© 2007 Canada Health Infoway Inc. 1 IHE Workshop 2007 June 11, 2007 Eugene Igras Lead Architect Canada Health Infoway Inc. Achieving Diagnostic Imaging.

1© 2007 Canada Health Infoway Inc.

IHE Workshop 2007June 11, 2007Eugene IgrasLead ArchitectCanada Health Infoway Inc.

Achieving Diagnostic Imaging Data Sharing


Agenda

• Introducing Canada Health Infoway

• Key Clinical and Business Requirements

• Key EHRS Concepts

• Standards in Canada

• Infoway and IHE

• Alberta DI XDS-I Affinity Domain - Sharing DI Data

• Summary


Canada Health Infoway

• MissionTo foster and accelerate the development and adoption of electronic health information systems with compatible standards and communications technologies on a pan-Canadian basis, with tangible benefits to Canadians. To build on existing initiatives and pursue collaborative relationships in pursuit of its mission .

• VisionA high-quality, sustainable and effective Canadian health care system supported by an infostructure that provides residents of Canada and their healthcare providers timely, appropriate and secure access to the right information when and where they enter into the healthcare system. Respect for privacy is fundamental to this vision.

• GoalInfoway’s plan is to have an interoperable electronic health record in place across 50 percent of Canada (by population) by the end of 2009.

Shared Governance Facilitates Collaboration

Canada Health Infoway is an independent not-for-profit organization, whose Members are Canada’s 14 federal, provincial and territorial Deputy Ministers of Health.


• Patient centric, life-long longitudinal record of clinical data

• Support for accurate, complete, timely delivery of information

• Allowing private and secured access to data made available in the EHR

• Focused on clinically relevant data shared beyond organizational boundaries

• Shared across multiple organizations, jurisdictions

• Scalable to allow continuous, extensive growth of clinical information with a ROI• More POS applications sourcing data to EHR

• More users accessing and using data from EHR

• Towards more physician order entry and decision support

• Interoperable, integrated

• Standards based

EHR Key Clinical & Business Requirements


EHR SOLUTION (EHRS)

EHR INFOSTRUCTURE (EHRi)

EHR ViewerPoint of Service

Application

Point of Service

Application

EHRSLocator

Longitudinal Record Services

Health Information Access Layer (HIAL)

AncillaryData &

Services

HealthInformation

DataWarehouse

EHRData &

Services

RegistriesData &

Services

Publish Clinically Relevant Data

Standardize and coordinate patient

centric access

Subscribe to access, search and

view

Key EHRS Architecture Concepts


EHRSEHRS EHRSEHRS EHRS EHRSEHRS

EHRS In Canada Federated Databases, Peer-to-Peer, Message Based

EHR SOLUTION (EHRS)



Application

Point of Service

Application

AncillaryData &

Services

HealthInformation

DataWarehouse

EHRData &

Services

RegistriesData &

Services



EHR SOLUTION (EHRS)



Application

Point of Service

Application

AncillaryData &

Services

HealthInformation

DataWarehouse

EHRData &

Services

RegistriesData &

Services



Resilient and highly scalable systems within the EHRS

Legal Environment to support

exchange of clinical patient

information between systems

Near real-time publish and update

Real-time read requests – sub 2

seconds


JURISDICTIONAL INFOSTRUCTUREAncillary Data

& ServicesRegistries Data

& ServicesEHR Data& Services

DataWarehouse

OutbreakMgmt

PHSReporting

SharedHealth

Record

DrugInformation

DiagnosticImaging

LaboratoryHealth

Information

ClientRegistry

ProviderRegistry

LocationRegistry

TerminologyRegistry

POINT OF SERVICE

BusinessRules

EHRIndex

MessageStructures

NormalizationRules

Security Mgmt

Privacy Data Configuration


Hospital, LTC,CCC, EPR

PhysicianOffice EMR

EHR Viewer

Physician/Provider

Physician/Provider

Physician/Provider

Lab System(LIS)

Lab Clinician

RadiologyCenter

PACS/RIS

Radiologist

PharmacySystem

Pharmacist

Public HealthServices

Public Health

Provider

HIALCommunication BusCommon Services

EHR IPEHR IPEHR IPEHR IPEHR IP

HIAL

HIAL

HIAL

HIA

LH

IAL

HIA

LH

IAL

HIAL HIAL HIAL HIAL HIAL HIAL

EHR IPEHR IP

EHR IPEHR IPEHR IPEHR IPEHR IPEHR IPEHR IP

EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP StandardsEHR SCP Standards

EHR Infostructure: Standards Based Connectivity


Why Standards?

