1. IBM Healthcare Roadshow Eithne Reichert, RN, MN, PMP President, RWI Informatics Informatics Consultant, Saskatchewan, Canada Email: rwi@sasktel.net Lorraine Fernandes, RHIA Global Healthcare Ambassador IBM Software Group San Francisco,, USA Email: lfernand@us.ibm.com

2. © 2009 IBM Corporation Building a smarter planet 2 Agenda  Australian Health Reform – Challenges and Opportunities  Comparison to Canadian approach for national EHR services  Starting on the Path – Building Blocks –Technical & Business Architecture & Standards –Identification requirements to support Integration of Records –The Canadian experiences and lessons learned  Continuing on the Path –Access to More Information, Chronic Disease Management, Integration to Point of Service –Opportunities for future  Questions / Discussion

3. © 2009 IBM Corporation Building a smarter planet 3 Global Health Care State: Inefficiencies from Fragmented Data 3 A unified view of patients & providers improves processes & increases efficiencies Patient Healthcare Data Patient Symptoms Treatment Records Family History Admission History Exam Records Prescription History Ambulatory Data Clinicians …re-entering patient demographic information is time consuming & error prone Health information systems unable to recognise clinicians …multiple sources & contact information is outdated …communication is not timely or consistent as a result Costs continue to increase …simply implementing new systems does not solve the problem System adoption is slow …clinicians continue to ‘hunt & peck’ for information, waste 20-40% of their time …lack of complete information affects decision making, treatment & outcomes Registration systems are not connected Clinicians don't have access to all information

4. © 2009 IBM Corporation Building a smarter planet  Australia The future health system is to be powered by the smart use of data and enabled by the electronic flow of essential information between individuals and the health professionals from whom they seek care and advice. There should be a passionate commitment to measure and improve health and performance outcomes. PCEHR is the core infrastructure element to enable the quick and seamless exchange of patient-controlled, high priority healthcare information.  Canada A high quality, sustainable and effective Canadian health care system supported by an infrastructure 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. Strategies are similar 4

5. © 2009 IBM Corporation Building a smarter planet 5 How Does Canada & Australia Compare? CanadaAustralia Year Started20012005 when NEHTA formed PrioritiesCommon architecture and core services Foundation infrastructure. Health Identifier, Standards and Snomed PrivacyProvincial and Federal Privacy commissioners with well established policy Currently no privacy bill for PCEHR. Health Identifier has clauses to prevent privacy commissions prior to PCEHR ArchitectureDefined with HIAL, standardsTo be defined by NEHTA and finalised with PCEHR at a national level. High level architecture released. State level – working on architecture CertificationStarted in 2010Certification for accessing Health Identifier Funding$CAN 1.6B to date flow through to Provinces and Projects $467 Million over 2 years for PCEHR National infrastructure and Community based infrastructure has been funded. No funding at state levels to date. OutcomesClinical adoption and outcomes impact now being addressed Citizens and Providers have a Health Identifier. National Authentication Service and Snomed available. Adoption levels currently low WeaknessesLater emphasis on adoption and impact on clinical outcomes. Slow movement towards eHealth – 6 years building. Lack of roadmap to achieve integration.

6. © 2009 IBM Corporation Building a smarter planet 6 Canada – Health Care Governance Source: Canada Health Infoway Health care is delivered locally by health authorities (multiple hospitals) and community physicians and providers Health care is mostly funded by each province (state) to the delivery organisations Standards & directions are developed nationally. EHR projects funded nationally if fit within the standards and directions

7. © 2009 IBM Corporation Building a smarter planet 7 Linking Information across Jurisdictions implementations Source: Canada Health Infoway Architecture allows some variability in implementation EHR SOLUTION (EHRS) EHR INFOSTRUCTURE (EHRi) EHR Viewer Point of Service Application Health Information Data Warehouse EHR Data & Services Ancillary Data & Services Registries Data & Services Longitudinal Record Services EHR SOLUTION (EHRS) EHR INFOSTRUCTURE (EHRi) EHR Viewer Point of Service Application Health Information Data Warehouse EHR Data & Services Ancillary Data & Services Registries Data & Services Longitudinal Record Services Health Information Access Layer Diagnostic Hospital Emergency Specialist Clinic Homecare Clients / Patients Community Care Center Emergency Services Pharmacy Laboratory Health Information Access Layer Diagnostic Hospital Emergency Specialist Clinic Homecare Clients / Patients Community Care Center Emergency Services Pharmacy Laboratory

