Infoway Architecture Update
March 2006
Solution Architecture Group
1
Outline
Introducing Infoway
EHRS Blueprint Scope
Business Context
Clinical/Work Process Architecture
System Architecture
Information Architecture
Integration & Deployment Options
Potential Applications
Summary & Conclusion
2
What Does Infoway Do?
End User Adoption &
Setting the Future
Direction
Innovation & Adoption
The Electronic Health
Record
Interoperable EHR
Domain Repositories &
Healthcare Applications
Cross Program
Foundation
Components
Architecture &
Standards
$60M
$175M
Drug
Information
Systems
Laboratory
Information
Systems
Diagnostic
Imaging
Systems
$185M
$150M
$220M
Public
Health Systems
$100M
TeleHealth
$150M
Client, Provider & Location Registries
$110M
Infostructure
$125M
3
EHRS Blueprint Scope
EHRS BLUEPRINT V1.0 ADDRESSED BUSINESS CONTEXT
(Mission, objectives, stakeholders, benefits)
WORK PROCESS
INFORMATION
SYSTEM
Conceptual
Blueprint V1
Blueprint V2
Blueprint V2
Blueprint V1
Blueprint V2
Logical
Blueprint V2
Blueprint V2
Blueprint V2
TECHNOLOGY
Physical
EHR Implementations across Canada
4
Architecture Perspectives
Business
Architecture
Clinical
Work Process
Architecture
Potential
Applications
CONTEXT
Integration &
Deployment
Models
System
Architecture
Information
Architecture
5
Architecture Perspectives
Business
Architecture
Clinical
Work Process
Architecture
Potential
Applications
CONTEXT
Integration &
Deployment
Models
System
Architecture
Information
Architecture
6
Business Context
7
Healthcare Industry
Ministry
of Health
Elected
Government
Provides $
Planning &
Resources
Planning &
Resources
Health Authority
Health Authority
Health Authority
Tax
$$$
Homecare
Community
Care Center
Emergency
Services
Tax Payer
Providers
Clients/Patients
Pharmacy
Specialist Clinic
Hospital
Emergency
Laboratory
Diagnostic
8
International Industry: IT Spending Comparisons
IT spending as a % of total expenditures
Financial Services
12.1
5.7
Government
5.5
Telcos
Worldwide Health Providers
4.2
3.3
Transportation
2.7
Utilities
Textiles
2.2
1.9
Manufacturing
Petroleum
1.7
Pulp & Paper
1.6
Canadian Healthcare
Food & Bev
1.4
1.2
SOURCE: Gartner Group – as reported in the Health Services Restructuring Commission’s (www.hsrc.gov.on.ca) report: Ontario Health Information Management Action Plan, June 1999
9
Mean Hospital: IT spending in Canada <2%
Canadian IT budgets as a % of total
hospital budget
less than 1%
25
1-1.4%
27
1.5-1.9%
27
12
2-2.4%
2.5% or more
10
0
5
10
15
20
25
30
SOURCE: 2003 Report on I.T. in Canadian Hospitals: Top issues, applications and vendors. Canadian Healthcare Technology, 2003. CIHI NHex 2002 (Hospital Expenditures)
10
Why an EHR?
The World of Healthcare
is Changing…
The Old World
The New World
Provider-focused
Illness
Site-of-care
Episode Management
Supply Management
Solitary decision making
Efficiency
De-centralized, generalized care
Patient & family-focused
Wellness
Continuum of care
Disease Management
Demand Management
Collaborative, evidence-based decisions
Effectiveness
Centralized, specialized care
11
Why an EHR?
The World of Healthcare
is Changing…
The changes in healthcare require
significant capability from the
health infostructure, capability
which does not fully exist today
12
The Timing Has Never Been Better!
