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

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

3. 2008 Canada Health Infoway Inc. 3 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

4. 2008 Canada Health Infoway Inc. 4 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 Value Proposition

5. 2008 Canada Health Infoway Inc. 5 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: EHRS Blueprint v2  Privacy & Security:Jurisdictional privacy protection legislation Privacy & Security Requirements & Architecture ISO/IEC 17799  Content & Messaging: HL7 v2.x and v3, 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 HL7 v3 ATNA – to support security Other IHE Radiology and IT Profiles  Electronic Business & Internet Standards

6. 2008 Canada Health Infoway Inc. 6 Standards used in DI Domain An array of standards address DI Requirements in Canada Internet Standards HTML/XML, HTTP, PDF, JPEG, MIME, UTF-8 … Electronic Business Standards ebXML, Web Services Healthcare Content, Messaging, Terminology HL7/CDA, DICOM, SNOMED CT LOINC, ICD-10-CA… EHRS Blueprint v2 Privacy & Security Privacy Legislation IHE Integration Profiles XDS/XDS-I, PIX/PDQ, ATNA…

7. 2008 Canada Health Infoway Inc. 7 Scope of the XDS Affinity Domain in the EHR Context JURISDICTIONAL INFOSTRUCTURE Ancillary Data & Services Registries Data & Services EHR Data & ServicesData 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 Hospital, LTC, CCC, EPR Physician Office EMR EHR Viewer Physician/ Provider Business Rules EHR Index Message Structures Normalization Rules Security Mgmt Privacy Data Config Services Physician/ Provider Lab System (LIS) Lab Clinician Radiology Center PACS/RIS Radiologist Pharmacy System Pharmacist Public Health Services Public Health Provider Longitudinal Record Services HIAL Communication Bus Common Services

8. 2008 Canada Health Infoway Inc. 8 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 HL7 v3 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 v3 messaging  Leverage MESA tools for conformance testing  Provide resources to IHE International through IHE Canada Infoway and IHE

9. 2008 Canada Health Infoway Inc. 9 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)

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

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

12. 2008 Canada Health Infoway Inc. 12 Real-world Systems vs. XDS-I Actors Document Registry Document Repository Imaging Document Source Patient Identity Source Document Consumer Imaging Document Consumer PACS Mod DI Repository (DI-R) Stores and maintains a lifetime record of relevant DI data including Images and reports Key image notes, image processing results & overlay information Presentation states and other evidence documents 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 DI-R PACS Mod RIS Mod

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

14. 2008 Canada Health Infoway Inc. 14 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? Issues To Be Addressed (1)

15. 2008 Canada Health Infoway Inc. 15 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

16. 2008 Canada Health Infoway Inc. 16 Terminology & Classification Systems Current & Future State Acquisition Modalities POS Information Systems Storage & Retrieval DI-rs Doc Repositories Document Sharing Document Registry HIAL CT MRI X- Ray US PACS HIS RIS EMR / Viewer Content & Format Images – DICOM Discrete Data Terminology/Codes DICOM (SNOMED RT, LOINC) ICD-9/10 HL7 v2.x Current State Content & Format Images - DICOM Reports - DICOM SR, Text, PDF Discrete Data Terminology/Codes DICOM (SNOMED RT, LOINC) ICD-10/10CA CCI HL7 v2.x and v3 Content & Format Images & Manifests - DICOM Reports - DICOM SR, HL7 CDA R2 Terminology/Codes Implementation-specific Future State Content & Format Registry entries - ebXML Terminology/Codes To be standardized Content & Format Images & Manifests - DICOM Reports - DICOM SR, HL7 CDA R2 Terminology/Codes Adopted / Adapted / developed Harmonized with pan-Canadian Terminology Content & Format Images - DICOM Reports - DICOM SR, Text, PDF Discrete Data Terminology/Codes DICOM (SNOMED CT, LOINC) ICD-10CA, ICD-PSC HL7 v3 Content & Format Images – DICOM Discrete Data Terminology/Codes DICOM (SNOMED CT, LOINC) ICD-10-CA HL7 v3 Normalization

17. 2008 Canada Health Infoway Inc. 17 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 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

18. 2008 Canada Health Infoway Inc. 18 XDS-I Metadata Attributes - Sample Metadata Attribute / Source Document Author AttributesPatient Attributes authorSpecialty / Source systempatientId / Imaging Document Source authorInstitution / Source systemsourcePatientId / Source system authorPerson / Imaging Document SourcesourcePatientInfo / Source system authorRole / Imaging Document SourceService Attributes authorRoleDisplayName /practiceSettingCode / Imaging Document Source Document Submission Set AttributespracticeSettingCodeDisplayName / classCode / Imaging Document SourceserviceStartFime, serviceStopTime / Source system confidentialityCode / Source systemtypeCode, typeCodeDisplayName / Source system creationTime / Source systemXDS Submission Set Attributes formatCode / Imaging Document SourceauthorDepartment, authorInstitution, authorPerson parentDocumentRelationship /Source systemcontentTypeCode, contentTypeCodeDisplayName parentDocumentId / Source systempatientId mimeType / Imaging Document SourcesourceId submissionTime / Source system uniqueId

19. 2008 Canada Health Infoway Inc. 19 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 XDS-I Value Proposition

20. 2008 Canada Health Infoway Inc. 20 2008 Events Infoway Partnership Conferences  April 2008 (Toronto)  October 2008 (Montr é al) 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

21. 2008 Canada Health Infoway Inc. 21 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

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