EHR Profiles for Interoperability between DI and RegistriesEHR Profiles for Interoperability between DI and Registries

Diagnostic Imaging Program Diagnostic Imaging Program Canada Health InfowayCanada Health Infoway

Peter BakRon Parker

Sharon Moore

September 29, 2004

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Agenda

Overview of Canada Health Infoway (Infoway) What is Infoway all about? What is the DI Program within Infoway?

Overview of DI-5 Project: EHR Interoperability Profiles for DI-r

Problem Statement Solution Proposal Deliverables

Current thinking Jurisdictional EIP Cross-jurisdictional EIP

IISIG input Discuss existing initiatives / alignment with this project Discuss how IISIG can contribute to the process/solution

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Overview of Canada Health Infoway…

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About Infoway

Infoway was created in response to a commitment of Canada's First Ministers to "work together to strengthen a Canada-wide health infostructure to improve quality, access and timeliness of health care for Canadians."

Infoway is an independent, not-for-profit corporation. Our members are the deputy ministers of health from across Canada.

Infoway now has $1.1 billion in investment capital. The Government of Canada allocated an initial $500 million in 2001, and provided an additional $600 million following the 2003 First Ministers' Accord on Health Care Renewal.

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About Infoway cont…

Infoway is a strategic investor. Our priority is interoperable electronic health record (EHR) solutions and related telehealth development.

Our business is investing with partners to develop, replicate and deploy robust, reusable interoperable EHR solutions faster, better and more cost effectively than any of our partners can do alone.

Once investment decisions are made, our partners lead the development, implementation and deployment of the EHR solutions.

Infoway’s plan envisions having the basic elements of interoperable EHR solutions in place in half of all Canadian jurisdictions by 2010.

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Infoway’s Mission and Vision

Infoway’s mission is 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. Infoway will build on existing initiatives and pursue collaborative relationships in pursuit of our mission.

Our vision is a high-quality, sustainable and effective Canadian health care system supported by an infostructure that provides residents of Canada and their health care providers timely, appropriate and secure access to the right information when and where they enter into the health care system. Respect for privacy is fundamental to this vision.

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Infoway’s Strategy

Mandate: Develop the key elements of a pan-Canadian interoperable EHR solutions – six year timeframeMandate: Develop the key elements of a pan-Canadian interoperable EHR solutions – six year timeframe

The Strategy1. Focus on six Investment Programs2. Collaborative planning with health ministries and other

partners3. Form strategic alliances with private sector4. Focus on end-users to gain acceptance5. Public sector sponsors with investment in projectsInfoway’s Investing Philosophy Accelerate the development of EHRS involves breaking new

ground Reduce costs and overall risk; accelerate implementation Adjust strategy to reflect learning and experience

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Building Blocks of the EHRS

Registries – applications that serve as the source of truth for patients, physicians and facilities

Laboratory Information Systems (LIS) – applications that collect, manage and distribute laboratory results

Diagnostic Imaging (DI) Systems – applications that collect, manage and distribute diagnostic imaging results

Drug Information Systems (Rx) – applications that manage and track drug prescribing and usage

Infostructure – applications that allow EHR applications to inter-operate and users to access information from anywhere and at anytime i.e. the “glue” of the EHR

Telehealth – applications that allow for distance medicine

Public Health Surveillance – application to monitor exceptional health events

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EHRS Blueprint

Registries Program• Client• Provider• Location

Clinical Domain Programs• Rx• Lab• DI

Infostrcture Program• EHR• HIAL

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Implementation Strategy

Taking a “bottom up” approach Implement components of the EHR using existing

infrastructure Develop standards to ensure interoperability Connect the components when they are ready

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Infoway DI Investment Program

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Infoway Diagnostic Imaging (DI) Program

Mandate Facilitate the EHR by deploying Diagnostic Imaging domain

repositories (DI-r) across Canada

Connect facilities together through the DI-r Drive “filmless” operation in every facility in the country Deploy DI-r within half of all Canadian jurisdictions within the next six

years Delivered through five projects, each with a different focus

System Definition: Diagnostic Imaging Repository A solution that allows “view-only” access to DI images and reports

(“results”) by physicians from any location and regardless of where the exam was completed

A PACS (Picture Archive and Communication System) application shared among hospitals in a jurisdiction with over 1M population, and scalable to over 1.5M exams annually