8. © 2009 IBM Corporation Building a smarter planet Canada EHR Projects

9. © 2009 IBM Corporation Building a smarter planet 9 Canadian Progress

10. © 2009 IBM Corporation Building a smarter planet Starting on the Path The Building Blocks: Identification of Clients, Providers Drugs Labs DI Images 10

11. © 2009 IBM Corporation Building a smarter planet 11 Connecting Information - Unified Patient Record for the PCEHR 11 Local Care Centre Social Services General Practitioner Urgent Care Hospital PharmacyDiagnostics Record Locator Service / EMPI / Patient Registry Local Care Centre First: Last: City/Cntry: Treatment: Visit: Colm Heaney London, Eng Arthroscopy CCR 08/2008 Social Services First: Last: City/Cntry: Treatment: Visit: Colum Heaney Manchester, Eng Immunization Records 05/1980 General Practitioner First: Last: City/Cntry: Treatment: Visit: Colm Heaney Manchester, Eng History & Physical 09/1987 Urgent Care First: Last: City/Cntry: Treatment: Visit: Coln Heany London, Eng Penicillin Allergy 11/1997 Hospital First: Last: City/Cntry: Treatment: Visit: Colm Heaney London, Eng Myocardial Infarction 04/2008 Diagnostics First: Last: City/State: Treatment: Visit: Colm Heanie London, Eng CT Scan 04/2008 Mental Health First: Last: City/Cntry: Outcome: Visit: Colum Heaney Manchester, Eng Disability Approval 06/2008 Pharmacy First: Last: City/Cntry: Prescription: Visit: Coln Heany Manchester, Eng Coumadin 2mg 04/2008 Mental Health Health Record 08/2008 06/2008 04/2008 11/1997 09/1997 05/1980 Colm Heaney Colum Heaney Colm Heanie Colm Heany Colm Heaney Colm Heany Colm Heaney Colum Heaney Arthroscopy CCR Disability Approval CT Scan Coumadin 2mg Myocardial Infarction Penicillin Allergy History & Physical DTaP, IPV, PCV, Rota Name: Colm HeaneyCity/Country: London, Eng Yes No Yes No Yes Visit Date: Name: Treatment / Prescription: Consent:

12. © 2009 IBM Corporation Building a smarter planet 12 Sole reliance on National or State Identifiers needs to be considered….  Unique Health Identifiers don’t provide total solution  Governance considerations are significant  Human and business processes can affect capture and use  Implementation and back-porting to legacy records costs are high  Identifiers easily associated with personally identifiable health information provides increased opportunity for privacy breaches 12 Accuracy using a UHI alone is insufficient to meet identification requirements

13. © 2009 IBM Corporation Building a smarter planet 13 How It Works… Source: Canada Health Infoway POINT OF SERVICE Ancillary Data & Services Registries Data & Services EHR Data & Services Data Warehouse Outbreak Management PHS Reporting Shared Health Record Drug Information Diagnostic Imaging Laboratory Health Information Hospital, LTC, CCC, EPR Physician Office EMR EHR Viewer Physician/ Provider Business Rules EHR Index Message Structures Normalization Rules Security Mgmt Data Privacy Data Configuration 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 Common Services Provider Registry Location Registry Terminology Registry Client Registry I need to know what information is available for Mr. R. Smith as he is a new patient referred to me Drug ProfileVisit History Laboratory Diagnostic Imaging Patient InfoEnd-User Info Clinical View