WILL
• Public wants more
accessibility
• Health Authorities
recognize benefits
• Increased financial
pressures
• Healthcare
professionals
embracing technology
• Willingness to
collaborate
CONVERGENCE
CAPACITY
• Better infrastructure
• More mature
application
technologies
CAPABILITY
• Political will
• Funding is now available
• Infoway mandated to pursue investments
13
EHRS Blueprint:
Key Definitions
14
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.
15
EHR Solution
The EHR Solution is a combination of people,
organizational entities, business processes, systems,
technology and standards that interact and exchange
clinical data to provide high quality and effective
healthcare.
16
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 for the EHR,
data definitions for the EHR and messaging standards for the EHR.
17
EHRS Outcomes
Providers
Researchers & Health
Surveillance
Professionals
• Relevant data, granular
• Real time
• Rapid access from multiple
locations, anywhere,
anytime
• Decision support
•
•
•
Clinical reference data
Guidelines & protocols
Common terms & codes
• Case management &
workflow
• Safety
• Improved quality of care
• Appropriately summarized
data
• Anonymized
• Designed for analysis:
Authoritative,
reliable, secure,
private
•
•
•
•
•
•
Statistical sampling
Trends
Outbreak detection
Outcome analysis
Regional
Pan-Canadian
• Regulation & accountability
Payer/Payee
• Relevant data to adjudicate claim
• Workflow management
Patient/Public/Clients
• Convenient, relevant access to
accredited health information
• Access to relevant personal health
information
• Safety
• Improved quality of care
Public Sector Health Managers
• Registry solutions & initiatives
• Objective analysis of results & benefits
• Management reports
• Funding & resource allocation
• Policy
18
Key EHRS Architecture Concepts
EHR SOLUTION (EHRS)
EHR INFOSTRUCTURE (EHRi)
EHRS
Locator
Health
Information
Data
Warehouse
Ancillary
Data &
Services
EHR
Data &
Services
Registries
Data &
Services
Longitudinal Record Services
Health Information Access Layer
Point of Service
Application
Point of Service
Application
EHR Viewer
19
EHRS Blueprint Recommended Approach:
A Pan-Canadian EHR Service
EHR SOLUTION (EHRS)
EHR SOLUTION (EHRS)
EHR INFOSTRUCTURE (EHRi)
EHR INFOSTRUCTURE (EHRi)
Health
Information
Data
Warehouse
Ancillary
Data &
Services
EHR
Data &
Services
Registries
Data &
Services
Health
Information
Data
Warehouse
Ancillary
Data &
Services
Longitudinal Record Services
Point of
Service
Application
EHRS
Health Information Access Layer
Point of
Service
Application
EHR Viewer
EHRS
Registries
Data &
Services
Longitudinal Record Services
Health Information Access Layer
Point of
Service
Application
EHR
Data &
Services
EHRS
EHRS
EHRS
Point of
Service
Application
EHRS
EHR Viewer
EHRS
20
EHR Infostructure: Conceptual Architecture
JURISDICTIONAL INFOSTRUCTURE
Ancillary Data
& Services
Registries Data
& Services
Client
Registry
Outbreak
Management
EHR Data
& Services
PHS
Reporting
Shared
Health Record
Drug
Information
Diagnostic
Imaging
Data
Warehouse
Health
Information
Laboratory
Provider
Registry
Location
Registry
Business
Rules
EHR
Index
Message
Structures
Terminology
Registry
Normalization
Rules
Longitudinal Record Services
Security Mgmt
Data
Privacy Data
Configuration
Common Services
HIAL
Communication Bus
Public Health
Services
POINT OF SERVICE
Public Health
Provider
Pharmacy
System
Pharmacist
Radiology
Center
PACS/RIS
Radiologist
Lab System
(LIS)
Lab Clinician
Hospital, LTC,
CCC, EPR
Physician/
Provider
Physician
Office EMR
Physician/
Provider
EHR Viewer
Physician/
Provider
21
Guiding Principles for EHRS
• Patient-centric
• Leverage legacy systems & solutions
• Mass customized views of all clinical data
• Value add for the provider
• Design for phased rollout with near
term results
• Timely, accurate information
• Scalable
