DICOM INTERNATIONAL DICOM INTERNATIONAL CONFERENCE & SEMINAR April 8-10, 2008 Chengdu, China 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 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

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.

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.

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.

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

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.

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.

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.

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

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

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.

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

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.

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.

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

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.

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

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.

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

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).

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

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).

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

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

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.

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.

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

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.

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.

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.

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.

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)

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.

Diagnostic Accuracy GROUND GLASS OPACITY

JPEG :1ORIGINAL Comparison side-by-side

Examples PNEUMOTHORAX JPEG :1ORIGINAL

CALCIFICATIONS JPEG :1ORIGINAL Examples

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

Results

J2K vs. JPG J2K 15:1JPEG 15:1 Noticeable degradationNo 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.

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 CR/DRCTUSMRNMMG Angio Body20-30JPEG J2K Breast Chest MSKJPEG J2K NeuroJPEG 8-12 J2K Ped

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

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.

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

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

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

Interoperable EHR Implementation of solutions that allow clinicians to view and update an integrated patient-centric health record anywhere at any time. Supports EHR initiatives that demonstrate value and benefits in a specific health practice domain integrating information across multiple points of service and multiple caregivers. Commercially available integrated EHR solutions will be deployed regionally or supra-regionally to demonstrate interoperability, scalability and replicability.

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

Innovation & Adoption Infoway supports initiatives that bring clinical value and optimize the use of EHR: –Knowledge portals –Evidence-based medicine –Computerized physician order entry and clinical decision support systems. –Disease management solutions.

Conclusion Canada started late in the implementation of a nationwide Electronic Health Record, but has developed a tremendous effort to get 50% of the population covered by end of 2010 through a number of initiatives supported by Canada Health Infoway. We’ll do our best to reach this goal.

Conclusion Thank you.