1. Standards at Infoway Overview for HITSP April 26, 2006 Dennis Giokas
Chief Technology Officer
Canada Health Infoway Inc.

2. Outline Introducing Infoway Key Definitions
Key Clinical and Business Requirements
Solution Architecture
Standards for Interoperability
Standards Landscape
Infoway Standards Collaborative
Standards Projects
Challenges and Lessons Learned 2

3. Canada Health Infoway Mission Vision Goal
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. Infoway’s Role – Strategic Investor
Infoway focuses on initial investment in a solution & its deployment. Our unique role is in providing strategic leadership.
Funder
Strategic Investor
Intervener
Developer
“Invest, advise & monitor”
“Fund & ignore”
“Work alongside & take over if needed”
“Write code & build modules”
Invests with Partners
Involved in project planning
Monitors progress of projects and quality of deliverables
Gated funding manages risk
Infoway is Not
A Granting Agency
A Venture Capital Fund
A builder, direct implementer or holder of proprietary solutions
Leadership in setting strategic direction and standards for EHR deployment across Canada
An active partner, contributing to all aspects of the projects, while establishing a broad knowledge & experience base across Canada

5. © 2006 Canada Health Infoway Inc.
EHR
An Electronic Health Record (EHR) provides each individual in Canada with a secure and private lifetime record of their key health history and care within the health system. The record is available electronically to authorized health providers and the individual anywhere, anytime in support of high quality care.
This record is designed to facilitate the sharing of data – across the continuum of care, across healthcare delivery organizations and across geographies.
© 2006 Canada Health Infoway Inc. 5

6. 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
Longitudinal View Assumptions
Care provider professionals recognize high value in having access to the longitudinal view of the clinical picture of a patient. Enough so to accept changes towards their use of HIS in every day practice of care. The foremosts benefits must be:
Better information equal better decisions
Saves time – more patient can benefit from care
Reduces potential for error
Reduces costs
Value is tangible and high enough to enable change
Care professionals
Care organizations management and board of directors
Shared across territories Assumptions
Legal - Provincial policies towards privacy and confidentiality (i.e. HIA) will be written in a way that does not prohibit cross-jurisdictional use of clinical data;
Adaptive to future - Assumptions
Net new – Nation wide, province or state wide EHRS do not currently exist in Canada or elsewhere in industrialized countries.
Healthcare delivery constantly evolving: The future of healthcare in Canada incorporates more specialty care centres in large cities while maintaining high levels of service for rural populations. Expected growth of travelling patients, across regions, across provinces.
Specialty care centres – localized expertise in specific domains
Maintain high level of service for rural populations
State of readiness of care providers varies greatly
Internal interoperability enabled and evolving
CDR in early adoption cycle
The state of readiness towards integration and interfaces with a provincial EHR varies greatly. We expect system interfacing solutions to be omnipresent and CDR solutions to still be in early adoption cycles by the time EHR is ready for mainstream deployment.

7. © 2006 Canada Health Infoway Inc.
High Level View of the Solution Architecture
© 2006 Canada Health Infoway Inc. 7

8. © 2006 Canada Health Infoway Inc.
EHR Infostructure
The EHR Infostructure is a collection of common and reusable components in the support of a diverse set of health information management applications. It consists of software solutions to support integration with the EHR, data definitions for the EHR and messaging standards for integration and interoperability.
It is made up of:
Registry systems to manage and provide peripheral information required to uniquely identify the actors and resources in the EHR. Specifically, these are patient/person, provider, the location, end users of applications, the terminologies used to describe diseases, acts or others.
EHR domain repositories that manage and persist subsets of clinical data pertinent to the clinical picture of a client. A diagnostic imaging PACS solution is an example of a Domain Repository.
A Longitudinal Record Service to coordinate the patient centric accesses, updates and location of data across multiple domains and registries.
Standardized common services and communication services to sustain the privacy, security and overall interoperability of the different components within the infostructure, as well as to sustain interoperability and a high degree of abstraction between the EHR infostructure and the Point of Service (PoS) applications.
Standardized information and message structures as well as business transactions to support the exchange of information in and out of the EHR;
An EHR viewer as a generic presentation application allowing end-users to access, search and view relevant and authorized clinical data about clients
© 2006 Canada Health Infoway Inc. 8