• They facilitate information exchange; are a critical foundation for EHR

• They create opportunity for future cost reduction as vendors and systems converge on pan-Canadian and international standards

• They ease effort required for systems integration

Mandatory Investment Eligibility Requirements

• Compliance to standards (infostructure, architecture)

• Initiatives must comply with existing guidelines or standards adopted by Infoway

• Where standards or guidelines do not exist, projects must support longer-term interoperability and congruence of solutions

Infoway’s role is to set standards and requirements for

robust, interoperable products and

outcomes

Standards-based Solutions


JURISDICTIONAL INFOSTRUCTURE

Ancillary Data& Services

Registries Data& Services

EHR Data& Services

DataWarehouse

POINT OF SERVICE

EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards

EHR IPEHR IPEHR IPEHR IPEHR IP

HIAL

HIAL

HIAL

HIA

L

HIAL HIAL HIAL HIAL HIAL HIAL

EHR IPEHR IP

EHR IPEHR IPEHR IPEHR IPEHR IPEHR IPEHR IP

HIA

LH

IAL

HIA

L

Architecture Standards

• EHRS Blueprint

• EHR Use Cases

• EHR Data Model

• EHR Services Model

• EHR Interoperability Profiles

Data & Messaging Standards

• Client Registry HL7 v2.4 & HL7 v3

• Provider Registry HL7 v3

• Drug Information Systems HL7 v3

• Laboratory HL7 v3

• Diagnostic Imaging/Teleradiology

• iEHR Clinical Messaging HL7 v3

• iEHR Technical Standards

• Public Health Standards HL7 v3

• Clinical Terminology Strategy

• Terminology Standards (SNOMED, LOINC, ICD10-CA, CCI)

EHR Infostructure: Standards-based Connectivity


Connecting Standards in Canada

Canada is currently in the midst of a major transformation initiative,

bringing together a complex health information standards

community into a single cohesive, coordinated collaborative.

Council ofHISCs

Infoway

ProvincialStandardsCouncils

ISO (TC 215)

SCC

PartnershipHL7

Canada

HL 7 Inc. WHOACR/NMEA

CIHI

CAC/Z295

CSA CHI

Mulit-Provincial

Collaboratives



ISO WorkingGroups Special

InterestGroups

TechnicalCommittees

IHE

IHE Canada

IHE North America

SCP

pCSGs

Task Groups

NeCST

ESC

FC, ICs

ISO WorkingGroups HL7 Inc TCs SNOMED

SDO GroupsLOINCGroups

Infoway CIHISCC

Standards CollaborativeStrategic Committee

Investment Sub-Committee

Standards CollaborativeCoordinating Committee

CSA

Technical Sub-Committee Clinical Sub-Committee

Health Care StandardsDomain #1 pCSG







The Future

• A single point of contact for coordination ofPan-Canadian standards throughout thestandards life cycle: development, implementation support, education,maintenance and conformance

• Streamlined governance, processes and operations

• Efficiencies gained by combining administrative services such as communications, website management, event planning/management, education and administrative support

• Coordination of development, maintenance and balloting processes, such that they are harmonized in a way that each adds value without duplication or real/perceived conflict


