© 2007 canada health infoway inc. 1 ihe workshop 2007 june 11, 2007 eugene igras lead architect...
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1© 2007 Canada Health Infoway Inc.
IHE Workshop 2007June 11, 2007Eugene IgrasLead ArchitectCanada Health Infoway Inc.
Achieving Diagnostic Imaging Data Sharing
2© 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
3© 2007 Canada Health Infoway Inc.
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.
4© 2007 Canada Health Infoway Inc.
• 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
5© 2007 Canada Health Infoway Inc.
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
6© 2007 Canada Health Infoway Inc.
EHRSEHRS EHRSEHRS EHRS EHRSEHRS
EHRS In Canada Federated Databases, Peer-to-Peer, Message Based
EHR SOLUTION (EHRS)
EHR INFOSTRUCTURE (EHRi)
EHR ViewerPoint of Service
Application
Point of Service
Application
AncillaryData &
Services
HealthInformation
DataWarehouse
EHRData &
Services
RegistriesData &
Services
Longitudinal Record Services
Health Information Access Layer (HIAL)
EHR SOLUTION (EHRS)
EHR INFOSTRUCTURE (EHRi)
EHR ViewerPoint of Service
Application
Point of Service
Application
AncillaryData &
Services
HealthInformation
DataWarehouse
EHRData &
Services
RegistriesData &
Services
Longitudinal Record Services
Health Information Access Layer (HIAL)
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
7© 2007 Canada Health Infoway Inc.
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
Longitudinal Record Services
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
8© 2007 Canada Health Infoway Inc.
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
9© 2007 Canada Health Infoway Inc.
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
10© 2007 Canada Health Infoway Inc.
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
ProvincialStandardsCouncils
ProvincialStandardsCouncils
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
Health Care StandardsDomain #2 pCSG
Health Care StandardsDomain #3 pCSG
Health Care StandardsDomain #4 pCSG
Health Care StandardsDomain #5 pCSG
Health Care StandardsDomain #6 pCSG
11© 2007 Canada Health Infoway Inc.
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© 2007 Canada Health Infoway Inc.
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
13© 2007 Canada Health Infoway Inc.
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© 2007 Canada Health Infoway Inc.
• 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
15© 2007 Canada Health Infoway Inc.
• 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
16© 2007 Canada Health Infoway Inc.
Alberta Diagnostic Imaging Domain in the EHR ContextJURISDICTIONAL INFOSTRUCTURE
Registries Data& Services
EHR Data & Services
ClientRegistry
ProviderRegistry
LocationRegistry
TerminologyRegistry
POINT OF SERVICE
BusinessRules
MessageStructures
NormalizationRules
SecurityServices
PrivacyServices
Configuration
Longitudinal Record Services
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)
17© 2007 Canada Health Infoway Inc.
XDS-I Actors and Interactions - Modification
18© 2007 Canada Health Infoway Inc.
Alberta DI XAD – Physical View in the EHR ContextJURISDICTIONAL INFOSTRUCTURE
Registries Data& Services
ClientRegistry
ProviderRegistry
LocationRegistry
TerminologyRegistry
POINT OF SERVICE
BusinessRules
MessageStructures
NormalizationRules
SecurityServices
PrivacyServices
Configuration
Longitudinal Record Services
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
19© 2007 Canada Health Infoway Inc.
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
Active/Active Replication
DR DR
PACsArchive
PACsArchive
Capital Repository
Primary Secondary
Active/Active Replication
DR DR
PACsArchive
PACsArchive
Calgary Repository
Primary Secondary
Active/Active Replication
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
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3
4
5
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8
9
9
20© 2007 Canada Health Infoway Inc.
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© 2007 Canada Health Infoway Inc.
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
22© 2007 Canada Health Infoway Inc.
Approach to Sharing Text Reports – Possible Future State
23© 2007 Canada Health Infoway Inc.
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© 2007 Canada Health Infoway Inc.
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© 2007 Canada Health Infoway Inc.
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© 2007 Canada Health Infoway Inc.
Acknowledgements
• Diagnostic Imaging Architecture Working Group, Alberta
• Solution Architecture Group, Infoway
• Standards Collaborative, Infoway
27© 2007 Canada Health Infoway Inc.
Website: www.infoway-inforoute.ca
E-mail: eigras@infoway-inforoute.ca
Thank you!
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