Achieving Diagnostic Imaging Data Sharing IHE Workshop 2007

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

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 © 2007 Canada Health Infoway Inc. 2

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. 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. • 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. © 2007 Canada Health Infoway Inc. 3

EHR Key Clinical & Business Requirements • Patient centric, life-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 © 2007 Canada Health Infoway Inc. 4

Key EHRS Architecture Concepts EHR SOLUTION (EHRS) EHR INFOSTRUCTURE (EHRi) Health EHR Information Data & Data Services Warehouse Standardize Ancillary Data & Services EHRS Locator Registries Data & Services and Subscribe to coordinate patient access, search and centric access view Longitudinal Record Services Publish Clinically Relevant Data Health Information Access Layer (HIAL) Point of Service Application © 2007 Canada Health Infoway Inc. EHR Viewer 5

EHRS In Canada Federated Databases, Peer-to-Peer, Message Based EHR SOLUTION (EHRS) Resilient and EHR INFOSTRUCTURE (EHRi) highly scalable EHR INFOSTRUCTURE (EHRi) systems within. Ancillary the Health Ancillary EHR Registries Information Data & Data & EHRS Services Data Services Services Warehouse Real-time read Legal Environment Longitudinal Record Services requests – sub 2 Near. Information Access Layer (HIAL) real-time to support Health Information Access Layer (HIAL) seconds publish and update exchange of clinical patient Point of information Point of Service EHR Viewer Service Application between systems Longitudinal Record Services EHRS EHRS © 2007 Canada Health Infoway Inc. EHRS 6

EHR Infostructure: Standards Based Connectivity JURISDICTIONAL INFOSTRUCTURE Ancillary Data & Services HIAL Registries Data & Services Client Registry Outbreak Mgmt Shared Health PHS Reporting HIAL EHR Data & Services HIAL Provider Registry HIAL Location Registry Business Rules Drug Information Diagnostic Imaging Laboratory HIAL Record HIAL EHR Index Message Structures HIAL Terminology Registry Data Warehouse Health Information Normalization Rules Longitudinal Record Services HIAL Privacy Data Configuration Common Services Communication Bus HIAL EHR SCP Standards Security Mgmt HIAL EHR IP EHR IP Standards EHR IP Standards EHR IP EHR IP EHR IP Public Health Services Pharmacy System Radiology Center PACS/RIS Lab System (LIS) Hospital, LTC, CCC, EPR Physician Office EMR EHR Viewer POINT OF SERVICE Public Health Provider Pharmacist Radiologist Lab Clinician © 2007 Canada Health Infoway Inc. Physician/ Provider 7

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) Infoway’s role is to set standards and requirements for robust, interoperable products and outcomes • 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 © 2007 Canada Health Infoway Inc. 8

EHR Infostructure: Standards-based Connectivity JURISDICTIONAL INFOSTRUCTURE Ancillary Data & Services EHR Data & Services Data Warehouse HIAL Registries Data & Services HIAL Architecture Standards HIAL • EHRS Blueprint Data & Messaging Standards HIAL • Client Registry. HIAL v 2. 4 & HL 7 v 3 HL 7 • Provider Registry HL 7 v 3 • EHR Data Model • Drug Information Systems HL 7 v 3 • EHR Services Model • Laboratory HL 7 v 3 • EHR Interoperability Profiles • Diagnostic Imaging/Teleradiology HIAL • EHR Use Cases HIAL • i. EHR Clinical Messaging HL 7 v 3 HIAL • i. EHR Technical Standards EHR IP EHR IP Standards EHR IP • Public Health Standards HL 7 v 3 EHR IP Standards EHR • EHR IP Standards. Terminology Strategy. IP Standards Clinical EHR IP EHR IP Standards EHR IP • Terminology Standards (SNOMED, LOINC, ICD 10 -CA, CCI) POINT OF SERVICE © 2007 Canada Health Infoway Inc. 9

Connecting Standards in 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. © 2007 Canada Health Infoway Inc. 10

The Future • A single point of contact for coordination of Pan-Canadian standards throughout the standards 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 © 2007 Canada Health Infoway Inc. 11

