity
ranges =
------------------------------------
[high]: |>30 kg/m^2|,
[normal]: |>=15 .. <= 30 kg/m^2|,
[low]: |< 15 kg/m^2|;
------------------------------------
input
amniotic_fluid_state: Terminology_term
currency = 24h
uterine_fundal_height: Quantity
currency = 24h
vaginal_blood_flow: Quantity
currency = 30mins
ranges =
[critical_high]: |> 500 mL/hr|
input -- <source = "manual">
haemorrhage: Boolean
contractions_commenced: Boolean
braxton_hicks_contraction: Boolean
amniotic_volume: Real
ranges =
------------------------------------
[polyhydramnios]: |> 14|,
[normal]: |>= 5 .. <= 14|,
[oligohydramnios]: |< 5|;
------------------------------------
rules
anaemia_type: Terminology_term
Result := not has_anaemia_of_pregnancy ? [excluded] : [anaemia_of_pregnancy]
risk_evaluation: Terminology_term
....
amniotic_fluid_risk: Terminology_term
Result := case amniotic_fluid_state in {
====================================================
[premature_rupture],
[polyhydramnios]: [obstetric_emergency],
----------------------------------------------------
[oligohydramnios]: [refer_high_risk_care],
----------------------------------------------------
*: [normal_obstetric_care]
====================================================
}
hypertension_risk: Terminology_term
Result := choice of {
============================================================
has_pre_eclampsia or
has_eclampsia: [obstetric_emergency],
------------------------------------------------------------
previous_obstetric_hypertension or
previous_pre_eclampsia or
previous_eclampsia or
has_pregnancy_hypertension: [refer_high_risk_care],
------------------------------------------------------------
*: [normal_obstetric_care]
============================================================
}
gestational_diabetes_risk: Boolean
Result :=
bmi.in_range ([high]) or
previous_macrosomic_baby or
previous_gestational_diabetes or
family_history_of_diabetes or
race_related_diabetes_risk
anaemia_risk: Terminology_term
Result := case anaemia_type in {
========================================================
[severe_anaemia_of_pregnancy]: [obstetric_emergency],
--------------------------------------------------------
[anaemia_of_pregnancy]: [refer_high_risk_care],
--------------------------------------------------------
*: [normal_obstetric_care]
========================================================
}
terminology
term_definitions = <
["en"] = <
["normal_obstetric_care"] = <
text = <"Normal obstetric care">
description = <"...">
>
["obstetric_emergency"] = <
text = <"Obstetric emergency">
description = <"...">
>
["refer_high_risk_care"] = <
text = <"Refer to high risk care">
description = <"...">
>
["premature_rupture"] = <
text = <"Premature rupture of membranes">
description = <"...">
>
["polyhydramnios"] = <
text = <"polyhydramnios">
description = <"...">
>
["oligohydramnios"] = <
text = <"oligohydramnios">
description = <"...">
>
["severe_anaemia_of_pregnancy"] = <
text = <"anaemia of pregnancy, severe">
description = <"...">
>
["anaemia_of_pregnancy"] = <
text = <"anaemia of pregnancy">
description = <"...">
>
["amniotic_fluid_risk"] = <
text = <"Risk of pregnancy-related amniotic fluid">
description = <"...">
>
["hypertension_risk"] = <
text = <"Risk of pregnancy-related hypertension">
description = <"...">
>
["diabetes_risk"] = <
text = <"Risk of pregnancy-related diabetes">
description = <"...">
>
["anaemia_risk"] = <
text = <"Risk of pregnancy-related anaemia">
description = <"...">
>
["previous_macrosomic_baby"] = <
text = <"Baby weighing 4.5kg or above">
description = <"...">
>
["previous_gestational_diabetes"] = <
text = <"xxx">
description = <"...">
>
>
>
7. Breast Cancer Decision Protocol
7.1. Decision Logic Module
dlm guideline Oncology_breast_cancer.v0.5.0
input
tnm_t: String
currency = 60 days
tnm_n: String
currency = 60 days
tnm_m: String
currency = 60 days
tnm_g: String
