1. Achieving Interoperability Across Canada
Standards
HIMSS Interoperability Showcase
February 15, 2006
Dennis Giokas
Chief Technology Officer
Canada Health Infoway Inc.

2. © 2006 Canada Health Infoway Inc.
Outline
Introducing Infoway
Key Definitions
Why an Interoperable EHR?
Key Clinical and Business Requirements
Solution Architecture
Integration Challenges
Standards for Interoperability
Standards Collaboration and Projects
Summary
© 2006 Canada Health Infoway Inc. 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. © 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. 4

5. © 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. 5

6. Why Pursue The EHR: Circle of Care
Homecare
Clinic
Emergency Services
Community Care Center
Pharmacy
Specialist Clinic
Laboratory
Hospital Emergency
Diagnostic
© 2006 Canada Health Infoway Inc.

7. Why Pursue The EHR: Benefits
Homecare
Clinic
Emergency Services
QUALITY
SAFETY
ACCESSIBILITY
Community Care Center
Pharmacy
Specialist Clinic
Laboratory
Hospital Emergency
Diagnostic

8. The EHR is a Key to a Renewed Health System!
EHR solutions provide an
opportunity to
Improve the quality, safety, accessibility and timeliness of care for Canadians
Support more informed healthcare decision making, research and management
Improve the efficiency of the healthcare system and reduce costly duplication
Maximize return on IT investments
Achieve standards based solution allowing interoperability
© 2006 Canada Health Infoway Inc. 8

9. EHR Key Clinical & Business Requirements
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
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.

10. © 2006 Canada Health Infoway Inc.
Different Approaches To Achieving the EHR
© 2006 Canada Health Infoway Inc. 10

11. EHR: How Do We Do This? Sharing Information From Multiple Systems
Homecare
Clients/Patients
Clinic
Emergency Services
INTEGRATED VIEW
Community Care Center
Pharmacy
Specialist Clinic
Laboratory
Hospital Emergency
Diagnostic

12. Guiding Principles for EHRS
Patient-centric
Mass customized views of all clinical data
Value add for the provider
Timely, accurate information
Enable sharing at local, regional, cross-jurisdictional
Interoperable, integrated
Standards based
Replicable solution – patterns, components
Leverage legacy systems & solutions
Design for phased rollout with near term results
Scalable
Extensible to support future growth
Cost-effective
Secure & private
Allow for innovation & competition
Comprehensive

13. Methods of Sharing EHR Information
The “Big Database
in the Sky”
All Point-of-Service (POS) systems share same data store
Broadcast to all or
a logical subset of
systems
Replication of data from one system to all other relevant/ participating POS systems
Every POS system holds same information
The “Big Index in
the Sky”
EHR Index or locator service that holds links to all POS systems where information resides
Each POS system interfaces to other systems
Use of a
shared reference
information source
POS systems populate it
POS systems or viewers reference it
External to the “operational” store

14. 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
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

15. 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
HIAL
EHR Data & Services
Registries Data & Services
Ancillary Data & Services
Health Information Data Warehouse
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

16. Canada has approximately 40,000 systems
Locations of Electronic Clinical Data Today: Number of Systems to Integrate
Homecare
Clinic
Clients/Patients
Emergency Services
Canada has approximately 40,000 systems
Community Care Center
Pharmacy
Specialist Clinic
Laboratory
Hospital Emergency
Diagnostic

17. Integrating Health Information Systems: Key Challenges
Protecting Privacy
Governance, accountability & data custodianship
Controlling access
Managing & applying consent directives
Controlling feeds and queries to the data
Trust relationships & contracts
Existence & availability of data
Discovery capability
Availability in electronic format
Timeliness
Harmonization
Data structures (format)
Vocabularies (encoding, normalization)
Semantics
Heterogeneous technology environments
Number of organizations, connection points & systems
Costs inherent to integration

18. EHR Infostructure: Services Drill-Down
JURISDICTIONAL INFOSTRUCTURE
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
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 Data
Privacy Data
Configuration
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