Integrated & Coordinated pan-Canadian Standards Services 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 Simple, Open & Transparent Governance Maintenance Services • Ongoing standards sustainability and relevance • Prioritize, fund and deliver maintenance of Infowaydeveloped standards Conformance Services • Develop conformance strategy & governance • Promote adherence to Standards • Develop & publish conformance criteria • Liaison with e. Health Collaboratory Needs Identification & Business Definition Development Support Options Research and Analysis Standards Development Maintenance Integrated & Coordinated Pan. Canadian Services Test Pilot Conformance Implementation Support Training Education Implementation Services • Development Strategy • Development • Alignment of Development principles, approaches and deliverables Education & Training • Development of Training materials & programs • Provision of general and specific standards education • Outreach training services • Implementation resource development • Implementation acceleration & support services • Stable For Use Standard quality validation & promotion © 2007 Canada Health Infoway Inc. 12

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 Ne. CST • Secretariat services to support: • HL 7 Canada • Canada’s ISO committees (CAC/Z 295) with CSA • Partnership for Health Information Standards • Liaison roles to the following Standards Development Organizations: • • HL 7 Inc DICOM LOINC ISO/TC 215 SNOMED CT IHE Canada and IHE Health Canada © 2007 Canada Health Infoway Inc. 13

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 HL 7 v 3 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 v 3 messaging • Leverage MESA tools for conformance testing • Provide resources to IHE International through IHE Canada © 2007 Canada Health Infoway Inc. 14

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 © 2007 Canada Health Infoway Inc. 15

Alberta Diagnostic Imaging Domain in the EHR Context JURISDICTIONAL INFOSTRUCTURE Registries Data & Services Client Registry Ancillary Data & Services EHR Data & Services Diagnostic Imaging Repository Provider Registry Location Registry Data Warehouse Business Rules Terminology Registry XDS Doc Registry Message Structures Normalization Rules Longitudinal Record Services Security Services Privacy Services Configuration Common Services Communication Bus p. HIE POINT OF SERVICE RSHIP* Capital Health Calgary Health Region PACS/RIS EHR Viewer * RSHIP – Regional Shared Health Information Program - (non-metro RHAs) © 2007 Canada Health Infoway Inc. 16

XDS-I Actors and Interactions - Modification © 2007 Canada Health Infoway Inc. 17

Alberta DI XAD – Physical View in the EHR Context JURISDICTIONAL INFOSTRUCTURE Registries Data & Services Client Registry Ancillary Data & Services EHR Data & Services Data Warehouse Provider Registry Location Registry Business Rules Terminology Registry XDS Doc Registry Message Structures Normalization Rules Longitudinal Record Services Security Services Configuration Common Services Communication Bus p. HIE RSHIP PACS/RIS PACS Archive Privacy Services XDS Doc Repository Capital Health PACS/RIS PACS Archive XDS Doc Repository Calgary Health Region PACS/RIS PACS Archive EHR Viewer XDS Doc Repository POINT OF SERVICE © 2007 Canada Health Infoway Inc. 18

Alberta DI XAD – Physical View (still in the development stage) © 2007 Canada Health Infoway Inc. 19

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). © 2007 Canada Health Infoway Inc. 20

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 HL 7 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 HL 7 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 Under considerations: Index, DI users query XDS Registry • 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 © 2007 Canada Health Infoway Inc. 21

Approach to Sharing Text Reports – Possible Future State © 2007 Canada Health Infoway Inc. 22

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 © 2007 Canada Health Infoway Inc. 23

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 p. HIE execute a PIX transaction and substitute EID for ULI • XDS Patient Identity feed will come from Provincial Client Registry © 2007 Canada Health Infoway Inc. 24

Summary • All Provinces and Territories are working towards implementation of the EHRi architecture • i. EHR 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 © 2007 Canada Health Infoway Inc. 25

Acknowledgements • Diagnostic Imaging Architecture Working Group, Alberta • Solution Architecture Group, Infoway • Standards Collaborative, Infoway © 2007 Canada Health Infoway Inc. 26

Thank you! Website: www. infoway-inforoute. ca E-mail: eigras@infoway-inforoute. ca © 2007 Canada Health Infoway Inc.