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The Canadian Electronic Health Records Strategy for Better Care Delivery

The Canadian Electronic Health Records Strategy for Better Care Delivery. David A. Koff MD McMaster University, Hamilton ZHE FENG MD Sunnybrook Health Science Centre, Toronto. Geographic Specificities.

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The Canadian Electronic Health Records Strategy for Better Care Delivery

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  1. The Canadian Electronic Health Records Strategy for Better Care Delivery David A. Koff MD McMaster University, Hamilton ZHE FENG MD Sunnybrook Health Science Centre, Toronto

  2. Geographic Specificities Average distance that people have to travel to reach the nearest specialist living in the same province or territory. Specialists tend to be found in urban areas. Rural and northern residents must travel considerable distances to see specialists. > 100 km

  3. Definitions • Telehealth is the use of communications and information technology for clinical care, education and healthcare services at a distance. • Telemedicine is the use of communication and information technologies to provide or support clinical care at a distance. • Teleradiology is the electronic transmission of diagnostic imaging studies from one location to another for the purposes of interpretation and/or consultation. • Teleradiology represents 90% of telemedicine activity. • More and more telehealth transactions include transmission of images.

  4. Numerous projects • All Provinces and Territories involved in Telehealth. • Over 100 active telehealth programs. • Many of those programs have to include medical images. • Heterogeneous networks and multi-vendor programs and telecommunications services.

  5. A few examples • Health Infostructure Atlantic Project • Interprovincial Integration of Images and Information (TELE-i4) • Images shared within the 4 Atlantic Provinces • North Network • 80 sites through northern and central Ontario • Alberta Wellnet • Integrated system-wide health information • Provincial PACS project.

  6. Electronic Health Record • Canada is focusing its efforts in improving healthcare by implementing an interoperable electronic health records.

  7. What is an EHR ? • An electronic health record provides each individual in Canada with a secure and private lifetime record of their health history. • Electronic health record systems provide authorized healthcare professionals with rapid access to patient information anywhere anytime. • Today, only 9% of Canadians have an electronic health record.

  8. Canada Health Infoway • Canada Health Infoway • Launched mid-2001, Infoway is an independent federally funded agency that works with the 10 provinces and 3 territories to invest in electronic health records projects. • Mission • To foster and accelerate the development and adoption of electronic health information systems to have an interoperable EHR in place across 50 percent of Canada by the end of 2009 and all Canadians covered by 2016.

  9. Canada Health Infoway • Infoway acts as a strategic investor: • invests with partners and funds 50% or more of the cost of a project; • is involved in project planning; • monitors progress of projects and quality of deliverables: gated strategy links reimbursement to achievement of milestones.

  10. Infoway’s Investment Programs End-user Adoption and Setting the Future Direction Innovation & Adoption - $60m The Electronic Health Record Interoperable EHR - $175m Laboratory Information Systems$150m Diagnostic Imaging Systems$310 Public Health Systems$100m Drug Information Systems$185m Domain Repositories and Healthcare Applications Telehealth$150m Cross Program Components Client, Provider and Location Registries - $135m Architecture and Standards Infostructure - $25m

  11. Infostructure End-user Adoption and Setting the Future Direction Innovation & Adoption - $60m The Electronic Health Record Interoperable EHR - $175m Laboratory Information Systems$150m Diagnostic Imaging Systems$310 Public Health Systems$100m Drug Information Systems$185m Domain Repositories and Healthcare Applications Telehealth$150m Cross Program Components Client, Provider and Location Registries - $135m Architecture and Standards Infostructure - $25m

  12. Infostructure • Development of common solution architecture and standards to ensure interoperability of EHR. • Provide to hospitals and vendors the business and technical guidelines: • Toolkits: technical and business knowledge (case studies, templates, plans, reports, etc…) • EHRS Blueprint, including the Privacy and Security requirements.

  13. The Use of Standards • Teleradiology • Standards and Guidelines for Teleradiology - CAR • ACR Technical Standards for Teleradiology - ACR • Integration • IHE (Integrating the Healthcare Enterprise) • Diagnostic Imaging Data • DICOM • JPEG and JPEG 2000 • TIFF • BMP • Electronic Health Information • HL7 v3 • CCR (Continuity of Care Record) - ASTM International • Multimedia Conferencing • ITU-T H.323/H.320 for video and audio • ITU-T T.120 for data

  14. The Use of Standards • Launched in 2006, the Standards Collaborative is a new Canada-wide coordination structure created to support and sustain health information standards in Canada. • Housed at Infoway, the Standards Collaborative will be responsible for the implementation, support, education, conformance, and maintenance for EHR standards currently being developed by Infoway.