19. EHR Infostructure: Standards Based Connectivity
JURISDICTIONAL INFOSTRUCTURE
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
Client Registry
Provider Registry
Location Registry
Terminology Registry
POINT OF SERVICE
Business Rules
EHR Index
Message Structures
Normalization Rules
Security Mgmt Data
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

20. EHR Infostructure: Communication Bus
JURISDICTIONAL INFOSTRUCTURE
Ancillary Data & Services
Registries Data & Services
EHR Data & Services
Data Warehouse
POINT OF SERVICE
Communication Bus
COMMUNICATION BUS
MESSAGING
Transformation Services
Routing Services
Encrypt/Decrypt
Services
En/Decoding
Parser Services
Serialization Services
PROTOCOL
App Protocol Services
Network Protocol Services

21. EHR Infostructure: Common Services
JURISDICTIONAL INFOSTRUCTURE
Ancillary Data & Services
Registries Data & Services
EHR Data & Services
Data Warehouse
POINT OF SERVICE
Security Mgmt Data
Privacy Data
Configuration
Communication Bus
Common Services
COMMON SERVICES
INTEROP
Interoperability Services
Search/Resolution Services
INTEGRATION
Service Catalogue Services
Broker Services
Mapping Services
Queuing Services
CONTEXT
Session Mgmt Services
Caching Services
Identity Protection Services
Identity Mgmt Services
Anonymization Services
User Authentication Services
Consent Directives Mgmt Services
Encryption Services
Access Control Services
Secure Auditing Services
Digital Signature Services
General Security Services
SUBSCRIPTION
Alert/Notification Services
Pub/Sub Services
MANAGEMENT
Management Services
Configuration Services
GENERAL
Auditing Services
Log Mgmt Services
Policy Mgmt Services
Exception/Error Handling Services
PRIVACY & SECURITY

22. EHR Infostructure: Longitudinal Record Services
JURISDICTIONAL INFOSTRUCTURE
Ancillary Data & Services
Registries Data & Services
EHR Data & Services
Data Warehouse
POINT OF SERVICE
Business Rules
EHR Index
Message Structures
Normalization Rules
Longitudinal Record Services
LONGITUDINAL RECORD SERVICES
DATA
Key Mgmt Services
ETL Services
BUSINESS
Data Quality Services
Domain Business Components (Registries, EHR, Domains, User, Context)
EHR Index Services
Orchestration Services
Normalization Services
Business Rules Services
Assembly Services
Data Services
Replication Services

23. EHR Infostructure: EHR Viewer
JURISDICTIONAL INFOSTRUCTURE
Ancillary Data & Services
Registries Data & Services
EHR Data & Services
Data Warehouse
POINT OF SERVICE
EHR VIEWER
EHRi Interoperability Services
EHR Viewer Business Objects Components
Normalization Services
End-user Navigation Services
Business Rules Services
End-user Display Services
Data Services
EHR Viewer
Physician/ Provider

24. Standards-based Solutions Standardized Architecture
Standardized Interfaces
Standards-based
Solutions
Standardized Data
Structures
Standardized Data
Vocabularies
Standardized Functional
Behaviour
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25. 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 replication
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

26. 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

27. 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

28. 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 (complete)
Provider Registry HL7 v3 (in ballot)
Drug Information Systems HL7 v3 (in ballot)
Laboratory HL7 v3 (in development)
Diagnostic Imaging/Teleradiology (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)
EHR IP
HIAL

29. Summary Supporting Clinicians
Provider adoption – Approach designed to support use cases across continuum of care with timely and accurate information for the clinician
Mass customized views of data tailored to provider needs that is authoritative, reliable, responsive
Semantic harmonization of health information across service delivery points
Healthcare Information Solution Architecture
Interoperability that is cost effective
Common model of integration, secure and private, scalable, extensible, preserves current investments – an application abstraction layer that provides a common integration view and EHR view across Canada
Standards – common messages and nomenclatures adopted across Canada
Enables high degree of flexibility in reconfiguration of health services delivery networks

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