9. Key EHRS Architecture Concepts
EHR SOLUTION (EHRS)
EHR INFOSTRUCTURE (EHRi)
EHRS Locator
Ancillary Data & Services
Health Information Data Warehouse
Longitudinal Record Services
EHR Data & Services
Registries Data & Services
Health Information Access Layer (HIAL)
How does data get into the EHR?
Data is pushed or published into EHR
From source systems
Viewing data in the EHR
Generally from the applications the providers use in their daily context
E.g. primary care doctor EPR applications have means to view and navigate the EHR
Emergency room doctor from the hospital CDR and EHR
Point of Service Application
Point of Service Application
EHR Viewer

10. EHRS In Canada Federated Databases, Peer-to-Peer, Message Based
EHR SOLUTION (EHRS)
EHR SOLUTION (EHRS)
EHR INFOSTRUCTURE (EHRi)
EHR INFOSTRUCTURE (EHRi)
Longitudinal Record Services
Longitudinal Record Services
Ancillary Data & Services
Health Information Data Warehouse
Health Information Access Layer (HIAL)
EHR Data & Services
Registries Data & Services
Ancillary Data & Services
Health Information Data Warehouse
Health Information Access Layer (HIAL)
EHR Data & Services
Registries Data & Services
Point of Service Application
Point of Service Application
EHR Viewer
Point of Service Application
Point of Service Application
EHR Viewer
Speed
Real-time on read requests: response time under 2 seconds
Near real-time on updates
Legal Assumption - Exchanges of clinical patient information between systems will be achievable at reasonable speeds while applying consent policies as part of privacy and confidentiality rules and regulations
Scalable
From growth in number of source systems
From growth in point-of-care usage
From growth in territory coverage
From growth in surveillance usage
From growth in administrative usage
Reliable (High Availability)
Redundancy: Power, Network, Servers (Application & Database), Disks
Healthy economic balance in HIS vendor industry
It is possible to maintain healthy business dynamics in the HIS vendor industry while insuring the uptake of a central source of EHR data in all provinces;
EHRS
EHRS
EHRS
EHRS
EHRS
EHRS
EHRS

11. Standards-based Solutions Standardized Architecture
Standardized Interfaces
Standards-based
Solutions
Standardized Data
Structures
Standardized Data
Vocabularies
Standardized Functional
Behaviour
© 2006 Canada Health Infoway Inc. 11

12. 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
Standards
Infoway’s role is to set standards and requirements for robust, interoperable products and outcomes

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

14. Principles for Establishing Pan-Canadian EHRS Standards
Infoway has created Principles for Establishing pan-Canadian EHRS
Standards to provide guidance in the adoption of standards-based solutions
11 Principles – accessible via the Infoway Knowledge Way
Business-driven
Adoption of existing standards where ever possible
HL7 V3 for all new message development
Establishment of pan-Canadian EHR standards is coordinated via an open, transparent and inclusive Stakeholder Collaboration Process as defined by our stakeholders
International collaboration and balloting of standards work

15. Canadian Standards Community
Complexity of the Standards Landscape
Standards Organizations
Standards Development Organizations (SDOs)
Licensing and Maintenance
Certification and Conformance
Approval and Endorsement
Integrators
Funders & Investors

16. Infoway Standards Projects
1- Need Identification
& Business Definition 8 1 7
2- Options Analysis & Selection Decision
3- Development & Stable for Use Decision 6
Standards Selection Decision Point (e.g. Use existing, adapt, develop)
4- Test/Pilot & Approval 2
5- Training/Education 5 3
6- Implementation 4
7- Conformance
Stable for Use decision point (optional)
Final Approval decision point
8- Maintenance & Support
Note: Process is not linear
Standards
Collaborative
Program
Projects