Integrated & Coordinated pan-Canadian Standards Services

• Ongoing standards sustainability and relevance

• Prioritize, fund and deliver maintenance of Infoway-developed standards

Maintenance Services

• Implementation resource development

• Implementation acceleration & support services

• Stable For Use Standard quality validation & promotion

Implementation Services

• Development Strategy• Development• Alignment of Development

principles, approaches and deliverables

Development Support

• Development of Training materials & programs

• Provision of general and specific standards education

• Outreach training services

Education & Training• Develop conformance strategy &

governance• Promote adherence to Standards• Develop & publish conformance

criteria • Liaison with eHealth Collaboratory

Conformance Services

Options Research

and Analysis

Standards Development

Needs Identification

& Business Definition

Maintenance

TrainingEducation

Conformance

ImplementationSupport

Test Pilot

Integrated &

Coordinated

Pan-CanadianServices

Integrated &

Coordinated

Pan-CanadianServices

Simple, Open & Transparent GovernanceSimple, Open & Transparent Governance

Standards Collaboration Engagement and Process Services

• Stakeholder Engagement Strategy & Framework

• Clinical Alignment & Support• Communications & Marketing• SC Evaluation• Knowledge Management• Standards Uptake Strategies• SC Governance & Transition

Client Services & SDO Relations

• Client Services• Information Desk• Membership Management• Conferences

• SDO Relations• Formal & Informal SDO Liaison• Distribution & Rights Management• Govern and manage SDO affiliates


Standards Collaborative Scope

• Coordination of Pan-Canadian standards throughout the standards life cycle: development, implementation support, education, maintenance and conformance

• Support for EHR pan-Canadian messaging, terminology and interoperability profile standards

• Support for NeCST

• Secretariat services to support:• HL7 Canada • Canada’s ISO committees (CAC/Z295) with CSA• Partnership for Health Information Standards

• Liaison roles to the following Standards Development Organizations: • HL7 Inc • DICOM • LOINC • ISO/TC215 • SNOMED CT• IHE Canada and IHE• Health Canada


• Leverage IHE integration profiles as much as possible• DI domain

– Co-authored XDS-I content supplement– Funded development of XDS-I MESA tool set– Driven XDS/XDS-I through the Standards Collaborative Process – declared as a

pan-Canadian Standard (with “Stable for Use” designation)

• Client Registry– Authoring/funding a change proposal to PIX and PDK to support HL7 v3

messaging

• EHR infostructure– Reviewing ITI integration profiles for consideration as pan-Canadian “standards”– The EHR Index will comply to the XDS Registry actor…but support event

notifications, and other data types

• Coordinate with IHE to avoid duplication• Leverage IHE technical committees to develop new profiles and/or

propose changes to existing profiles e.g. support for v3 messaging• Leverage MESA tools for conformance testing • Provide resources to IHE International through IHE Canada

Infoway and IHE


• XDS-I declared a pan-Canadian Standard – Stable for Use• Followed the Standards Collaborative Process

• As “Stable for Use”, we are:– Declaring commitment to this profile

– Piloting the profile in real-world scenarios to refine deployment models and stress capabilities

• Anticipate a number of Change Proposals• Modify the profile to suit Canadian deployment model

• Modify the profile to address “issues” arising out of projects

• XDS-I compliance required in all DI projects funded by Infoway• Completed several RFPs with requirements for XDS-I compliance

• More Provinces are planning the deployment of XDS-I

XDS-I within Canada


Alberta Diagnostic Imaging Domain in the EHR ContextJURISDICTIONAL INFOSTRUCTURE


EHR Data & Services

ClientRegistry

ProviderRegistry

LocationRegistry

TerminologyRegistry

POINT OF SERVICE

BusinessRules

MessageStructures

NormalizationRules

SecurityServices

PrivacyServices

Configuration


EHR Viewer

pHIECommunication BusCommon Services

Data Warehouse

Ancillary Data & Services

Calgary Health Region

PACS/RIS

Capital Health

PACS/RIS

RSHIP*

PACS/RIS

DiagnosticImaging

Repository

XDS Doc

Registry

* RSHIP – Regional Shared Health Information Program - (non-metro RHAs)


XDS-I Actors and Interactions - Modification


Alberta DI XAD – Physical View in the EHR ContextJURISDICTIONAL INFOSTRUCTURE


ClientRegistry

ProviderRegistry

LocationRegistry

TerminologyRegistry

POINT OF SERVICE

BusinessRules

MessageStructures

NormalizationRules

SecurityServices

PrivacyServices

Configuration


EHR Viewer

pHIECommunication BusCommon Services

Data Warehouse

Ancillary Data & Services

XDS Doc

Registry

RSHIP PACS/RIS

PACSArchive

XDS DocRepository

Capital Health PACS/RIS

PACSArchive

XDS DocRepository

Calgary Health Region PACS/RIS

PACSArchive

XDS DocRepository

EHR Data & Services


Alberta DI XAD – Physical View(still in the development stage)