currency = 60 days
estrogen_receptor: Terminology_term «pos_neg_vs»
currency = 60 days
progesterone_receptor: Terminology_term «pos_neg_vs»
currency = 60 days
her2_expression: Terminology_term «pos_neg_vs»
currency = 60 days
ki67: Quantity
currency = 60 days
ranges =
-------------------
[high]: |>= 14%|,
[normal]: |< 14%|;
-------------------
ejection_fraction: Quantity
currency = 60 days
ranges =
--------------------
[normal]: |>= 40%|,
[low] : |< 40%|;
--------------------
has_heart_failure_class_II: Boolean
has_heart_failure_class_III: Boolean
has_heart_failure_class_IV: Boolean
has_allergy_to_taxanes: Boolean
rules -- Conditions
er_negative:
Result := estrogen_receptor = [negative]
er_positive:
Result := estrogen_receptor = [positive]
pr_negative:
Result := progesterone_receptor = [negative]
pr_positive:
Result := progesterone_receptor = [positive]
her2_negative:
Result := her2_expression = [negative]
her2_positive:
Result := her2_expression = [positive]
has_non_class_I_heart_failure:
Result := has_heart_failure_class_II
or has_heart_failure_class_III
or has_heart_failure_class_IV
anthracyclines_contraindicated:
Result := has_transmural_MI
or ejection_fraction.in_range ([low])
or has_non_class_I_heart_failure
taxanes_contraindicated:
Result := is_type1_diabetic
or has_allergy_to_taxanes
or has_intolerance ([taxanes])
rules -- Guideline
molecular_subtype: Terminology_term
Result :=
choice of {
=========================================================
er_positive and
her2_negative and
not ki67.in_range ([high]): [luminal_A],
---------------------------------------------------------
er_positive and
her2_negative and
ki67.in_range ([high]): [luminal_B_HER2_negative],
---------------------------------------------------------
er_positive and
her2_positive: [luminal_B_HER2_positive],
---------------------------------------------------------
er_negative and
pr_negative and
her2_positive and
ki67.in_range ([high]): [HER2],
---------------------------------------------------------
er_negative and
pr_negative and
her2_negative and
ki67.in_range ([high]): [triple_negative],
---------------------------------------------------------
*: [none];
=========================================================
}
chemotherapy_regime: Terminology_term
Result :=
choice of {
================================================================================
not metastatic:
choice of {
========================================================================
molecular_subtype in
{[luminal_B_HER2_negative],
[triple_negative]} and
(tnm_t > '1a' or tnm_n > '0'): [taxanes],
------------------------------------------------------------------------
molecular_subtype = [luminal_A] and
(tnm_t >= '3' or tnm_n >= '2' or tnm_g >= '3'): [anthracyclines],
------------------------------------------------------------------------
molecular_subtype = [luminal_B_HER2_positive] and
(tnm_t = '1b' or tnm_t = '1c' and tnm_n = '0') or
molecular_subtype = [HER2_positive] and
(tnm_t = '1b' and tnm_n = '0'): [paditaxel_trastuzumab]
========================================================================
},
--------------------------------------------------------------------------------
*:
choice of {
=====================
yyy: aaa,
---------------------
xxx: bbb,
---------------------
*: ccc
=====================
}
=================================================================================
}
terminology
term_definitions = <
["en"] = <
["luminal_A"] = <
text = <"xxx">
description = <"...">
>
["luminal_B_HER2_positive"] = <
text = <"xxx">
description = <"...">
>
["luminal_B_HER2_negative"] = <
text = <"xxx">
description = <"...">
>
["HER2_positive"] = <
text = <"xxx">
description = <"...">
>
["HER2_megative"] = <
text = <"xxx">
description = <"...">
>
["triple_negative"] = <
text = <"xxx">
description = <"...">
>
["oligohydramnios"] = <
text = <"xxx">
description = <"...">
>