• Enable sharing at local, regional,
cross-jurisdictional
• Extensible to support future growth
• Interoperable, integrated
• Secure & private
• Standards based
• Allow for innovation & competition
• Replicable solution – patterns, components
• Comprehensive
• Cost-effective
22
Generations of EHR Capabilities
Gen 5
Full
The Mentor
Gen 4
The Colleague
Gen 3
Functionality
The Helper
Gen 2
The Documentor
Gen 1
The Collector
Minimal
1993
1998
2005
2010
2015+
End of 2009
Source: Gartner (December 2005)
Availability of Products
23
A Few Misconceptions About EHR Solutions
Misconception
Reality
• A person’s health data is in only one
physical EHR
• EHR: an integrated service covering
all available EHR Solutions; a client’s
record is seen as coming from a single
integrated EHR
• All data for a person must be in the
EHR to have value and generate
adoption
• A jurisdiction is a province/territory
• The EHR is a data warehouse to
support research and surveillance
• Quality, safety & effectiveness
enhanced with only subsets of clinically
relevant data available for sharing
• Any geo-political entity mandated to
govern the operation of an EHR
Solution
• The EHR: an information support
service available to caregivers in the
daily context of care provision work
activities
24
Business/Clinical Scope
25
EHRS Serving Healthcare Service Delivery
EHR SOLUTION (EHRS)
EHR SOLUTION (EHRS)
EHR INFOSTRUCTURE (EHRi)
EHR INFOSTRUCTURE (EHRi)
Health
Information
Data
Warehouse
Ancillary
Data &
Services
EHR
Data &
Services
Registries
Data &
Services
Health
Information
Data
Warehouse
Ancillary
Data &
Services
Longitudinal Record Services
Registries
Data &
Services
Longitudinal Record Services
Health Information Access Layer
Point of Service
Application
EHR
Data &
Services
Poin of Service
Application
Health Information Access Layer
Point of Service
Application
EHR Viewer
Homecare
Community
Care Center
Community
Care Center
Clients/Patients
Emergency
Services
Clients/Patients
Specialist
Clinic
Pharmacy
Laboratory
Diagnostic
EHR Viewer
Homecare
Emergency
Services
Hospital
Emergency
Point of Service
Application
Specialist
Clinic
Pharmacy
Hospital
Emergency
Laboratory
Diagnostic
26
Public Health Business Requirements
• Focuses on managing health status of populations
• Managed and executed through complex network of public/private organizations acting at different
levels of the health system (Federal, Provincial/Territorial, Regional, Local, Individual)
• Involves:
•
Research & analysis to identify/define population health programs
•
Surveillance activities to detect and pro-actively react to potential population health problems
•
Application of health programs to prevent the appearance and/or dissemination of preventable diseases
•
Active management of communicable disease outbreaks
•
Active management of the delivery of health services to individuals in the context public health related programs
• Current focus limited to:
•
Surveillance and detection (focused on human health-related diseases)
•
Outbreak Management
•
Public Health Alert Management
•
Disease Information Dissemination
•
Immunization Management
•
Communicable Disease Case Management
27
Integrating Public Health in the Architecture
New services required to support:
• Surveillance & Detection: introduces a formal business need for the Health information
data warehouse introduced in V2
• Outbreak Management: requires the addition of a new category of service called Ancillary
Services where a specific service is introduced to address outbreak management
• Disease Information Dissemination: introduces the need for a formal terminology registry
system that would maintain information about diseases and other key terminologies
required for many services of the EHRi
• Terminology registry would go beyond simply maintaining to allow for maintenance, dissemination of education, etc.