A PACS application integrated with Hospital Information Systems (HIS), Radiology Information Systems (RIS), Modalities (CT, MRI, X-Ray, etc.) and the Infoway EHRS using interoperability standards

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DI Investment Targets

DI-rDI-r

DI-rDI-r

DI-r

DI-r

DI-r

DI-r

DI-r

DI-r

DI-r

DI-r

DI-r DI-r

DI-r

DI-r

DI-r

DI-r

DI-r

DI-r

DI-r

DI-r

DI-r

• DI investment estimate $220-280M

• Assumes a total of 22 to 25 implementations @ $8-12M

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DI Architecture Approach

Challenges To achieve filmless operation in the smaller rural facilities in a

cost effective and timely fashion To allow the sharing of DI results among stakeholders within

and across jurisdictions

Approach: “shared system” Minimize the amount of PACS infrastructure deployed in the

smaller facilities by centralizing it at a regional “hub” or the DI-r

Share PACS management resources across the region Leverage economies of scale to drive down capital and

operating costs Implement “Interoperability” profiles for DI-r

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DI Architecture Approach

Single centralized PACS Single PACS database managed out of a single facility. No local cache and no local database Reliant on high bandwidth network

Single vendor / distributed PACS Centralized primary database and long term archive (DI-r) Multiple instances of the database and local cache deployed at

facilities within the region

Multiple vendor / distributed PACS Centralized DI-r Multiple instances of PACS deployed throughout the region.

These PACS are from multiple vendors and are connected to the DI-r

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Overview of the DI-5 Project…

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Problem Statement

Client and provider registries are being considered for replication in several provinces.

In five provinces (NL, NS, NB, SK and MB) one or more registries will be deployed in conjunction with a Provincial DI repository (DI-r).

While the EHRS Blueprint provides the high-level descriptions of the role each component plays, it does not include detailed requirements and specifications on how components will interoperate.

Within the next few months, Infoway will have to provide guidance to the Provinces on how to integrate these components in a standard approach.

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Solution Proposal

Develop the required EHR interoperability specifications through a cross-program project, including: Registries and DI programs Solution architecture group Group of external experts

Define the business and technical requirements for integration between DI, registries and EHR users

Identify and scope the standards development effort of creating the messages required to meet these requirements

Promote adoption by IHE

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Deliverables

EHR Interoperability Profiles Between DI-r and Client Registry Between DI-r and Provider Registry Between DI-r and EHR users

EHR Business Use Cases Express use cases using standards based methodology e.g.

UML as per IHE EHR Application Role definition (functional requirements)

Identification of solution models Includes DI Repository, client and provider registries

Definition of EHR Transactions Interaction diagrams for EHR Transactions

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Current thinking…

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Jurisdictional EIP

Following the IHE Cross Enterprise Document Sharing (XDS) Profile nomenclature…

…a jurisdiction is defined by A single affinity domain A single document registry (preferred) One or more document repositories Multiple document sources Multiple document consumers

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Jurisdictional EIP Based on IHE Cross Enterprise Document Sharing (XDS)

Profile “Document Repository” – hosts DI images and reports

– DI-r

– Expected to be based on a PACS application

“Document Registry” – index of documents = EHR Directory– Eventually become the “registry” for all EHR “documents”: Lab results, Rx,

etc.

– For DI, includes images, reports and orders

“Document Source” – RIS or Voice Recognition system provide reports

– Modalities, but more likely a PACS, provide images

XDS assumes a normalized PID is available at the document source. However, in Canada… … we wish to limit the number of Patient ID Consumers that interact

with the Client Registries … most CR implementations will NOT provide a UPI to consumer

systems … we need a variation to the current XDS profile!

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Jurisdictional EIP

XDS does not prescribe the service for delivery of “documents” XDS notifies consumer of document type Up to implementation model to define the delivery

method of the document e.g. transfer syntax for images

Current information distribution solutions are proprietary Images via proprietary wavelet and streaming

techniques Reports via a multitude of formats: Structured report,

CDA, html, etc.

