Meeting the Challenge;
Creating Collaborative Harmonization for
Canadian Drug Information Systems
eHealth 2013
May 28, 2013
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Welcome!
Panelists
Lynne Zucker, VP Clinical Systems Integration, Canada Health Infoway
Paul Caines, CIO & Chief Privacy Officer, NL Centre for Health Information
Justin Bates, VP Pharmacy Affairs, Canadian Ass. of Chain Drug Stores
Bonnie Cochrane, VP Clinical Information Programs and Quality, NL
Centre for Health Information
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Faculty/Presenter Disclosure
•Faculty: Lynne Zucker
Relationships with commercial interests: NIL
• Faculty: Paul Caines
Relationships with commercial interests: NIL
• Justin Bates
Relationships with commercial interests: NIL
• Faculty: Bonnie S. Cochrane
Relationships with commercial interests: NIL
Now that you know us...........................................
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15:30 – 15:35
15:35 – 15:55
15:55 – 16:15
16:15 – 16:30
16:30 – 16:45
16:45 – 16:50
16:50 – 17:00
AGENDA
Welcome and introductions
Setting the Context
DIS Harmonization; How did we Get Here?
DIS Harmonization; Pharmacy Industry Perspective
Harmonized Message Set with Impacts
Summary
Q&A; Close
Bonnie
Lynne
Paul
Justin
Paul
Bonnie
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Panel Session Objectives
1.
Introduce diverse perspectives related to challenges, complexities and
opportunities faced implementing provincial Drug Information Systems
(DIS) in Canada
2.
Provide an overview of the identified need & opportunity for a broad &
inclusive national multi-stakeholder partnership to tackle the challenges
and opportunities
3.
Describe ongoing work toward the achievement of Harmonization
4.
By sharing lessons learned, provide an understanding of the evolutionary
nature of this work, necessary for optimal benefits realization for the DIS
and beyond, while setting the stage for the future.
Setting the Context
Lynne Zucker
Program Activity Summary
(December 31, 2012)
Legend
Registries
Diagnostic Imaging
Drug Info Systems
Lab Info Systems
Telehealth
Interoperable EHR
Health Surveillance
Innovation & Adoption
Patient Access to Quality Care
Electronic Medical Record
and Integration
Consumer Health Solutions
386 active and completed projects with
an estimated value of $2.10 billion as
at December 31, 2012
Drug Information System Programs
Shared common objectives among all major stakeholders:
• Reducing adverse drug events
• Provide the best possible medication history to support
clinical decision making across the health system
Fitting the Pieces Together
JURISDICTIONAL INFOSTRUCTURE
EHR Data & Services
Registries Data
& Services
HIAL
Client
Registry
Domain and
Shared EHR
Repositories
HIAL
Terminology
Registry
HIAL
Drug
Information
System
HIAL
Location
Registry
Inter-Jurisdiction:
EHR PCSStandards
Domain and
Shared EHR
Repositories
HIAL
Provider
Registry
Domain and
Shared EHR
Repositories
Common Services
Communication Bus
HIAL
EMR
Pharmacy
System
Hospital
System
EHR Viewer
POINT OF SERVICE SYSTEMS
Consumer
Systems
POS-6
Long-Term Benefits
Early Benefits
Benefits Evolve with System Maturity
Estimated Access to Drug Information Systems (DIS)*
Per cent Access
Western
Jurisdictions
Setting
National
BC
Community
Pharmacists
34%
100%
Hospital
Pharmacists
46%
Hospital
(ED Only)
70%
AB
SK
Central
Jurisdictions
Eastern
Jurisdictions
MB
ON
QC
PE
NL
100% 100%
100%
-
11%
100%
40%
100%
100% 100%
100%
40%
<1%
100%
-
100%
100% 100%
100%
100%
3%
100%
1 pilot
live
* Original source: National Impacts of Generation 2 Drug Information Systems Technical Report, September 2010. Numbers in table above
updated September 2012.
Standards
Drug Information Systems use many standards
-
Architecture
Messaging Standards
Terminology
In Spite of the Standards….
The Drug Information Systems in place across Canada make use of
these standards, however, each jurisdiction had to adapt to balance
many requirements:
• legacy systems already in production
• needs of clinical stakeholders
• level of EMR use
• legislation and policy requirements
• capabilities of vendors
• optionality included in the standards
• procurement of commercial components
The resulting variety of models and approaches has resulted in a
variation in requirements between provinces. This creates a challenge
for companies that need to manage streamlined, national solutions
that can interact with multiple DIS environments.
E-Prescribing Harmonization
In addition to harmonization for pharmacy systems, there is also work underway to
align e-Prescribing approaches for Electronic Medical Records (EMR) and other
prescriber systems
1. First pass identification of jurisdiction variances and targeted reduction of
50%
2. Creation of jurisdiction message sets – libraries to support more plug and
play capabilities
This work is to be completed in collaboration with the pharmacy harmonization
initiatives.