associated with diseases
• Public Health Alert Management
• Public health disease alert reporting requires use of specific applications also positioned as ancillary services
• Public health alerts dissemination relies on terminology registry and HIAL Alerts and Notification services
• Immunization Management
• Immunization programs and their management requires a specific application that would live under the ancillary
services category
• Delivery of immunisation would be tracked by the drug information domain as part of the EHR
• Communicable Disease Case Management
• Delivery of health services in relation with the treatment of a CD case would be tracked by the shared health record and
other domains as part of the EHR
• Management of a CD case from the perspective of the public health specialists involved in detection and tracking would
require a specific application that would live under the ancillary services category
28
Integrating Public Health in the Architecture
Some Public Health business requirements can be sustained by the
existing services of the EHR Infostructure
• Public Health Alert Management: HIAL and LRS to provide for mechanism to help with
detection & reporting on communicable diseases
• Immunization Management: Drug Information Domain is the home of immunisation
information as part of the core clinical data in client’s health records. HIAL and LRS to provide
mechanisms to communicate the data and coordinate its location and access within the EHRi
• Communicable Disease Case Management: CD Cases, from the perspective of the EHR
are treated like any other health delivery encounter
29
EHRS Serving Public Health Service Delivery
JURISDICTIONAL INFOSTRUCTURE
Immunization
“Registry“
Ancillary Data
& Services
Registries Data
& Services
Client
Registry
Outbreak
Management
Provider
Registry
EHR Data
& Services
PHS
Reporting
Shared
Health Record
Drug
Information
Data
Warehouse
Diagnostic
Imaging
Health
Information
Laboratory
Case
Management
Reference
Management
Location
Registry
Business
Rules
EHR
Index
Message
Structures
Terminology
Registry
Normalization
Rules
PHS Data
Warehouse
Services
Longitudinal Record Services
Alert Notification
Services
Content &
Knowledge
Management
Messaging
Security &
Privacy Services
Security Mgmt
Data
Privacy Data
Configuration
Common Services
HIAL
Communication Bus
PHS Systems
Operational data
PHS
A
CM
OM
AM
IM*
Other PH
System(s)
Pharmacy
System
Radiology
Center
PACS/RIS
Lab System
(LIS)
Hospital,
Community,
etc… EPR
Physician
Office EMR
EHR Viewer
Public Health Surveillance Portal
Pharmacist
POINT OF SERVICE
Public Health Providers
Radiologist
Lab Clinician
Physician/
Provider
Physician/
Provider
Physician/
Provider
30
Telehealth Business Requirements
• Telehealth: the use of information & communication technologies to deliver health
services in contexts where the providers and clients are in separate locations
• Telecommunication infrastructure is a pre-requisite
• Telehealth solutions enable health service delivery channels:
Tele-consultations
Videoconferencing
stations, communication
enabled medical
devices
Tele-education
Videoconferencing
stations used for
training/education
Tele-homecare
Active or passive
monitoring of remote
patients for pre-/
post-op procedures,
chronic diseases
management, etc
Tele-triage
Centralized call centers
to offer first line delivery
of service to clients as
part of primary care and
emergency response
• Scheduling solutions – a key enabler required for the effective use of telehealth service delivery
• EHR Infostructures support telehealth applications as per any other Point-of-Service Application
31
EHRS Serving Telehealth Scheduling
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Client
Registry
Ancillary Data
& Services
Outbreak
Management
EHR Data
& Services
PHS
Reporting
Shared
Health Record
Drug
Information
Diagnostic
Imaging
Data
Warehouse
Health
Information
Laboratory
Provider
Registry
Location
Registry
Terminology
Registry
Business
Rules
EHR
Index
Message
Structures
Normalization
Rules
Longitudinal Record Services
Security Mgmt
Data
HIAL
Privacy Data
Configuration
Common Services
Communication Bus
TSA
Database
Patient
Info
End-user
Info
Event
History
Clinical
Profile