14. © 2009 IBM Corporation Building a smarter planet 14 Use of the EHR Identification Registries Across Canada  Eight out of nine larger provinces using IBM ® Initiate ® Patient as the provincial EMPI/Client Registry –Smaller provinces and territories using clinical systems  Two provinces also using IBM ® Initiate ® Provider as the provider registry –Nova Scotia, Alberta  Six of eight provinces actively integrating EHR with client registry for real time patient identification  Four of eight provinces integrate client registry with Provincial PACS  Five of eight provinces integrate client registry with provincial Lab results

15. © 2009 IBM Corporation Building a smarter planet British Columbia: The First Implementation…  British Columbia is the westernmost of Canada's provinces  Health services primarily delivered through six integrated networks called regional health authorities  Ethnically diverse population with significant Asian and Aboriginal citizens  2009 estimated population 4,420,000 15

16. © 2009 IBM Corporation Building a smarter planet Current status of British Columbia: IBM ® Initiate ® Patient  Links patient identity data from multiple sources –3 regional health authorities and the Ministry’s legacy Client Registry System using HL7 v3.0 message –Includes 6 contributing sources and 8 million unique person records  Enables data quality remediation –Manage linkages and duplicates across 12 million individual source records –Manages EHR IDs and changes across receiving systems  Multiple integration points –Source of identity authentication for lab results contributed by two Health Authorities to the Provincial lab information system 16

17. © 2009 IBM Corporation Building a smarter planet Saskatchewan:  Home of publicly funded universal health care: Province funds 90% of health care services  Health services primarily delivered through 11 integrated networks called regional health authorities  Multiple ethnic origins: English, Irish, French, German, Ukrainian, Russian, Middle Eastern, Oriental, and significant Aboriginal population  Many communities bordering Alberta and Manitoba  2009 population 985,000 17

18. © 2009 IBM Corporation Building a smarter planet Current status of SCI: IBM ® Initiate ® Patient  Links patient identity data from multiple sources –11 regional health authorities, the Saskatchewan Cancer Agency, the provincial insurance registry –Includes 80 facilities and 2.3 million unique person records  Enables data quality remediation –Manage linkages and duplicates across 5 million individual source records –Manages EHR IDs and changes across receiving systems  Multiple integration points –Source of identity authentication for provincial PACS, lab results, and drug repositories –Future integration with public health surveillance and document repository 18

19. © 2009 IBM Corporation Building a smarter planet 19 How IBM ® Initiate ® Patient Helped Address Client Identification Challenges  Very good algorithm tweaked to your specific demographics  Excellent recognition of duplicates – even hard to find ones  Consistent data linkage matching across sources  Ability to query at point of service against all records  System recognises manual review & intervention when required as higher authority  Ability to be flexible in the configuration settings and business requirements to manage sources uniquely  Application is easy to use, easy to train users Manual Review Lowest Possible Score Highest Possible Score Don’t Link Link Lowest Threshold Upper Threshold Should be Linked Should not be Linked

20. © 2009 IBM Corporation Building a smarter planet Lessons Learned Implementations and Directions 20

21. © 2009 IBM Corporation Building a smarter planet Benefits of client & provider identification for EHR services  Building block for EHR communication  Better identification through improved search and verification from different sources and consuming systems  Better understanding of health care recipients & referral patterns between sources  Improved health record - both paper & electronic  Better duplicate identification & less duplicate creation  Information more accurate and comprehensive in real time  Assistance with management of paper health records and outcome measurement An EHR starts with a solid foundation for patient identification 21

22. © 2009 IBM Corporation Building a smarter planet 22 Challenges for projects and programs TechnicalChallenges OrganisationalChallenges Data quality & integrity is affected by processes Differences in collection & use of records within and across sources Data quality role(s) within the organisation is lacking Privacy is an issue when sharing data - how much, whom to share, for how long Best practices & processes need to be confirmed regardless of standards Clinical use of data may be different than departments who send data Business Process Challenges Hard to influence change in other organisations and other people Stakeholders may have to ‘choose’ to participate Politics, opinions and vision issues Requires large & diverse. working groups Stakeholders are busy and involved in other needs Who was going to manage the combined data? It seems to be so hard – how can we make it easier/ quicker? Older systems, limited money for replacements Each hospital & office may be managed independently Common practice may not be used across organisations doing the same thing ‘Integration’ knowledge & experience is limited Limited interoperability platforms established Network, firewalls, infrastructure connectivity issues