… we need to standardize how information is delivered to document consumers

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EIP within a Jurisdiction/Affinity Domain

XDS Document Registry(Patient Identity Consumer)

XDSDocument

Repository

ADTPatient Identity Source

Patient Patient Identification Identification

Domain CDomain C

Patient Patient Identification Identification Domain D2Domain D2

DocumentEntryDm=CPid=Pc

Client Registry(Patient Identity X-Ref Mgr)

XDS Document Source

XDS Doc

XDS Doc

XDS Document Consumer

EMR EHR Portal

Dm=D2Pid=Pd

Dm=CPid=Pc

Dm=CPid=Pc

Jd = NL Dm=D2Pid=Pz

Jd = NL Dm=D2Pid=Pa

Jd = NL Dm=D2Pid=P1

Jd = NL Dm=CPid=Pd

Images

RIS

Register Document MRN Document ID (OID)

RIS

Report (RIS)Images (PACS)

Reading Station

Reports

PACS?

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EIP within a Jurisdiction/Affinity Domain

XDS Document Registry(Patient Identity Consumer)

XDSDocument

Repository

ADTPatient Identity Source

Patient Patient Identification Identification

Domain CDomain C

Patient Patient Identification Identification Domain D2Domain D2

DocumentEntryDm=CPid=Pc

Client Registry(Patient Identity X-Ref Mgr)

XDS Document Source

XDS Doc

XDS Doc

XDS Document Consumer

EMR EHR Portal

Dm=D2Pid=Pd

Dm=CPid=Pc

Dm=CPid=Pc

Jd = NL Dm=D2Pid=Pz

Jd = NL Dm=D2Pid=Pa

Jd = NL Dm=D2Pid=P1

Jd = NL Dm=CPid=Pd

Images

RIS

Register Document MRN Document ID (OID)

RIS

Report (RIS)Images (PACS)

Reading Station

Reports

PACS?

Reports:• Could come from the RIS or VR system

Images:• PACS serves as the document source as it may be impractical

to have all modalities comply as document sources

PID• Make use of local MRN – do not normalize PID with Client

Registry• Need to pass accession # and possibly other #s even though

the document registry is OID based

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EIP within a Jurisdiction/Affinity Domain

XDS Document Registry(Patient Identity Consumer)

XDSDocument

Repository

ADTPatient Identity Source

Patient Patient Identification Identification

Domain CDomain C

Patient Patient Identification Identification Domain D2Domain D2

DocumentEntryDm=CPid=Pc

Client Registry(Patient Identity X-Ref Mgr)

XDS Document Source

XDS Doc

XDS Doc

XDS Document Consumer

EMR EHR Portal

Dm=D2Pid=Pd

Dm=CPid=Pc

Dm=CPid=Pc

Jd = NL Dm=D2Pid=Pz

Jd = NL Dm=D2Pid=Pa

Jd = NL Dm=D2Pid=P1

Jd = NL Dm=CPid=Pd

Images

RIS

Register Document MRN Document ID (OID)

RIS

Report (RIS)Images (PACS)

Reading Station

Reports

PACS?

Reports:• The RIS may be the Document repository for the

reports• The PACS may be the Document repository for

the reports• Need to consider “actors” specifically for reports

(??)

Images:• PACS is the likely candidate to be the repository

Document Registration• As per XDS profile

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EIP within a Jurisdiction/Affinity Domain

XDS Document Registry(Patient Identity Consumer)

XDSDocument

Repository

ADTPatient Identity Source

Patient Patient Identification Identification

Domain CDomain C

Patient Patient Identification Identification Domain D2Domain D2

DocumentEntryDm=CPid=Pc

Client Registry(Patient Identity X-Ref Mgr)

XDS Document Source

XDS Doc

XDS Doc

XDS Document Consumer

EMR EHR Portal

Dm=D2Pid=Pd

Dm=CPid=Pc

Dm=CPid=Pc

Jd = NL Dm=D2Pid=Pz

Jd = NL Dm=D2Pid=Pa

Jd = NL Dm=D2Pid=P1

Jd = NL Dm=CPid=Pd

Images

RIS

Register Document MRN Document ID (OID)

RIS

Report (RIS)Images (PACS)

Reading Station

Reports

PACS?

Serve as a peer to the Client Registry• Maintain x-ref of patient IDs• Respond to document queries with a full list of OIDs and MRNs

CR to Document Registry interface• Could follow IHE PIX Profile actor• May need expansion – looking into this

Access Control• Does the registry need to manage access rights or does this reside with the

document consumer to reconcile (with other actors)?• Do we need to support transactions that address access controls?