17. Infoway Standards Collaborative
Scope
Infoway will be home for development, ongoing operations, SDO liaisons, and pan-Canadian collaboration and coordination of standards
Includes collaboration and coordination functions of HL7 Canada, Partnership, ISO (as shared with Canadian Standards Association), DICOM Liaison
Scope is standards within Infoway’s mandate for the EHR and eClaims standard (NeCST)
Type of standards include: Messaging, Vocabulary and Interoperability Profiles

18. Conformance for pan-Canadian Standards
Definition of Conformance
Conformance includes the development of pan-Canadian standards business requirements, the conformance testing against these business requirements, and certification.
Scope
Functional, message level interoperability, privacy and security, usability
Infoway and the eHealth Collaboratory will share responsibilities for conformance on pan-Canadian Standards
Infoway (Standards Collaborative) will undertake the development of business requirements, including the development of conformance statements, for the pan-Canadian approved standards;
The eHealth Collaboratory (Collaboratory) will undertake the building of the conformance testing environment, the development of the testing processes and will undertake the actual conformance testing against the established business requirements.

19. Infoway Standards Collaborative Functional Model
CTO
Governance
Group Director
Standards
Collaboration
Process
Support, Conformance,
Maintenance
Education,
Training, Events
Standards
Development
SDO Secretariat
& Liaison
Complete to approval
Test/pilot
Stds. Maintenance
Implementation support
Conformance/Certification
Change Management
SNOMED
LOINC
Others terminologies
Structural codes for iEHR
OIDs
Artifacts repository
Training artifacts
Training services
Train-the-trainer
Marketing/Communications
Partnership
HL7 Canada education
IHE Canada education
Strategy
Development
Investment oversight
Approvals – Investment deliverables
Compliance (gated funding)
Benefits Evaluation
Adoption
HL7 Inc.
IHE
ISO
SNOMED
LOINC
DICOM
HL7 Canada
IHE Canada
CAC/Z295
Distribution and Rights Management
HISCs
Example – not meant to represent any organizational model

20. Standards Collaboration Process (SCP)
The EHR Standards Steering Committee which leads and approves pan-Canadian EHR information standards within the context of Infoway investment programs
The EHR Standards Advisory Committee which recommends information standards for approval by the EHR Standards Steering Committee and coordinates and guides the activities of pan-Canadian Standards Groups
A number of pan-Canadian Standards Groups that guide the standards requirements of individual Infoway programs
An expert group of resources available to provide cross-program technical and subject matter expertise in standards

21. Standards Portfolio Data & Messaging Standards
Architecture Standards
EHRS Blueprint
EHR Use Cases
EHR Data Model
EHR Services Model
EHR Interoperability Profiles
Data & Messaging Standards
eClaims (Primary Care, Oral, Vision, Chiro/Physio) HL7 v3 (complete)
Client Registry HL7 v2.4 & HL7 v3 (complete)
Provider Registry HL7 v3 (in ballot)
Drug Information Systems HL7 v3 (in ballot)
Laboratory HL7 v3 (in development)
Diagnostic Imaging/Teleradiology DICOM, IHE (complete)
iEHR Clinical Messaging HL7 v3 (in development)
iEHR Technical Standards (in planning)
Public Health Standards HL7 v3 (in development)
Clinical Terminology Strategy (complete)
Terminology Standards (SNOMED, LOINC, ICD10-CA, CCI)

22. Standards Projects – Typical Deliverables
Standards Specifications
Messaging schemas
Codesets
IHE Profiles
Business Requirements
Use Cases
Implementation Guide
Training, Marketing Materials; White Papers; Project Governance Artifacts (project reports, decision criteria)