Canadian Stakeholders Coming Together
•
Challenges facing our provinces are not unique – other jurisdictions have
discovered there is no simple answer
•
In June 2012, a group of stakeholders came together – public sector jurisdictions
and private sector pharmacies and vendors to try a different approach to achieve
harmonization necessary for success
•
Fellow panelists going to share not only the issues and opportunities but also how
this approach has built stronger buy in and participation in achieving a common
resolution
Pharmacy Harmonization
“How did we get here?”
A provincial perspective
May 2013
19
Reminder…
JURISDICTIONAL INFOSTRUCTURE
EHR Data & Services
Registries Data
& Services
HIAL
Client
Registry
Domain and
Shared EHR
Repositories
HIAL
Terminology
Registry
HIAL
Drug
Information
System
HIAL
Location
Registry
Inter-Jurisdiction:
EHR PCSStandards
Domain and
Shared EHR
Repositories
HIAL
Provider
Registry
Domain and
Shared EHR
Repositories
Common Services
Communication Bus
HIAL
EMR
Pharmacy
System
Hospital
System
EHR Viewer
POINT OF SERVICE SYSTEMS
Consumer
Systems
POS-6
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A Complex Environment
• Many vendors
…with legacy products
• Many jurisdictions
…with legacy environments
…diverse , complex stakeholder groups
…many different starting points
• Other complex ingredients in our ‘regimes’:
- Standards: international considerations, different jurisdictional
implementations, etc
- Business processes, service desk interactions, on-call protocols…
Jurisdictional variances expected
21
NL Standards History
• Fully involved in development of pan-Cdn standard
• Made sense to adopt broad implementation of standard
- Adopt next generation after PEI
- Build in flexibility through variances
- Others adopted a narrower standard, but maintained more
rigidity
• Working with vendor community
Good work done; we are building on that
22
A Dynamic Environment
Since NL go-live:
• Core Drug system has evolved
- Version 1.3 to 1.6.5
• All POS systems have evolved
- Kroll: 8.3 to 9.2
- Telus: Assyst to Ubik (new platform)
• Conformance process has evolved
• Major Client Registry upgrade
• Clearer shared understanding among partners
BUT - core standard - and protocols - have (essentially) remained the same!
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Time is Right for Harmonization Discussion
• Critical mass of implementations
• Different stakeholders now “speak the same language”
• Vendors: DIS, POS, etc
• Technical, clinical, standards, management, etc
• Operational processes (conformance, training, etc)
• March 2013 harmonization forum
• Go-forward approach needs further work…
• …but such a conversation was not possible even 2 years ago!
Standards are a success: they have gotten us to this point
Can build on
DIS Harmonization
Pharmacy Industry Perspective
Justin Bates
May 2013
CACDS
• We are the voice and advocate of our members who:
• Operate more than 6,500 neighbourhood pharmacies across Canada
and provide pharmacy and other core healthcare products and
services;
• Focus on wellness, treatment and prevention;
• Ensure fulfillment of almost 70% of Canadian prescriptions each year;
• Employ more than half a million Canadians, including 75% of
pharmacists practicing in neighbourhood pharmacies across Canada;
• We engage stakeholders in dialogue about our industry, our people and
our role in providing quality neighbourhood-based healthcare products
and services.
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CACDS Members
• Pharmacy retailers
•
Independent Banners
•
Grocery
•
Mass Merchandisers
•
Corporate
• Represent pharmacy software vendors
• 120+ organizations in the supply chain
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Background
• Pharmacy organizations are partners in making eHealth work
in a cost effective framework
• Provincial eHealth agencies, software vendors, and pharmacy
organizations are working collaboratively to learn from
experience to date and:
• Design a truly pan-Canadian system that can be adopted
across all jurisdictions
• Focus on health outcomes and clinical value
• Pharmacy software vendors and the NL Centre for Health
Information began to work together in the Spring of 2012 to
address the need for national harmonization
• CACDS become involved to bring the industry perspective
and help drive change
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Overview
• Goal is to mesh past and current harmonization efforts into a new
multi stakeholder group
• Canada Health Infoway, provinces, pharmacy retailers, CACDS
and pharmacy software vendors
• Develop priority areas
• Inaugural meeting held in Toronto in June 2012
• Established an executive committee to oversee efforts
• NL Center for Health Information and pharmacy software vendors
co-developed harmonized message set
• Harmonized message set presented to all stakeholders in Feb 2013
• Proposal simplifies DIS with a reduced message set with a focus
on clinically relevant messages
• Pharmacy supports a basic DIS with harmonized national message
set that includes:
• e-Prescribing – harmonize regulations for e-signature
• Adverse Drug Reaction Reporting
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Guiding Principles
•
eHealth must drive positive patient outcomes
• Must provide additional value added information to assist
healthcare professionals improve health outcomes
•
Support a minimal set of standard messages – simplify
solution to:
• Decrease implementation time for PMS vendors and DIS,
thereby;
•Decrease time for patients to realize benefits of a well
designed and implemented solution
• Lower bandwidth burden to allow for:
• Implementable solution across different provincial IT
infrastructures
• Reasonable message response times
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Guiding Principles Continued
