IBM Healthcare Roadshow
Eithne Reichert , RN, MN, PMP
Lorraine Fernandes, RHIA
President, RWI Informatics
Informatics Consultant,
Saskatchewan, Canada
Email: rwi@sasktel.net
Global Healthcare Ambassador
IBM Software Group
San Francisco,, USA
Email: lfernand@us.ibm.com
Building a smarter planet
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
2
© 2009 IBM Corporation
Global Health Care State: Inefficiencies from Fragmented Data
Building a smarter planet
Registration systems
are not connected
…re-entering patient
demographic information is
time consuming
& error prone
Clinicians don't
have access
to all information
… lack of complete
information affects
decision making,
treatment & outcomes
Family
History
Exam
Records
Patient
Symptoms
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
Patient
Healthcare
Data
Treatment
Records
Admission
History
Ambulatory
Data
Prescription
History
Clinicians
Health information
systems unable
to recognise
clinicians
…multiple sources &
contact information
is outdated
…communication is
not timely
or consistent
as a result
A unified view of patients & providers improves processes & increases efficiencies
33
© 2009 IBM Corporation
Building a smarter planet
Strategies are similar
 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.
4
© 2009 IBM Corporation
Building a smarter planet
How Does Canada & Australia Compare?
Canada
Australia
Year Started
2001
2005 when NEHTA formed
Priorities
Common architecture and core
services
Foundation infrastructure. Health Identifier, Standards and
Snomed
Privacy
Provincial 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
Architecture
Defined with HIAL, standards
To be defined by NEHTA and finalised with PCEHR at a
national level. High level architecture released.
State level – working on architecture
Certification
Started in 2010
Certification 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.
Outcomes
Clinical adoption and outcomes
impact now being addressed
Citizens and Providers have a Health Identifier.
National Authentication Service and Snomed available.
Adoption levels currently low
Weaknesses
Later emphasis on adoption and
impact on clinical outcomes.
Slow movement towards eHealth – 6 years building.
Lack of roadmap to achieve integration.
5
© 2009 IBM Corporation
Building a smarter planet
Canada – Health Care Governance
• 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
Source: Canada Health Infoway
6
© 2009 IBM Corporation
Linking Information across Jurisdictions implementations
Building a smarter planet
EHR INFOSTRUCTURE (EHRi)
Ancillary
Data &
Services
Health
Information
Data
Warehouse
EHR SOLUTIONLongitudinal
(EHRS)
EHR INFOSTRUCTURE (EHRi)
Registries
Data &
Services
EHR
Data &
Services
Ancillary
Data &
Services
Record Services
Health
Information
Data
Warehouse
EHR SOLUTIONLongitudinal
(EHRS)
Health Information Access Layer
Point of Service
Application
Record Services
Point of Service
Application
Point of Service
Application
Homecare
Emergency
Services
Community
Care Center
Emergency
Services
Clients / Patients
Clients / Patients
Specialist
Clinic
Pharmacy
Laboratory
Source: Canada Health Infoway
7
EHR Viewer
Homecare
Community
Care Center
Diagnostic
Registries
Data &
Services
Health Information Access Layer
EHR Viewer
Hospital
Emergency
EHR
Data &
Services
Specialist
Clinic
Pharmacy
Hospital
Emergency
Laboratory
Diagnostic
Architecture allows some
variability in implementation
© 2009 IBM Corporation
Building a smarter planet
Canada EHR Projects
© 2009 IBM Corporation
Building a smarter planet
Canadian Progress
9
© 2009 IBM Corporation
Building a smarter planet
Starting on the Path
The Building Blocks:
Identification of Clients, Providers
Drugs
Labs
DI Images
10
© 2009 IBM Corporation
Connecting
Information - Unified Patient Record for the PCEHR
Building a smarter planet
Local Care Centre
First:
Last:
City/Cntry:
Treatment:
Visit:
Social Services
Colm
Heaney
London, Eng
Arthroscopy
CCR
08/2008
Social Services
General Practitioner
First:
Colum
Last:
Heaney
City/Cntry: Manchester, Eng
Treatment: Immunization
Records
Visit:
05/1980
First:
Colm
Last:
Heaney
City/Cntry: Manchester, Eng
Treatment: History &
Physical
Visit:
09/1987
General
Practitioner
Record Locator Service / EMPI / Patient Registry
Urgent Care
Urgent Care
Health Record
Name: Colm Heaney
Visit Date:
Name:
Local Care Centre
First:
Last:
City/Cntry:
Treatment:
City/Country: London, Eng
Treatment / Prescription:
Consent:
08/2008
Colm Heaney
Arthroscopy CCR
Yes
06/2008
Colum Heaney
Disability Approval
Yes
04/2008
Colm Heanie
CT Scan
No
04/2008
Colm Heany
Coumadin 2mg
Yes
04/2008
Colm Heaney
Myocardial Infarction
Yes
11/1997
Colm Heany
Penicillin Allergy
Yes
09/1997
Colm Heaney
History & Physical
No
05/1980
Colum Heaney
DTaP, IPV, PCV, Rota
Yes
Visit:
Mental Health
First:
Last:
City/Cntry:
Outcome:
Visit:
Colum
Heaney
Manchester, Eng
Disability
Approval
06/2008
Hospital
First:
Last:
City/Cntry:
Treatment:
Visit:
Mental Health
Colm
Last:
Heanie
First:
Coln
Last:
Heany
City/Cntry: Manchester, Eng
Prescription: Coumadin 2mg
Visit:
04/2008
City/State: London, Eng
Treatment: CT Scan
Visit:
11
11
04/2008
Hospital
Colm
Heaney
London, Eng
Myocardial
Infarction
04/2008
Pharmacy
Diagnostics
First:
Coln
Heany
London, Eng
Penicillin
Allergy
11/1997
Diagnostics
Pharmacy
© 2009 IBM Corporation
Building a smarter planet
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
Accuracy using a UHI alone is insufficient to meet
identification requirements
12
© 2009 IBM Corporation
How
It Works…
Building a smarter planet
Ancillary Data
& Services
Registries Data
& Services
Client
Registry
Outbreak
Management
EHR Data
& Services
PHS
Reporting
Shared
Health Record
Drug
Information
Data
Warehouse
Diagnostic
Imaging
Health
Information
Laboratory
Provider
Registry
Location
Registry
Business
Rules
EHR
Index
Terminology
Registry
Message
Structures
Normalization
Rules
Longitudinal Record Services
Security Mgmt
Data
Privacy Data
Configuration
Common Services
HIAL
Public Health
Services
I need to know what
information is available
Radiology
Pharmacy
Center
for Mr.