23. Lessons Learned & Key Challenges
Standards Collaboration Process is a success!
Stable for Use Standards and Selected Standards Strategies in 1 year
Active engagement and collaboration across the country and internationally
Needed additional decision points along the Standards Life Cycle
Appropriate level of detail and amount of information to make decisions is different for different committees
Translating between technical and business “speak”
Stakeholder and expert overburden
Being very clear and specific on what decisions and words mean
E.g. select vs adopt vs mandate
Standards readiness – for test/pilot, for implementation projects
Policy and EHR implementation issues versus standards issues
One strategy or one development methodology doesn’t fit all

24. Thank you! Website: www.infoway-inforoute.ca

25. Client Registry Standard Business Functions Key Dates
Messaging: HL7 v2.4 & v3.0
Vocab: HL7 Domain Tables
EIP:
Currently Available at:
Messaging Package Overview
Implementation Guide,
V2.4 Conformance Profiles,
Client Registry Schemas
Add Client – to a registry
Update Client – to data in a registry
Delete Client – to delete a client record added in error to a registry
Link Client – linking of two records (both records remain active)
Unlink Client – the unlinking of two records in a registry
Merge Client – merging of two records
Unmerge Client – unmerging of two records
Get Client Demographics Query Request – to request demographic data when the client identification is known
Get Client Demographics Query Response
Query Client – list of clients matching query parameters
Query Client Response
International
HL7 PATC Committee Ballot – passed Sept 2005
HL7 Membership Ballot – due Jan06
ISO-TC215 “Subjects of Care” – harmonized
IHE Integration Profiles (PIX/PDQ) being re-purposed for HL7v3 – approved for 2006 Roadmap
National
HL7 Canada – Realm localization ballot reconciliation March 2006
Stable for Use approval by SSC March SAC Approved as Stable for Use January 2006
All Review cycle documents:

26. Provider Registry Standard Business Functions Key Dates
Messaging: HL7 v3.0
Vocab: Provider Role Types, HL7 Domain Tables
EIP:
Currently Available at:
Messaging Package Overview
Implementation Guide,
Provider Registry Schemas
Add Provider/Request Confirmation Response
Add Provider Notification (Broadcast)
Revise Provider Notification (Broadcast)
Revise Provider Request/Confirmation Response
Provider Details Query/Provider Detail Response
Find Associated Identifiers Query/Response
International
HL7 PMTC Membership Ballot – passed Sept 2005
National
HL7 Canada – Realm localization ballot reconciliation March 2006
Stable for Use approval by SSC March SAC Approved as Stable for Use January 2006
All Review cycle documents:

27. CeRx (Drug) Standard Business Functions Key Dates Messaging: HL7 v3.0
Vocab: Investigating HL7 Domain Tables, CCI, DIN, Encode FM, LOINC, Anatomical Therapeutic Classification, Investigating SNOMED CT, Uniform Codes for Unit of Measure, IETF RFC 1766, Mime Media Types, URLSchema, Active Ingredient Code
EIP:
Currently Available at:
Sept 2005 Version – 4 zip files –
Messaging Overview
Implementation Guide,
Schemas
Vocabulary
Technical & Business artefacts
Core Prescribing and Dispensing Functions
Prescribing
Dispensing
Patient Medication Queries
Prescription Status Management
Support (Generic Undo)
Updates (Notes)
Clinical Access Control
Related EHR Data with Drug Domain Significance
Allergy/Intolerance
Medical Conditions
Basic patient Observations
Immunization
Leverage Drug Knowledge Bases
Drug Queries
Contraindications
Related Functions
ADR
Professional Service
Infrastructure
International
HL7 Pharmacy SIG – Committee Ballot for core CeRx items - Jan 2006
National
Implementable Specifications Published Dec 2005
Approval as Stable for Use Spring 2006

