IHE Workshop 2007 June 11, 2007 Eugene Igras Lead Architect Canada Health Infoway Inc.

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

2. 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

3. Canada Health Infoway • Mission To 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. • Vision A 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. • Goal Infoway’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.

4. EHR Key Clinical & Business Requirements • 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

5. Key EHRS Architecture Concepts EHR SOLUTION (EHRS) EHR INFOSTRUCTURE (EHRi) EHRSLocator Longitudinal Record Services HealthInformationDataWarehouse AncillaryData &Services EHRData &Services RegistriesData &Services Health Information Access Layer (HIAL) Standardize and coordinate patient centric access Subscribe to access, search and view Publish Clinically Relevant Data Point of ServiceApplication EHR Viewer Point of ServiceApplication

6. EHRS In Canada Federated Databases, Peer-to-Peer, Message Based EHR SOLUTION (EHRS) EHR SOLUTION (EHRS) Resilient and highly scalable systems within the EHRS EHR INFOSTRUCTURE (EHRi) EHR INFOSTRUCTURE (EHRi) Longitudinal Record Services Longitudinal Record Services HealthInformationDataWarehouse HealthInformationDataWarehouse AncillaryData &Services EHRData &Services RegistriesData &Services AncillaryData &Services EHRData &Services RegistriesData &Services Health Information Access Layer (HIAL) Health Information Access Layer (HIAL) Real-time read requests – sub 2 seconds Legal Environment to support exchange of clinical patient information between systems Near real-time publish and update Point of ServiceApplication Point of ServiceApplication EHR Viewer EHR Viewer Point of ServiceApplication Point of ServiceApplication EHRS EHRS EHRS EHRS EHRS EHRS EHRS

7. Longitudinal Record Services Common Services Communication Bus JURISDICTIONAL INFOSTRUCTURE Ancillary Data& Services EHR Data& Services DataWarehouse Registries Data& Services OutbreakMgmt PHSReporting SharedHealth Record DrugInformation DiagnosticImaging Laboratory HealthInformation ClientRegistry HIAL ProviderRegistry HIAL HIAL HIAL HIAL HIAL HIAL HIAL LocationRegistry BusinessRules EHRIndex MessageStructures NormalizationRules HIAL TerminologyRegistry HIAL HIAL Security Mgmt Privacy Data Configuration HIAL HIAL HIAL EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP Public HealthServices PharmacySystem RadiologyCenterPACS/RIS Lab System(LIS) Hospital, LTC,CCC, EPR PhysicianOffice EMR EHR Viewer Public Health Provider Pharmacist Radiologist Lab Clinician Physician/Provider Physician/Provider Physician/Provider POINT OF SERVICE EHR Infostructure: Standards Based Connectivity EHR SCP Standards

8. Standards-based Solutions 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

9. JURISDICTIONAL INFOSTRUCTURE Ancillary Data& Services EHR Data& Services DataWarehouse Registries Data& Services HIAL 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) HIAL HIAL HIAL HIAL HIAL HIAL HIAL HIAL HIAL HIAL HIAL HIAL EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP POINT OF SERVICE EHR Infostructure: Standards-based Connectivity

10. 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.

11. 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

12. Implementation Services Client Services & SDO Relations Standards Collaboration Engagement and Process Services • Implementation resource development • Implementation acceleration & support services • Stable For Use Standard quality validation & promotion • Client Services • Information Desk • Membership Management • Conferences • SDO Relations • Formal & Informal SDO Liaison • Distribution & Rights Management • Govern and manage SDO affiliates • Stakeholder Engagement Strategy & Framework • Clinical Alignment & Support • Communications & Marketing • SC Evaluation • Knowledge Management • Standards Uptake Strategies • SC Governance & Transition Maintenance Services Development Support • Ongoing standards sustainability and relevance • Prioritize, fund and deliver maintenance of Infoway-developed standards • Development Strategy • Development • Alignment of Development principles, approaches and deliverables Conformance Services Education & Training • Develop conformance strategy & governance • Promote adherence to Standards • Develop & publish conformance criteria • Liaison with eHealth Collaboratory • Development of Training materials & programs • Provision of general and specific standards education • Outreach training services Integrated & Coordinated pan-Canadian Standards Services Simple, Open & Transparent Governance

13. 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

14. Infoway and IHE • 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

15. XDS-I within Canada • 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

16. Longitudinal Record Services Common Services DiagnosticImaging Repository RSHIP* PACS/RIS Capital Health PACS/RIS Calgary Health Region PACS/RIS Alberta Diagnostic Imaging Domain in the EHR Context Communication Bus JURISDICTIONAL INFOSTRUCTURE Ancillary Data & Services EHR Data & Services Data Warehouse Registries Data& Services ClientRegistry ProviderRegistry LocationRegistry BusinessRules XDS Doc Registry MessageStructures NormalizationRules TerminologyRegistry Security Services Privacy Services Configuration pHIE POINT OF SERVICE EHR Viewer * RSHIP – Regional Shared Health Information Program - (non-metro RHAs)

17. XDS-I Actors and Interactions - Modification

18. Longitudinal Record Services Common Services Calgary Health Region PACS/RIS Capital Health PACS/RIS RSHIP PACS/RIS PACS Archive XDS Doc Repository PACS Archive XDS Doc Repository PACS Archive XDS Doc Repository Alberta DI XAD – Physical View in the EHR Context Communication Bus JURISDICTIONAL INFOSTRUCTURE Ancillary Data & Services EHR Data & Services Data Warehouse Registries Data& Services ClientRegistry ProviderRegistry LocationRegistry BusinessRules XDS Doc Registry MessageStructures NormalizationRules TerminologyRegistry Security Services Privacy Services Configuration pHIE EHR Viewer POINT OF SERVICE

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

20. 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).

21. 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 Registry Under 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

22. Approach to Sharing Text Reports – Possible Future State

23. 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

24. 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

25. 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

26. Acknowledgements • Diagnostic Imaging Architecture Working Group, Alberta • Solution Architecture Group, Infoway • Standards Collaborative, Infoway

27. Thank you! Website: www.infoway-inforoute.ca E-mail: eigras@infoway-inforoute.ca