R. Smith as
he is a
System
PACS/RIS
new patient referred to
me
Public Health
Provider
Pharmacist
Radiologist
Patient Info
Lab System
(LIS)
End-User Info
Hospital, LTC,
Physician
CCC, EPR
Visit History
Laboratory
Lab Clinician
Office EMR
Drug
Profile
EHR Viewer
Diagnostic Imaging
Physician/
Provider
Physician/
Provider
Physician/
Provider
Clinical View
POINT OF SERVICE
Source: Canada Health Infoway
13
13
© 2009 IBM Corporation
Building a smarter planet
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
14
© 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
© 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
© 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
© 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
© 2009 IBM Corporation
How IBM® Initiate® Patient Helped Address
Client Identification Challenges
Building a smarter planet
 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
Should be Linked
Should not be Linked
Lowest
Possible
Score
Don’t
Link
Manual Review
Lowest
Threshold
19
Link
Highest
Possible
Score
Upper
Threshold
© 2009 IBM Corporation
Building a smarter planet
Lessons Learned
Implementations and Directions
20
© 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
© 2009 IBM Corporation
Challenges for projects and programs
Building a smarter planet
Technical
Challenges
• 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
Organisational
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?
22
Business Process
Challenges
• 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
© 2009 IBM Corporation
Building a smarter planet
Building an EHR: Lessons Learned
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
23
Technical
 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
© 2009 IBM Corporation
Implementation
timeframes can be fairly quick….
Building a smarter planet
2004
JUNE
2005
JULY
AUG
SEPT
OCT
NOV
DEC
JAN
Phase I
Phase I
Scoping & Planning
Funding
Approval
2006
FEB
MAR
APRIL
Phase II
Data
Analytics
MAY
JUNE
JULY
AUG
SEPT
OCT
NOV
DEC
JAN
Phase II
Requirements/
Specifications
Phase III
PIII PIII
Implementation
Data Message
Quality Testing
Phase IV
GO
Production + LIVE
24
© 2009 IBM Corporation
Know the business….
Building a smarter planet
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
25
© 2009 IBM Corporation
Building a smarter planet
Understand the Data Use and Reuse – Data
Governance Downstream
Error - Patient
presents sister’s
health card
Referral
Lab
EMR
Information shared
broadly and instantly
Drugs
Original
ID Data
PACS
Need to Audit data
back to a specific point
of time
Portal
Need consistent
validation & correction
Client
Registry
Consent
© 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……
© 2009 IBM Corporation
Implementation Words of Wisdom…
Building a smarter planet
28
Never
underestimate the
importance of
data quality at the
foundation of your
EHR initiatives
Understand
downstream
impacts
of data use & reuse
Allow adequate
time & resources
to address
governance &
accountability
Understand
impact of patient
& provider
misidentification
for shared data
© 2009 IBM Corporation
Building a smarter planet
Opportunities and Future Directions
So where to Next?
29
© 2009 IBM Corporation
Collaborate:
Client Care Team & Communities of Practice Building a smarter planet
Physician
Specialist
Nurse
Therapist
Client & Family
Nurse
Practitioner
Program
Educator
Pharmacist
Source – Primary Health Care Project
© 2009 IBM Corporation
Building a smarter planet
Manage: Chronic Disease Solutions
© 2009 IBM Corporation
Integrate: Tele-Health
Tele-Consultation, Tele-Home Care, Tele-Triage
Building a smarter planet
© 2009 IBM Corporation
Building a smarter planet
Create Access: Patient Portals - What Canadians Say:
Functions Most Likely to Use
Source: Canada Health Infoway
33
© 2009 IBM Corporation
Building a smarter planet
Launch Public Awareness Campaign
Source: Canada Health Infoway
34
© 2009 IBM Corporation
Start somewhere and get going…..it is a
longer path than you may imagine…..
Building a smarter planet
Questions /Comments???
35
© 2009 IBM Corporation
Building a smarter planet
Thank you.
36
© 2009 IBM Corporation