Scheduling
Video
Session
POINT OF SERVICE
Referring
Physician
Site
Physician/
Provider
Attending
Physician
Site
Physician/
Provider
TSA APPLICATION
32
EHRS Blueprint: Tele-Consultation
EHR INFOSTRUCTURE (EHRi)
Health
Information
Data
Warehouse
Ancillary
Data &
Services
EHR
Data &
Services
EHR INFOSTRUCTURE (EHRi)
Registries
Data &
Services
Ancillary
Data &
Services
Longitudinal Record Services
Lutselk’e,
NWT
Telehealth
Application
EHR
Data &
Services
Registries
Data &
Services
Longitudinal Record Services
Health Information Access Layer
Local Electronic
Medical Record
Health
Information
Data
Warehouse
Health Information Access Layer
Live Video-Conferencing
Session
Tele-Consultation Devices Data
Telehealth
Application
Local Electronic
Patient Record
Edmonton,
AB
33
EHRS Blueprint: Tele-Homecare
EHR INFOSTRUCTURE (EHRi)
Ancillary
Data &
Services
Health
Information
Data
Warehouse
EHR
Data &
Services
EHR INFOSTRUCTURE (EHRi)
Registries
Data &
Services
Longitudinal Record Services
Health
Information
Data
Warehouse
EHR
Data &
Services
Registries
Data &
Services
Longitudinal Record Services
Health Information Access Layer
Local Electronic
Medical Record
Ancillary
Data &
Services
Health Information Access Layer
Homecare
Application Server
Tele-Homecare Data Feed
Tele-Consultation Devices
Homecare
Client Application
Montreal,
QC
Dieppe,
NB
34
EHRS Blueprint: Tele-Triage
EHR INFOSTRUCTURE (EHRi)
Ancillary
Data &
Services
Health
Information
Data
Warehouse
EHR
Data &
Services
EHR INFOSTRUCTURE (EHRi)
Registries
Data &
Services
Longitudinal Record Services
End-user Info
Event
History
Clinical
Profile
Scheduling Video Session
EHR Viewer
Kingston, ON
London, ON
Health
Information
Data
Warehouse
EHR
Data &
Services
Registries
Data &
Services
Longitudinal Record Services
Health Information Access Layer
Patient Info
Ancillary
Data &
Services
Health Information Access Layer
Personal
Health Record
Application
Tele-Triage
Application
Sault Ste-Marie,
ON
Oshawa, ON
35
Clinical, Business &
Socio-economic Drivers
for EHR Solutions
36
Why is Value Created by an EHR Solution?
• Healthcare professionals make clinical decisions based on knowledge
• Better knowledge translates to better care
• Knowledge starts with accurate, relevant clinical information
• The EHR creates the capability to share relevant clinical information
• The 5 Rs of the EHR:
• The right information
• About the right client
• Available to the right person
• In the right place
• At the right time
37
How Is Value Delivered By An EHR?
The value of the EHR for clients, families and their providers
increases with the completeness of the information contained as well
as the level of standardization of the data
Point of
greatest value
Extent of the Care
Continuum Involved
(PCP office, Hospital, Long
Term Care Homecare, etc.)
# of Data Domains Included
(Encounter Summaries, Lab, DI, Drugs, etc.)
38
Why Pursue The EHR: Circle of Care
Homecare
Clinic
Emergency Services
Community
Care Center
Pharmacy
Specialist Clinic
Laboratory
Hospital
Emergency
Diagnostic
39
Why Pursue The EHR: Benefits
Homecare
Clinic
Emergency Services
Community
Care Center
Pharmacy
QUALITY
SAFETY
ACCESSIBILITY
Specialist Clinic
Laboratory
Hospital
Emergency
Diagnostic
40
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
41
EHR Key Clinical & Business Requirements
• Life-long longitudinal record of clinical data
• Allowing private and secured access to data made available in EHR
• Focused on clinically relevant data shared beyond organizational boundaries
• Support for accurate, complete, timely delivery of information
• Shared across multiple organizations, jurisdictions
• Adaptive to the future of healthcare delivery in the 21st Century
• Requiring ongoing governance and operations management with 24/7 high
availability service
• Affordable in relation to complexity and size of integration challenges (connecting large
numbers health points of service)
• Scalable to allow continuous, extensive growth of clinical and $ ROI
• More POS applications sourcing data to EHR
• More users accessing and using data from EHR
• Allowing natural growth of capabilities towards Generation 3 and beyond
42
Different Approaches To
Achieving EHR
43
EHR: How Do We Do This?