• eHealth should complement existing processes and workflow
• The workflow of healthcare professionals and retailer
operations varies, and cannot be dictated by technology
• Messages should be designed and implemented with the
flexibility to accommodate for different healthcare
professional workflow choices, and the evolving role of
pharmacists and technicians in community practices
• Best practice guidelines need to be developed
• Boards, colleges and associations should be involved in
guidelines. National guidelines (NAPRA) preferable
• Must be informed throughout development by stakeholders
with practical experience in developing and implementing
eHealth solutions
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Process Moving Forward
• eHealth Ontario developed a national template to collect
feedback to the harmonized message set proposal
• Pharmacy industry meetings with each province to discuss
harmonized proposal
• Develop national chart that identifies by province:
• Alignment
• Partial Alignment
• Requires Further analysis
• Establish a SME Task Force to work on a group of messages
• Develop proposal for proposed changes to SCWG
• Integrate other harmonization efforts with e-prescribing and
EMR
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Harmonized Message Set
With Impacts
May 2013
33
Disclaimer
NL metrics, examples used
…but the principles are the same for all
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JURISDICTIONAL
INFOSTRUCTURE
NL - Current Context
Registries
Data &
Client
Services
Registry
HIAL
EHR Data & Services
Location
Registry
HIAL
Domain and
Shared
EHR
Repositorie
s
Drug
Informati
on
System
Domain and
Shared
EHR
Repositorie
s
HIAL
Provider
Registry
Domain and
Shared
EHR
Repositorie
s
HIAL
Terminology
Registry
HIAL
Inter-Jurisdiction:
EHR PCSStandards
Common Services
Communication Bus
HIAL
EMR
Pharmacy
System
Hospital
System
EHR Viewer
POINT OF SERVICE SYSTEMS
Consumer
Systems
POS-6
35
NL - Current Context
Pharmacy deployed as an EHR application
– Thru a HIAL
– Real-time client registry integration
– Business processes support this integration
• EG Real time identity issue follow-up; on-call protocols
36
Messaging – NL Current Status
Large number of messages
– 82 in NL
Many are similar
– Eg abort, cancel
Extensive processes to build, sustain
– Value, but a cost: significant per-transaction overhead
Great example of where we have learned
– Time is right to step back more methodically
37
Proposal
27 areas for increased harmonization
– Messages (19)
• Reminder: NL currently has 82
– Business practice
• Conformance, training approaches
• Ongoing: system availability, service levels
– Data, terminology
38
Impact of proposed message set (NL)
Aligned:
– Fully:
– Partially:
Further Analysis required:
Gap:
11
6
9
1
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Example - Dispense
Current - separate messages for dispense of:
–
–
–
–
Drugs
Devices
OTCs
professional services
Proposed: one dispense message
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Example - Query
Current: 18 query messages
– Includes broad and narrow payloads
– Reality – with variances, there are more than 18…
Proposed: 3 query messages
– Broader messages
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Why?
Fewer messages (and more harmonized processes) to:
– Build, document, test, optimize, conform, maintain,
troubleshoot, etc….
– …Across multiple jurisdictions
• Each with some level of per-message variance
• (ie reality is that there are currently more than 18…)
– …Across each jurisdiction’s very complex technical environments
– …For each POS vendor–each with its own operation
..but still deliver the value; MUST deliver same content
42
More Benefits
Shift interoperability burden to HIAL
– From POS software
– HIAL designed to enable interoperability
Reduces overhead
– Currently significant per-transaction overhead
• Testing (development, UAT, conformance, etc)
Simplifies environment
– Facilitates communication
– Clarifies boundaries
Can still maintain flexibility
43
Challenges of harmonization
Notable effort
– Requires work on multiple fronts
• POS/jurisdiction/DIS-backend
– Has to be “right”
Will still have sustainability challenges
– Hopefully fewer/”better” ones!
May increase load for some transactions
44
Jurisdictional Benefits Summary
Harmonization brings benefits (simplification, etc)
Systems are evolving anyway
– Why not make the evolution in a harmonized way?
Won’t be easy
Aligned themes:
– Minister Aglukkaq: “ putting (ehealth) into action is hard”
– Peake (innovation): effective>efficient>improving>cutting>….
– Topol: “needs to be a changing of the guard”
Time to accelerate the change!
Summary
May 2013
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Summary – Key Messages
The vision of this partnership is to simplify our very complex systems, to
ensure optimal value is realized
The value to be realized is value to the health system, care providers and
patients
We need this broad and inclusive partnership, which is collaborative and
focused to achieve success
The work we are doing is part of an ongoing evolution; we are making
progress. Are we there yet? ……..the evolution continues!
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Panel Session Objectives
1.
Introduce diverse perspectives related to challenges, complexities and
opportunities faced implementing provincial Drug Information Systems
(DIS) in Canada
2.
Provide an overview of the identified need & opportunity for a broad &
inclusive national multi-stakeholder partnership to tackle the challenges
and opportunities
3.
Describe ongoing work toward the achievement of Harmonization
4.
By sharing lessons learned, provide an understanding of the evolutionary
nature of this work, necessary for optimal benefits realization for the DIS
and beyond, while setting the stage for the future.
48
THANK YOU