UPDATE Adoption of standards to share diagnostic imaging

UPDATE Adoption of standards to share diagnostic imaging information in the pan-Canadian EHR DICOM Standards Committee – December 4, 2008 Presented by Eugene Igras

Agenda • Sharing DI data in the pan-Canadian EHR context • Adoption of standards in the DI Domain • Issues to be addressed • 2008 Events • Conclusion 2 2008 Canada Health Infoway Inc.

Infoway Diagnostic Imaging Program • Vision Foster and accelerate the development and adoption of DI solutions to assist healthcare providers in acquisition, collection, storage, management, distribution and viewing patient radiology reports and images (any study, any time, any where) regardless of where the DI tests were conducted and/or the reports transcribed. • Strategy § Build on existing standard-based PACS / RIS capabilities § Use IHE XDS/XDS-I Integration Profiles to: § Implement Registry & Data Repository (or multiple Repositories) § Enable interoperability with the EHR components, including: • Clinical Viewer • Health Information Access Layer (privacy & security, consent management) • Registries (Client, Provider, Site and Terminology) § Ensure privacy and security of DI information 2008 Canada Health Infoway Inc. 3

Value Proposition • Improve Access to Services § Provide timely access to DI information irrespective of where the images were acquired and/or the report transcribed § Provide access to a longitudinal record of patient DI history § Improve timeliness and continuity of care § Enable real-time collaboration and clinical consultations § Improve training opportunities • Improve Productivity & Contain Costs § Increase patient throughput, reduce patient transfers and wait times § Provide capabilities for Radiologists to share workload across the region § Reduce DI exams by reducing avoidable retakes • Improve Quality of Care § Improve quality of DI information (accuracy, completeness, consistency) § Reduce radiation exposure § Reduce medical errors 2008 Canada Health Infoway Inc. 4

Common Approach Adherence to Infoway DI Program vision § Leverage existing RIS and PACS as operational film-less solutions § Consolidation of DI data into DI Repository (DI-r) or multiple Repositories § Seamless sharing of DI data among authorized users § Provide access to a longitudinal record of patient DI history Conformance & Compliance to Standards § Architecture: § Privacy & Security: § § EHRS Blueprint v 2 Jurisdictional privacy protection legislation Privacy & Security Requirements & Architecture ISO/IEC 17799 Content & Messaging: HL 7 v 2. x and v 3, CDA, DICOM Terminology: SNOMED CT & other terminology standards IHE Integration Profiles: XDS/XDS-I - to support DI data sharing PIX/PDQ – to support patient identity/CR with HL 7 v 3 ATNA – to support security Other IHE Radiology and IT Profiles Electronic Business & Internet Standards 5 2008 Canada Health Infoway Inc.

Standards used in DI Domain An array of standards address DI Requirements in Canada EHRS Blueprint v 2 Privacy & Security Privacy Legislation Healthcare Content, Messaging, Terminology HL 7/CDA, DICOM, SNOMED CT LOINC, ICD-10 -CA… IHE Integration Profiles XDS/XDS-I, PIX/PDQ, ATNA… Electronic Business Standards eb. XML, Web Services Internet Standards HTML/XML, HTTP, PDF, JPEG, MIME, UTF-8 … 6 2008 Canada Health Infoway Inc.

Scope of the XDS Affinity Domain in the EHR Context JURISDICTIONAL INFOSTRUCTURE Registries Data & Services Client Registry Provider Registry Ancillary Data & Services Outbreak Mgmt Location Registry PHS Reporting Business Rules EHR Index Terminology Registry EHR Data & Services Shared Health Record Message Structures Drug Information Diagnostic Imaging Data Warehouse Normalization Rules Longitudinal Record Services Security Mgmt Privacy Data Hospital, LTC, CCC, EPR Config Services Physician Office EMR Common Services Communication Bus HIAL Public Health Services POINT OF SERVICE Health Information Laboratory Public Health Provider 2008 Canada Health Infoway Inc. Pharmacy System Pharmacist Radiology Center PACS/RIS Radiologist Lab System (LIS) Lab Clinician Physician/ Provider EHR Viewer Physician/ Provider 7

Infoway and IHE • Leverage and implement IHE integration profiles § DI • • • domain Co-authored XDS-I content supplement Funded development of XDS-I MESA tool set Declared XDS/XDS-I as a pan-Canadian Standard (“Stable for Use”) • Implement XDS/XDS-I in current DI projects across Canada § Client Registry • Authored a change proposal to IHE PIX/PDQ to support HL 7 v 3 messaging § EHR Infostructure • Completed a review of IHE ITI integration profiles for consideration as pan-Canadian standards • 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 2008 Canada Health Infoway Inc. 8