Sharing Information From Multiple Systems
Homecare
Clinic
Emergency Services
Community
Care Center
Pharmacy
INTEGRATED
VIEW
Clients/Patients
Specialist Clinic
Laboratory
Hospital
Emergency
Diagnostic
44
Methods of Sharing EHR Information
The “Big Database
in the Sky”
Broadcast to all or
a logical subset of
systems
The “Big Index in
the Sky”
Use of a
shared reference
information source
• All Point-of-Service
(POS) systems share
same data store
• Replication of data
from one system to
all other relevant/
participating POS
systems
• EHR Index or locator
service that holds
links to all POS
systems where
information resides
• POS systems
populate it
• Every POS
system holds same
information
• Each POS system
interfaces to other
systems
• POS systems or
viewers reference it
• External to the
“operational” store
45
Key Factors Affecting How to Share
• Sharing creates some very profound issues & requirements
• Unique identification of clients, providers, service delivery locations, etc.
• Protecting privacy and confidentiality of patients and providers while
simultaneously not limiting the ability to deliver appropriate services
• Ensuring information is stored, shared securely
• Ensuring compatibility of how data is interpreted/understood
• Issues the same no matter which model is chosen to share patient
identified information
• Canadian governance model for healthcare means these issues are F/P/T
jurisdictional responsibilities – requirements vary
• People increasingly mobile, especially when considering long periods
of time
• Provider’s confidence in the mechanisms to enable sharing is crucial
46
The Integration Challenge
of EHR Solutions
47
Integrating Heterogeneous Systems
Homecare
Clinic
Emergency Services
Community
Care Center
Pharmacy
Clients/Patients
Specialist Clinic
Laboratory
Hospital
Emergency
Diagnostic
48
Integrating Heterogeneous Systems: Hospital
Hospital Emergency
Homecare
Clinic
Emergency Services
Finance,
inventory,
payroll
ADT
Order/
Results
Electronic
Patient
Record
Specialized
Care
Community
Care Center
Pharmacy
Pharmacy
Human
Resources
Scheduling
Laboratory
Clients/Patients
Clinical Data
Repository
Specialist Clinic
Radiology
PACS
Emergency
Laboratory
Hospital
Emergency
Diagnostic
49
Integrating Heterogeneous Systems: Hospital
Homecare
Clinic
Clinic
Emergency Services
Scheduling
Accountiing/
Billing
Electronic
Medical
Record
Community
Care Center
Pharmacy
Clients/Patients
Specialist Clinic
Laboratory
Hospital
Emergency
Diagnostic
50
Locations of Electronic Clinical Data Today: Number of
Systems to Integrate
Homecare
Clinic
Emergency Services
Community
Care Center
Pharmacy
40,000 systems
Clients/Patients
Canada has approximately
Specialist Clinic
Laboratory
Hospital
Emergency
Diagnostic
51
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
52
EHRS Blueprint
Recommended Approach:
The Cost of Integration
As A Key Driver
53
Integrating Health Information Systems:
Point-to-Point Connectivity
SYSTEMS TO CONNECT
ApplApp
1 1
Costs basis
AppAppl
1 2
• Cost of one integration
• Simple = $32K; Medium = $95K;
Complex = $190K
Contracts
App 1
App 1
2
Futile approach
SYSTEMS TO CONNECT
• 38,783 systems in Canada
ApplApp
1 App
1 1
AppAppl
1 2
ApplApp
3 App
1 1
• Simple = 4,527; Medium = 20,081;
Complex = 14,175
• 1.5 B integration points
6
• 183.928 B $CDN
SYSTEMS TO CONNECT
App 1
ApplApp
1 App
1 1
AppAppl
1 2
App 1
App 1
ApplApp
3 App
1 1
AppAppl
1 4
App 1