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EIP within a Jurisdiction/Affinity Domain

XDS Document Registry(Patient Identity Consumer)

XDSDocument

Repository

ADTPatient Identity Source

Patient Patient Identification Identification

Domain CDomain C

Patient Patient Identification Identification Domain D2Domain D2

DocumentEntryDm=CPid=Pc

Client Registry(Patient Identity X-Ref Mgr)

XDS Document Source

XDS Doc

XDS Doc

XDS Document Consumer

EMR EHR Portal

Dm=D2Pid=Pd

Dm=CPid=Pc

Dm=CPid=Pc

Jd = NL Dm=D2Pid=Pz

Jd = NL Dm=D2Pid=Pa

Jd = NL Dm=D2Pid=P1

Jd = NL Dm=CPid=Pd

Images

RIS

Register Document MRN Document ID (OID)

RIS

Report (RIS)Images (PACS)

Reading Station

Reports

PACS?

Reading Stations – Document Consumer:• On-demand architectures are proprietary• How do we make use of the Document registry• Does the “PACS” reconcile with the document

registry or does the workstation – do we care?• Should we add more meta data in the document

registry to support workflow• Hanging protocol resolution• Key image notes• Etc.

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EIP within a Jurisdiction/Affinity Domain

XDS Document Registry(Patient Identity Consumer)

XDSDocument

Repository

ADTPatient Identity Source

Patient Patient Identification Identification

Domain CDomain C

Patient Patient Identification Identification Domain D2Domain D2

DocumentEntryDm=CPid=Pc

Client Registry(Patient Identity X-Ref Mgr)

XDS Document Source

XDS Doc

XDS Doc

XDS Document Consumer

EMR EHR Portal

Dm=D2Pid=Pd

Dm=CPid=Pc

Dm=CPid=Pc

Jd = NL Dm=D2Pid=Pz

Jd = NL Dm=D2Pid=Pa

Jd = NL Dm=D2Pid=P1

Jd = NL Dm=CPid=Pd

Images

RIS

Register Document MRN Document ID (OID)

RIS

Report (RIS)Images (PACS)

Reading Station

Reports

PACS?

Web Clients – Document Consumer:• Assume local MRN as the ID• Need to respond with multiple MRNs and OIDs –

how to modify the transaction specification?

Information Distribution• Do we use WADO?• Do we use JPEG2000 and JPIP?• ??

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Cross-Jurisdictional EIP

Multiple affinity domains Multiple document registries Our thinking so far…

Reconciliation of available documents is between document registries

Document consumers do not query every document registry …. We have not detailed the transaction diagrams for this nor

developed the message sets Challenge (one of many)

How do we deliver documents from a document repository outside of the affinity domain to the diagnostic reading station…

– … on-demand architectures require images to be on the local PACS short term storage (cache)

– ... do we copy images from one repository to another (not desirable)

– … do we stream images directly into the reading stations: how, what standard, will vendors accept this ???

31Reports

EIP across multiple Jurisdictions/Affinity Domains

XDS Document Registry(Patient Identity Consumer)

XDSDocument

Repository

DocumentEntryDm=CPid=Pc

Client Registry(Patient Identity X-Ref Mgr)

XDS Doc

Dm=CPid=Pc

Images

Register Document MRN Document ID (OID)

XDS Document Registry(Patient Identity Consumer)

XDSDocument

Repository

DocumentEntryDm=CPid=Pc

Client Registry(Patient Identity X-Ref Mgr)

XDS Doc

Dm=CPid=Pc

Images

Register Document MRN Document ID (OID)

Reports

XDS Document Registry(Patient Identity Consumer)

XDSDocument

Repository

DocumentEntryDm=CPid=Pc

Client Registry(Patient Identity X-Ref Mgr)

XDS Doc

Dm=CPid=Pc

Images

Register Document MRN Document ID (OID)

Reports

XDS Document Consumer

EMR EHR Portal

Dm=D2Pid=Pd

PACS?

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IISIG input

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IISIG input

Comments from IISIG

Status of HL7 v3 artifacts relevant to this initiative

Is a collaboration between IISIG and this project desirable and possible?

Suggestions for Next Steps