  15. The Use of Standards • The Standards Collaborative also encompasses several standards initiatives formerly managed by the Canadian Institute for Health Information (CIHI): • Partnership for Health Information Standards, • HL7 Canada, • Canada's participation in DICOM (Digital Imaging and Communications in Medicine) and, • in conjunction with the Canadian Standards Association (CSA), the secretariat to the Canadian Advisory Committee to ISO/TC 215.

  16. Client, Provider and Location Registries End-user Adoption and Setting the Future Direction Innovation & Adoption - $60m The Electronic Health Record Interoperable EHR - $175m Laboratory Information Systems$150m Diagnostic Imaging Systems$310 Public Health Systems$100m Drug Information Systems$185m Domain Repositories and Healthcare Applications Telehealth$150m Cross Program Components Client, Provider and Location Registries - $135m Architecture and Standards Infostructure - $25m

  17. Client, Provider and Location Registries • Answers to the need to accurately identify patients, health professionals and healthcare facilities: • Client Registries: contain patient health identification number and demographic information. • Provider Registry: identification of doctors, pharmacists, dentists, nurses, etc… • Service Delivery Location Registry: hospital, clinics, physician offices.

  18. Drug Information Systems End-user Adoption and Setting the Future Direction Innovation & Adoption - $60m The Electronic Health Record Interoperable EHR - $175m Laboratory Information Systems$150m Diagnostic Imaging Systems$310 Public Health Systems$100m Drug Information Systems$185m Domain Repositories and Healthcare Applications Telehealth$150m Cross Program Components Client, Provider and Location Registries - $135m Architecture and Standards Infostructure - $25m

  19. Drug Information Systems • All data concerning a patient’s medication history: prescribed and dispensed drugs, allergies, ongoing drug treatment. • Drug and drug-interaction checks performed automatically and added to the patients' drug profiles in their Electronic Health Record (EHR). • Provide physicians and pharmacists with data to support appropriate and accurate prescribing and dispensing.

  20. Laboratory Information Systems End-user Adoption and Setting the Future Direction Innovation & Adoption - $60m The Electronic Health Record Interoperable EHR - $175m Laboratory Information Systems$150m Diagnostic Imaging Systems$310 Public Health Systems$100m Drug Information Systems$185m Domain Repositories and Healthcare Applications Telehealth$150m Cross Program Components Client, Provider and Location Registries - $135m Architecture and Standards Infostructure - $25m

  21. Laboratory Information Systems • To allow clinicians to view laboratory results and reports from all hospital, community and public health laboratories. • The results will be linked to patients' Electronic Health Records (EHR).

  22. Diagnostic Imaging Systems End-user Adoption and Setting the Future Direction Innovation & Adoption - $60m The Electronic Health Record Interoperable EHR - $175m Laboratory Information Systems$150m Diagnostic Imaging Systems$310 Public Health Systems$100m Drug Information Systems$185m Domain Repositories and Healthcare Applications Telehealth$150m Cross Program Components Client, Provider and Location Registries - $135m Architecture and Standards Infostructure - $25m

  23. Diagnostic Imaging Systems Digital Image Repositories • Electronic distribution of DI results to all facilities, referring community physicians and specialists over reliable networks (all studies, any time, any where). • Shared DI Repository scaleable to 1.5 million studies/year (single/multi jurisdiction or large regions) integrated with IHE-compliant RIS solution(s).

  24. Repository Current Status 22 shared PACS/Archive Solutions (DI-r) Target Planning Completed Implementation

  25. Benefits of DI-r • Patient impact • Improve report turnaround time • Reduction in duplicate exams ($132M/year in Ontario) • Reduction in patient transfers • Resources impact • Improve radiologist productivity by 25-28% • Improve technologist productivity by 10-12% • Improve clinician productivity

  26. Benefits of DI-r • Cost impact • Reduction in film related costs (3.2-4 B$) • Reduction in stand alone versus shared PACS system: savings estimated at 40%. • For the healthcare system • Overall cost $7.4 Billion but delivers $9.1 Billion in benefits over 10 years.

  27. Diagnostic Imaging Systems • Filmless working environment for all procedure types (CT, MR, X-Ray, ultra-sound, etc.) • Implementation of IHE profiles and EHR interoperability specifications (HL7/DICOM standards for image acquisition and report creation) • Use of optimal compression strategies for digital images.

  28. Use of a shared XDS infrastructure to access Radiology Reports and Images: development of XDS-I and related tools by IHE-Canada. IHE Profiles • Between Radiology and : • Imaging specialists • Non-imaging clinicians Hospital PACS Y Radiology -to-Radiology Radiology -to-Physicians PACS Z Imaging Center Physician Practice

  29. Image Compression Storage volume … • Even if the cost of storage is dropping, the savings are largely surpassed by the increasing amount of data. • The cost of operation remains high. • 40 million diagnostic imaging exams are performed annually in Canada. • With an average legal retention period of 7 years upon provincial regulations. • Use of irreversible compression at 10:1 could save M$100 million per year.