DI Projects Across Canada • Most provinces in Canada § Have deployed digital DI modalities and PACS/RIS solutions § Have completed architecture for DI Repository (or multiple Repositories) integrated with the EHR § Plan to deploy interoperable EHR / DI solutions All DI Solutions § Span multiple health regions, hundreds of hospitals, and DI clinics § Integrate multi-vendor PACS / RIS environment § Are designed to handle • Multiple patient identification domains and EMPI services • Multiple security domains • Millions of exams per year (e. g. , Alberta: over 4. 5 million) § Provide services to thousands of users (e. g. Alberta: over 15, 000) 2008 Canada Health Infoway Inc. 9

Patient Identity Source • Feeds identity of known patients to Document Registry Patient Identity Feed • • Stores and maintains metadata Creates and maintains links to documents Supports document search (query) Enforces policies at the time of registration Document Registry Query Register Document Set Document Source Provide & Register Document Set • Submits document sets • Creates and submits documents description (metadata) Document Repository • • Document Consumer • Initiates search (query) • Initiates retrieval of documents Retrieve Document Stores documents & metadata Creates & maintains document URI (Uniform Resource Identifier) Forwards metadata for registration Supports document retrieval XDS – Actors and Transactions 2008 Canada Health Infoway Inc. 10

Patient Identity Source • Feeds identity of known patients to Document Registry Patient Identity Feed • Receives, stores & maintains metadata • Creates and maintains document index • Supports document search (query) • Enforces policies for registration Document Registry Query Registry Document Consumer Register Document Set Provide & Register Document Set Imaging Document Source • Creates text / PDF report and/or imaging manifest documents • Submits document sets with document description (metadata) • Supports retrieval of DICOM objects Document Repository Retrieve Document WADO Retrieve • Stores documents and metadata • Enhances metadata with document URIs to enable retrieval • Forwards the enhanced metadata for registration • Supports document retrieval Imaging Document Consumer • Initiates search and retrieval of documents • Initiates retrieval of DICOM objects referenced within the manifest Retrieve Images Retrieve Presentation States Retrieve Reports Retrieve Key Imaging Note Retrieve Evidence Documents XDS-I – Actors and Transactions 2008 Canada Health Infoway Inc. 11

Patient Identity Source Mod Document Registry PACS Mod Imaging Document Source Document Consumer Document Repository DI Repository (DI-R) Mod • Stores and maintains a lifetime record of relevant DI data including RIS Mod • Images and reports DI-R • Key image notes, image processing results & overlay information • Presentation states and other evidence documents Mod PACS Mod • Serves as shared operational PACS for greenfield sites • Supports 2 -3 Million exams per year • Delivers DI data to consumer over a network • Facilitates seamless sharing of DI information • Maintains quality and integrity of data Real-world Systems vs. XDS-I Actors 2008 Canada Health Infoway Inc. 12

Patient Identity Source Document Registry Imaging Document Source Document Consumer Document Repository Imaging Document Consumer Mod Mod DI-R PACS Mod RIS Mod EMR Viewer Real-world Systems vs. XDS-I Actors 2008 Canada Health Infoway Inc. 13

Issues To Be Addressed • (1) How to ensure interoperability of XDS-based systems with other solutions that handle discrete data (e. g. , Lab, Drug)? § How does an XDS Registry for DI evolve into and/or co-exist with other indexing scheme? § How to ensure other XDS/XDS-I consumers (e. g. , EMR) adopt Document Consumer actor capabilities to access DI content? • How to provide document sharing capabilities across multiple affinity domains? • How to ensure data quality attributes (e. g. , accuracy, completeness, integrity) are maintained/preserved in a data sharing environment? • How to provide a uniform clinical terminology given a multitude of terminology schemes and vocabularies? • How does a jurisdiction approach XDS Affinity Domain policies for consumers that are “associated “with the Affinity Domain (GP, Specialist) but not “in” the Affinity Domain? 2008 Canada Health Infoway Inc. 14 14

Issues To Be Addressed • (2) Synchronization of shared radiology studies § Radiology study split § Radiology study attribute changes § Deletion of a study component (e. g. radiology image) • Standardized representation of DI study in the XDS Affinity Domain § A single manifest § Multiple manifests • • Standardized use of XDS Affinity Domain attributes and metadata Division of responsibilities between PACS and DI-r Data synchronization between local PACS systems and DI-r Linking of documents from multiple repositories and support for consultation workflows including creation of new objects 2008 Canada Health Infoway Inc. 15