We need a different approach
12
Interfaces = N (N-1)
54
Integrating Health Information Systems:
Hospital Networks Approach
SYSTEMS TO CONNECT
ApplApp
1 1
Costs basis
AppAppl
1 2
• Cost of one integration
• Simple = $32K; Medium = $95K;
Complex = $190K
Contracts
App 1
App 1
2
Hypothesis
SYSTEMS TO CONNECT
ApplApp
1 App
1 1
• 1,126 Hospital networks, each
includes 71 systems to integrate and
group (EAI) in 44 points of
integration
AppAppl
1 2
ApplApp
3 App
1 1
• 1,892 (44 x 43) integrations per
network totalling 2.1 M (1,126 x
1,892) integrations in Canada
6
SYSTEMS TO CONNECT
App 1
ApplApp
1 App
1 1
AppAppl
1 2
App 1
• Assuming existence of standardized
protocol for interfaces
• 68.172 M $CDN (if Simple – 32K)
App 1
ApplApp
3 App
1 1
AppAppl
1 4
12
App 1
• 202.316 M $CDN (if Medium – 95K)
We need a different approach
Interfaces = N (N-1)
55
Integrating Health Information Systems:
EHRS Blueprint Approach
EHR SOLUTION (EHRS)
Costs basis
• Cost of one integration
EHR INFOSTRUCTURE (EHRi)
•
Health
Information
Data
Warehouse
Ancillary
Data &
Services
EHR
Data &
Services
Registries
Data &
Services
Longitudinal Record Services
Health Information Access Layer
Point of Service
Application
Point of Service
Application
EHR Viewer
Simple = $32K; Medium = $95K;
Complex = $190K
Hypothesis
• All hospitals/long term care
organizations use an integration engine
and count as 1 integration point
• Simple = 4,575; Medium = 8,134;
Complex = 6,597
• 19,306 integration points
• Assuming existence of standardized
interface and protocols
• 2.170 M $CDN
56
Rational for Recommended Approach
• Only cost effective scenario to handle degree of application integration required
• Maximized ability to deliver proper response time and consistent access to data
across thousands of source systems
• Maximized ability to apply privacy and security policies in a harmonized and
consistent fashion
• Enables evolutionary path to semantic harmonization of health information
across service delivery points
• Enables high degree of scalability from local health services integration, to
regional, provincial or territorial and cross-jurisdictional
• Enables high degree of flexibility in reconfiguration of health services
delivery networks
57
Architecture Perspectives
Business
Architecture
Clinical
Work Process
Architecture
Potential
Applications
CONTEXT
Integration &
Deployment
Models
System
Architecture
Information
Architecture
58
EHRS Work Process Architecture
• The EHR Clinical Reference Framework: Life of the Lamberts
• Depiction of the use of an EHR Solution in different contexts of health service delivery
• 14 different storyboards created
• Extensible by adding new use cases
• System or security administration use cases not represented
• Life of the Lamberts
• Patient centric framework
• Focused on different members of a family and their health status evolution
• Focused on health related events
• Represented with UML use case notation
• Developed under Magic Draw case tool
• Published as artefacts under the Artefact Repository
• Available in HTML and PDF format
• Available in Magic Draw format and XMI for upload to other case tools
59
EHRS Reference Architecture
Comm Step Put New Patient
HIAL
POS APPLICATION
SIGNIFICANT REUSE
HERE
Encounter
Life Of
The Lamberts
COPD
Storyboard
Encounter
Clinical Activity
Clinical Events
Storyboard
New
Family Physician
Activity
New
Family Physician
Activity
Clinic Visit
Admission