AlbertaProvincial Health

Information Exchange

(pHIE)

Provincial iEHR Index - XDS Repository

Common Services

Communication Bus

Storage

DR

Storage

DR

Active/Active Replication

RSHIP Repository

Primary Secondary


DR DR

PACsArchive

PACsArchive

Capital Repository

Primary Secondary


DR DR

PACsArchive

PACsArchive

Calgary Repository

Primary Secondary


DR DR

PACsArchive

PACsArchive

Netcare Portal

Impax 6.x

XDS Repository XDS Repository XDS Repository XDS Repository XDS Repository XDS Repository

RSHIPIntegration Engine

CapitalIntegration Engine

CalgaryIntegration Engine

ASAS Provincial Client Registry

Provider Registry/Directory

Location Registry/Directory

Terminology Registry

RSHIP Client Registry Capital Client Registry Calgary Client Registry

2

1

3

4

5

6

7

8

9

9


Triggers for Data Sharing (still in the development stage)

• Images will be shared after Initial QA step by DI Technologists.

• Radiologists Report will be shared before verification.

• Each time an update to a study is made, a new imaging manifest will be created and registered in the XDS Registry.

• Requires ability of PACS system to manage object concurrency between Spoke and Archive Level (i.e., if update made on Spoke, updates must be propagated to Archive).


Approach to Sharing Reports – Possible Short-Term Solution • Alberta has a separate DITR (DI Text

Results Repository), that is not based on XDS

• DI Text Results come from the RIS systems via HL7 into the DITR

• An index entry is created in the Netcare EHR Index for the Text Result

• A URL for the images is also added as a separate EHR Index entry via an HL7 message from AGFA Web system

• Short-term, DITR will co-exist with the XDS based approach. Alternatives are being evaluated:

• Combined – EHR Index supports XDS

• Federated – EHR Index and XDS Registry as separate components, Query to Registry must be federated to both indexes

• Synchronized – XDS Registry updates EHR Index, EHR users query EHR Index, DI users query XDS RegistryUnder considerations:

• Netcare Portal users will be able to access the text results via the Text Results Repository OR via the Image Repository

• PACS users will only be able to access DI Text Results (stored as DICOM SR) via the DI Image Repository


Approach to Sharing Text Reports – Possible Future State


Streaming of Images (still in the development stage)

• Architecture specifies streaming of images using WADO and JPIP versus DICOM query/retrieve

• Desire is to avoid movement of studies/images and stream them from the source

• Performance to end user must be carefully considered

• Pre-Fetch – what to display to the user• Registry Entries Only

• Manifests which would avoid a two step retrieval

• Even if Manifests are pre-fetched this will still require streaming of images to user workstation when images are selected, this could be a performance issue

• Not currently part of the IHE profile or PACS capabilities


XAD Patient ID (still in the development stage)

• Provincial Enterprise ID (EID) from the Provincial Client Registry selected as the XAD Patient ID

• Unique Lifetime Identifier (ULI) was considered, but for broader EHR interoperability EID was selected

• Requires DI document sources to submit ULI and have the pHIE execute a PIX transaction and substitute EID for ULI

• XDS Patient Identity feed will come from Provincial Client Registry


Summary

• All Provinces and Territories are working towards implementation of the EHRi architecture

• iEHR planning projects underway in all Provinces

• Client Registries in planning/deployed in all Provinces

• Drug and Lab repositories in planning /deployment in some Provinces…others still developing strategies

• DI repositories in planning/deployed in all Province with the IHE Integration Profiles being in scope

• Standards Collaborative established to lead adoption of standards


Acknowledgements

• Diagnostic Imaging Architecture Working Group, Alberta

• Solution Architecture Group, Infoway

• Standards Collaborative, Infoway


Website: www.infoway-inforoute.ca

E-mail: [email protected]

Thank you!

© 2007 Canada Health Infoway Inc. 1 IHE Workshop 2007 June 11, 2007 Eugene Igras Lead Architect Canada Health Infoway Inc. Achieving Diagnostic Imaging.

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