  30. Image Compression … and transmission times • and if access to high bandwidth gets more available in local hospital networks, it is still premature to expect any health professional to use 100 mbps connections on their computers. • EHR networks cannot support large medical images and timely access to diagnostic images requires adequate level of compression.

  31. Image Compression • The Canadian Association of Radiologists PACS/Teleradiology committee has accepted the principle of irreversible (“lossy”) compression for use in primary diagnosis and clinical review, using DICOM JPEG or JPEG-2000 compression algorithms, at specific compression ratios set by image type. • Adoption conditional to the results of a large scale evaluation study.

  32. Image Compression • This study has been performed at Sunnybrook, supported by a grant from Canada Health Infoway. • Prior to that, CHI had commissioned 2 literature reviews and 2 legal assessments. • Radiologists have been enrolled from 9 out of 10 Canadian Provinces.

  33. Methodology Based on previous studies, our evaluation resulted from the association of 2 accepted methods: • Objective measurement of diagnostic accuracy with ROC analysis • Subjective image comparison with original-revealed forced choice (JND)

  34. Methodology • 3 readers per session, 23 sessions, more than 100 readers in total from all across Canada. • Had to read the images on the DICOM compliant, calibrated workstation they use in their daily activity. • The workstation had to be connected to the Internet ideally. • The answers were filled on-line and directly transferred to our server.

  35. Diagnostic Accuracy GROUND GLASS OPACITY

  36. Comparison side-by-side JPEG 2000 15:1 ORIGINAL

  37. Examples JPEG 2000 20:1 ORIGINAL PNEUMOTHORAX

  38. Examples JPEG 2000 25:1 ORIGINAL CALCIFICATIONS

  39. Results For 18 anatomical regions/modalities, there was no difference noted, but discrepancies were noted in 3 occurrences.

  40. Results

  41. Results

  42. Results

  43. J2K vs. JPG J2K 15:1 JPEG 15:1 Noticeable degradation No noticeable degradation Difference in performance is due to the fact that JPEG 2000 has good spatial resolution and discards the low energy high-frequency coefficients during quantization.

  44. Recommendations • Lossy compression can be used at the lowest levels of compression tested, as there was no significant loss of diagnostic information at those levels. • No difference between Lossy JPEG and JPEG 2000 at the lowest levels of compression.

  45. Results: recommended values

  46. Public Health Systems End-user Adoption and Setting the Future Direction Innovation & Adoption - $60m The Electronic Health Record Interoperable EHR - $175m Laboratory Information Systems$150m Diagnostic Imaging Systems$310 Public Health Systems$100m Drug Information Systems$185m Domain Repositories and Healthcare Applications Telehealth$150m Cross Program Components Client, Provider and Location Registries - $135m Architecture and Standards Infostructure - $25m

  47. Public Health Systems • Solutions that support the identification, management and control of infectious disease cases and outbreaks that pose a threat to the public's health. • In March 2004, taking into account the lessons learned from the SARS outbreak and public concern about the ability of public health authorities to deal with emerging communicable disease threats, the federal government assigned Infoway the task of developing a communicable disease surveillance system in partnership with the provinces and territories.

  48. Telehealth End-user Adoption and Setting the Future Direction Innovation & Adoption - $60m The Electronic Health Record Interoperable EHR - $175m Laboratory Information Systems$150m Diagnostic Imaging Systems$310 Public Health Systems$100m Drug Information Systems$185m Domain Repositories and Healthcare Applications Telehealth$150m Cross Program Components Client, Provider and Location Registries - $135m Architecture and Standards Infostructure - $25m

  49. Telehealth • Electronic solutions that facilitate the delivery of health information and services between patients and providers regardless of distance. • Multiple projects based on: • Geographic (tele-education, home healthcare,…) • Cultural (First Nations, language minorities) • Clinical (post cardiac surgery, wound care assistance, telepsychiatry…) • Management Models as well as Technology and Standards

  50. Interoperable EHR End-user Adoption and Setting the Future Direction Innovation & Adoption - $60m The Electronic Health Record Interoperable EHR - $175m Laboratory Information Systems$150m Diagnostic Imaging Systems$310 Public Health Systems$100m Drug Information Systems$185m Domain Repositories and Healthcare Applications Telehealth$150m Cross Program Components Client, Provider and Location Registries - $135m Architecture and Standards Infostructure - $25m

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