23. © 2009 IBM Corporation Building a smarter planet 23 Building an EHR: Lessons Learned  Need to understand business processes that generate data in messages so integration rules need context  Integration knowledge & experience is evolving  Need to work through and with standards & solutions  Technically integrated environments need comprehensive testing  Interoperability between systems has an overhead, regardless  No single solution is going to fit all needs, technology cannot mandate business process Business  Privacy concerns require education & discussion  Sensitivity with diagnostic & health data, in particular with mental health and infectious diseases  Real data is often required for testing and training to manage decision-making on configuration  Best practice & data standards help stakeholder understanding of accountabilities and risks  Need for people who know – health info professionals, knowledge leaders Technical

24. © 2009 IBM Corporation Building a smarter planet Implementation timeframes can be fairly quick…. JUNE 2004 2005 JULYAUGSEPTOCTNOVDECJANFEBMARAPRILMAYJUNEJULYAUGSEPTOCTNOVDECJAN Phase I Phase II Phase III PIII Phase IV Scoping & Planning Funding Approval Funding Approval Data Analytics Data Analytics Requirements/ Specifications Requirements/ Specifications Implementation Data Quality Message Testing Production + GO LIVE GO LIVE 2006 24

25. © 2009 IBM Corporation Building a smarter planet 25 Know the business…. Shared Information / Shared Accountability for Quality in the EHR Know what you are wanting to do: – Clinical quality and patient safety may be different than financial – Support the business needs of source systems – Understand the business processes that may affect shared data – Understand issues and plan for data governance program – Align the fit with community EMRs and hospital systems needs – Consider the future: – EHR identification to the clinical strategies, PACS, Lab, & Drugs, chronic disease, patient information – Understand the downstream use of data sent

26. © 2009 IBM Corporation Building a smarter planet Understand the Data Use and Reuse – Data Governance Downstrea m Original ID Data Lab Client Registry EMR Referral Portal Drugs Consent Error - Patient presents sister’s health card Information shared broadly and instantly Need to Audit data back to a specific point of time Need consistent validation & correction PACS

27. © 2009 IBM Corporation Building a smarter planet Evolving Standards Data & Message Standards provide a roadmap for implementation  Data integration quality is more than messaging;  Business process is key to quality  Continued work for integration and data quality of combined record  Implementation projects can challenge & evolve the standards  Accountability is imperative for data quality in the PCEHR  Small steps can go a long way! Start on the path……

28. © 2009 IBM Corporation Building a smarter planet 28 Implementation Words of Wisdom… Never underestimate the importance of data quality at the foundation of your EHR initiatives Understand downstream impacts of data use & re- use Allow adequate time & resources to address governance & accountability Understand impact of patient & provider misidentification for shared data

29. © 2009 IBM Corporation Building a smarter planet So where to Next? Opportunities and Future Directions 29

30. © 2009 IBM Corporation Building a smarter planet Collaborate: Client Care Team & Communities of Practice - Source – Primary Health Care Project Nurse Educator Pharmacist Specialist Physician Therapist Nurse Practitioner Program Client & Family

31. © 2009 IBM Corporation Building a smarter planet Manage: Chronic Disease Solutions

32. © 2009 IBM Corporation Building a smarter planet Integrate: Tele-Health Tele-Consultation, Tele-Home Care, Tele-Triage

33. © 2009 IBM Corporation Building a smarter planet Create Access: Patient Portals - What Canadians Say: Functions Most Likely to Use 33 Source: Canada Health Infoway

34. © 2009 IBM Corporation Building a smarter planet Launch Public Awareness Campaign 34 Source: Canada Health Infoway

35. © 2009 IBM Corporation Building a smarter planet 35 Start somewhere and get going…..it is a longer path than you may imagine….. Questions /Comments???

36. © 2009 IBM Corporation Building a smarter planet Thank you. 36