28. Cross Enterprise Document Sharing for Imaging EHR Interoperability Profile (XDS-I)
Standard
Business Functions
Key Dates
Interoperability Profile: XDS-I
EIP:
Currently Available at:
XDS-I White Paper Final
DI-TR pCSG Use Case Scenarios v4 Final
2 Technical Review artefacts
XDS-I Interoperability Profile specifies a solution for sharing imaging documents, specifically
Medical Images in DICOM format
Medical Images in JPEG format
Radiology reports in plain text and PDF format
All other DICOM objects
The objective of this interoperability profile is to address the technical challenges of sharing images and reports between operational Picture Archiving and Communications Systems (PACS) and Radiology Information Systems (RIS).
The interoperability profile standardizes the format, transactions and protocols for communcationg imaging information between systems as well as defines the interoperability expectations with client registries.
International
IHE International Approval August 2005
IHE Vendor Connectathon – Jan 2006
National
Implementable Interoperability Profile XDS-I Published Nov 2005
SCP Review – SSC Approval as Stable for Use March 2006

29. Laboratory Standard Business Functions Key Dates Messaging: HL7 v3.0
Interoperability Profiles
Vocab: HL7 Domain Tables, LOINC, SNOMED CT, SI Units and others that will be identified as the project progresses
EIP: Blueprint EIPs supported will be identified during the project
Will be Available at:
For the exchange of lab information between LIS-JLIS-EHR:
Order Requests, Referral of Orders, Redirect of Orders, Revise Orders, Cancel Orders, Order Promises, Order Status, Filler Orders, Unsolicited Results, Query Results, Result Query Response, Result Status
International
HL7 Balloting Mid 2006-Spring 2007
National
Implementable Specifications Published Fall 2006
SCP Review – SSC Approval as Standard Selection Strategy March 2006
Stable for Use approval of specification – Fall 2006

30. Public Health Surveillance
Standard
Business Functions
Key Dates
Messaging: HL7 v3.0
Interoperability Profiles
Vocab: HL7 Domain Tables, SNOMED CT, CCI, ICD10-CA, Free Text, and others that will be identified as the project progresses
EIP: Blueprint EIPs supported will be identified during the project
Will be Available at:
Infoway Knowledgeway
58 Transactions in 5 packages:
Package 1: Case & Outbreak Management
Package 2: Immunization Management
Package 3: Vaccine & Materials Management
Package 4: Alert Management
Package 5: Other
International
HL7 Balloting Mid 2006-Early 2007
National
Specifications Published December 2006
Stable for Use approval of specification – Early 2007

31. iEHR Standards Project
Business Functions
Key Dates
Messaging: HL7 v3.0
Vocab: HL7 Domain Tables, SNOMED CT, CCI, ICD10-CA, Free Text, and others that will be identified as the project progresses
EIP: Blueprint EIPs supported will be identified during the project
Will be Available at:
Infoway Knowledgeway
Package 1
Encounter History
Discharge Summary
Package 2
Clinical Summary
Service Delivery Location
Package 3
Observations
Referral Notes
Health Conditions
International
HL7 Balloting Mid 2006-March 2006
National
Implementable Specifications Published Summer 2006
Stable for Use approval of specification – Fall 2006

32. Clinical Terminology Integration Project
Standard
Business Functions
Key Dates
Messaging: none
Interoperability Profiles
Vocab: SNOMED CT, CCI, ICD10-CA, Free Text
EIP:
Information Currently Available at:
Selected Terminologies for:
Diagnosis, State of Diagnosis, Family History, Genetic Condition, Non-Drug Agent Adverse Reaction. , Non-Drug Offending Agent Type , Non-Drug Offending Agent Description, Severity relating to Non-Drug related Severities of Adverse Reactions, Allergy: Non-medication Allergy , Risk Factor, Exposure, Intervention, Clinical Symptom / Health Problem (Clinical Finding), Physical Assessment Finding, Psychological/Mental Assessment, External Cause, Place of Occurrence, Anatomical Site, Episodicity, Course, Occurrence, Number, Onset, Patient Health Problem
International
National
SCP Review – SSC Approval as Standard Selection Strategy March 2006