Terminology & Classification Systems Current & Future State Document Sharing • Document Registry Current State Future State Content & Format • Registry entries - eb. XML Terminology/Codes • To be standardized Storage & Retrieval • DI-rs • Doc Repositories Content & Format • Images & Manifests - DICOM • Reports - DICOM SR, HL 7 CDA R 2 Terminology/Codes • Implementation-specific Normalization HIAL POS Information Systems PACS Acquisition Modalities XRay 2008 Canada Health Infoway Inc. RIS CT Content & Format • Images & Manifests - DICOM • Reports - DICOM SR, HL 7 CDA R 2 Terminology/Codes • Adopted / Adapted / developed • Harmonized with pan-Canadian Terminology HIS MRI EMR / Viewer US Content & Format • Images - DICOM • Reports - DICOM SR, Text, PDF • Discrete Data Terminology/Codes • DICOM (SNOMED RT, LOINC) • ICD-10/10 CA • CCI • HL 7 v 2. x and v 3 Content & Format • Images - DICOM • Reports - DICOM SR, Text, PDF • Discrete Data Terminology/Codes • DICOM (SNOMED CT, LOINC) • ICD-10 CA, ICD-PSC • HL 7 v 3 Content & Format • Images – DICOM • Discrete Data Terminology/Codes • DICOM (SNOMED RT, LOINC) • ICD-9/10 • HL 7 v 2. x Content & Format • Images – DICOM • Discrete Data Terminology/Codes • DICOM (SNOMED CT, LOINC) • ICD-10 -CA • HL 7 v 3 16

Terminology Standardization: Candidate Data Entities Patient Provider and Delivery Site • Procedure Requestor, Facility • Request Recipient, Service Delivery Site Request • • Request Priority Indicator Clinical Reason for Request Status Consent Details Procedure • Modality • Anatomical Site, Position, Laterality, View Aspect • Contrast Medium • Specimen Details • Preparation Instructions • Procedure Performance Details • Procedure Substitution Details Clinical Status • Clinical Synopsis • Problem/Diagnosis • Observation • Adverse Reaction • Alert • Severity (of problem, diagnosis or allergic reaction) DI Study • Study & Series Details • Image Instances Report • • • Authorship, Review, Approval Interpretation, Findings, Comments Evidence Source: Diagnostic Imaging Data Specification; http: //www. nehta. gov. au 2008 Canada Health Infoway Inc. 17

XDS-I Metadata Attributes - Sample Metadata Attribute / Source Metadata Attribute/ Source Document Author Attributes Patient Attributes author. Specialty / Source system patient. Id / Imaging Document Source author. Institution / Source system source. Patient. Id / Source system author. Person / Imaging Document Source source. Patient. Info / Source system author. Role / Imaging Document Source author. Role. Display. Name / Document Submission Set Attributes Service Attributes practice. Setting. Code / Imaging Document Source practice. Setting. Code. Display. Name / class. Code / Imaging Document Source service. Start. Fime, service. Stop. Time / Source system confidentiality. Code / Source system type. Code, type. Code. Display. Name / Source system creation. Time / Source system XDS Submission Set Attributes format. Code / Imaging Document Source author. Department, author. Institution, author. Person parent. Document. Relationship /Source system content. Type. Code, content. Type. Code. Display. Name parent. Document. Id / Source system patient. Id mime. Type / Imaging Document Source source. Id submission. Time / Source system unique. Id 18 2008 Canada Health Infoway Inc.

XDS-I Value Proposition • Integrates information § Eliminates fragmentation of data captured and recorded in stand-alone systems through integration of data across organizations and systems § Improves quality of DI information (accuracy, completeness, consistency) § Addresses patient privacy and data security in a comprehensive and consistent manner • Improves Access § Provides timely access (anywhere, anytime) to DI information irrespective of where the images were acquired and the reports transcribed § Provides access to a longitudinal record of patient DI history § Improves timeliness and continuity of care § Enables collaboration among care providers § Improves training opportunity • Improves Productivity § Increases patient throughput, reduces patient transfers and wait times § Provides capabilities for Radiologists to share workload across the Affinity Domain § Reduces DI exams by reducing avoidable retakes • Improves Quality of Care § Reduces radiation exposure § Reduces medical errors 2008 Canada Health Infoway Inc. 19

2008 Events • Infoway Partnership Conferences § April 2008 (Toronto) § October 2008 (Montréal) Standards Collaborative Working Groups § § § § § SCWG 1 - Population Care SCWG 2 - Individual Care SCWG 3 - Managing the Healthcare System SCWG 4 - Medication Management SCWG 5 - Labs & Diagnostics SCWG 6 - Infostructure & Architecture SCWG 7 - Non-clinical Registries SCWG 8 - Privacy & IT Security Services SCWG 9 – Clinical Terminology • Project team meetings 2008 Canada Health Infoway Inc. 20

Conclusion • • IHE XDS-I is aligned with the pan-Canadian EHR architecture and accepted as the right approach to achieving seamless sharing of DI documents within the EHR § Declared a pan-Canadian Standard “stable for use” § All Provinces recognize the value of consolidating DI data in domain repositories § DI projects across Canada adopt XDS-I There are still outstanding issues to be addressed by: § Infoway invested DI projects § Infoway Standards Collaborative (Standards Collaborative Working Groups) § IHE Canada / IHE § Vendor community 21 2008 Canada Health Infoway Inc.

Thank you! Infoway Standards Collaborative Contact: Grant Gillis (ggillis@infoway-inforoute. ca) Infoway Solution Architecture Group Contact: Eugene Igras (eigras@infoway-inforoute. ca) 22 2008 Canada Health Infoway Inc.