1. Achieving Diagnostic Imaging Data Sharing
IHE Workshop 2007
June 11, 2007
Eugene Igras
Lead Architect
Canada Health Infoway Inc.

2. 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. 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. 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.

5. Key EHRS Architecture Concepts
EHR SOLUTION (EHRS)
EHR INFOSTRUCTURE (EHRi)
EHRS Locator
Longitudinal Record Services
Ancillary Data & Services
Health Information Data Warehouse
EHR Data & Services
Registries Data & Services
Health Information Access Layer (HIAL)
Standardize and coordinate patient centric access
Subscribe to access, search and view
Publish Clinically Relevant Data
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.
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

6. EHRS In Canada Federated Databases, Peer-to-Peer, Message Based
EHR SOLUTION (EHRS)
EHR SOLUTION (EHRS)
Resilient and highly scalable systems within the 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
Real-time read requests – sub 2 seconds
Legal Environment to support exchange of clinical patient information between systems
Near real-time publish and update
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

7. Ancillary Data & Services Registries Data & Services
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
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

8. 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
Infoway’s role is to set standards and requirements for robust, interoperable products and outcomes

9. Ancillary Data & Services Registries Data & Services
EHR Infostructure: Standards-based Connectivity
JURISDICTIONAL INFOSTRUCTURE
Ancillary Data & Services
Registries Data & Services
EHR Data & Services
Data Warehouse
POINT OF SERVICE
EHR IP Standards
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 IP
HIAL

10. 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.

11. The Future
A single point of contact for coordination of Pan-Canadian standards throughout the standards 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. Integrated & Coordinated pan-Canadian Standards Services
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
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
Simple, Open & Transparent Governance
Ongoing standards sustainability and relevance
Prioritize, fund and deliver maintenance of Infoway-developed standards
Maintenance Services
Development Strategy
Development
Alignment of Development principles, approaches and deliverables
Development Support
Develop conformance strategy & governance
Promote adherence to Standards
Develop & publish conformance criteria
Liaison with eHealth Collaboratory
Conformance Services
Development of Training materials & programs
Provision of general and specific standards education
Outreach training services
Education & Training
Implementation resource development
Implementation acceleration & support services
Stable For Use Standard quality validation & promotion
Implementation Services

13. 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. Infoway and IHE 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

15. XDS-I within Canada
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

16. Alberta Diagnostic Imaging Domain in the EHR Context
Longitudinal Record Services
Common Services
Alberta Diagnostic Imaging Domain in the EHR Context
Communication Bus
JURISDICTIONAL INFOSTRUCTURE
Registries Data & Services
Ancillary Data & Services
EHR Data & Services
Data Warehouse
Client Registry
Diagnostic Imaging
Repository
Provider Registry
Location Registry
Business Rules
XDS Doc
Registry
Message Structures
Normalization Rules
Terminology Registry
Security
Services
Privacy
Services
Configuration
pHIE
RSHIP*
PACS/RIS
Capital Health
PACS/RIS
Calgary Health Region
PACS/RIS
POINT OF SERVICE
EHR Viewer
* RSHIP – Regional Shared Health Information Program - (non-metro RHAs)

17. XDS-I Actors and Interactions - Modification

18. Alberta DI XAD – Physical View in the EHR Context
Longitudinal Record Services
Common Services
Alberta DI XAD – Physical View in the EHR Context
Communication Bus
JURISDICTIONAL INFOSTRUCTURE
Registries Data & Services
Ancillary Data & Services
EHR Data & Services
Data Warehouse
Client Registry
Provider Registry
Location Registry
Business Rules
XDS Doc
Registry
Message Structures
Normalization Rules
Terminology Registry
Security
Services
Privacy
Services
Configuration
pHIE
RSHIP PACS/RIS
PACS
Archive
XDS Doc
Repository
Capital Health PACS/RIS
PACS
Archive
XDS Doc
Repository
Calgary Health Region PACS/RIS
PACS
Archive
XDS Doc
Repository
EHR Viewer
POINT OF SERVICE

19. Alberta DI XAD – Physical View (still in the development stage)

20. 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. 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 Registry
Under 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. Approach to Sharing Text Reports – Possible Future State

23. 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. 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. 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. Acknowledgements
Diagnostic Imaging Architecture Working Group, Alberta
Solution Architecture Group, Infoway
Standards Collaborative, Infoway

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