EHR IP
Clinical Activity
Clinical Events
EHR IP
Clinical Events
EHR IP
Storyboard
EHR IP
Public Health
Services
POINT OF SERVICE
Public Health
Provider
EHR IP
Pharmacy
System
Pharmacist
EHR IP
Radiology
Center
PACS/RIS
Radiologist
EHR IP
Lab System
(LIS)
Lab Clinician
EHR IP
Hospital, LTC,
CCC, EPR
Physician/
Provider
EHR IP
Physician
Office EMR
Physician/
Provider
EHR IP
Add New Patient
EHR IP
EHR Viewer
Physician/
Provider
EHRS Reference
Architecture
60
Documenting EHRi Services Requirements
JURISDICTIONAL INFOSTRUCTURE
Ancillary Data
& Services
HIAL
Provider
Registry
HIAL
Location
Registry
EHR Data
& Services
Data
Warehouse
Outbreak
Management
PHS
Reporting
Shared
Health Record
Drug
Information
Diagnostic
Imaging
Laboratory
HIAL
HIAL
HIAL
HIAL
HIAL
HIAL
Business
Rules
EHR
Index
HIAL
Client
Registry
HIAL
Registries Data
& Services
Terminology
Registry
Message
Structures
Health
Information
Normalization
Rules
Longitudinal Record Services
HIAL
HIAL
HIAL
Privacy Data
Configuration
Common Services
IP “Put”
EHR IP
Data
EHR IP
Hospital, LTC,
CCC, EPR
POINT OF SERVICE
Security Mgmt
Data
HIAL
Radiologist
IP “List”
Communication
Bus
IP “Get”
EHR IP
Data
EHR IP
Physician
Office EMR
Lab Clinician
EHR IP
Data
IP “List”
EHR IP
Data
IP “Get”
EHR IP
Data
EHR IP
EHR IP
EHR IP
Physician
Office EMR
EHR Viewer
EHR Viewer
Physician/
Provider
Physician/
Provider
Physician/
Provider
EHRS Reference
Architecture
61
People Use Cases: Caregiver Perspective
JURISDICTIONAL INFOSTRUCTURE
Ancillary Data
& Services
Registries Data
& Services
EHR Data
& Services
Data
Warehouse
• First class of deliverables are contextual & informational
• They describe the end-user functional requirements and assumptions for use of an EHR Solution
• Establish when POS applications expected to interact with an EHRi in the context of daily work activities
for caregivers
• Infoway not attempting to document all forms of potential uses of an EHR
• Scope is broad enough to cover large spectrum of healthcare and public health service delivery to
achieve representative set
Security Mgmt
Data
Privacy Data
Configuration
Common Services
HIAL
Communication Bus
EHR INTERFACE REQUIREMENTS DOCUMENTATION
Public Health
Services
Pharmacy
System
Life of the
Lamberts
POINT OF SERVICE
Public Health
Provider
Radiology
Center
PACS/RIS
Lab System
(LIS)
Storyboards
Pharmacist
Radiologist
Hospital, LTC,
CCC, EPR
Encounters
Lab Clinician
Physician/
Provider
Physician
Office EMR
EHR Viewer
Clinical
Activities
Physician/
Provider
Physician/
Provider
62
EHR Interoperability Profile (EHR IP)
JURISDICTIONAL INFOSTRUCTURE
Ancillary Data
& Services
Registries Data
& Services
EHR Data
& Services
Data
Warehouse
• Second class of deliverables normative; specify the interfaces between POS applications
and EHR
• Establishes a language to describe types of service requests made to an EHRi
• Positions which data to be exchanged by referring to data views of the data model
• Assumes SOAP-based web services calls where XML encoded HL7 V3 message requests
and responses are carried between POS applications and the EHRi
HIAL
EHR INTEROPERABILITY PROFILE
Public Health
Services
Pharmacy
System
Radiology
Center
PACS/RIS
EHR IP
POINT OF SERVICE
Public Health
Provider
Pharmacist
Radiologist
Lab System
(LIS)
Hospital, LTC,
CCC, EPR
Communication
Steps
Lab Clinician
Physician/
Provider
Physician
Office EMR
Physician/
Provider
EHR Viewer
Physician/
Provider
63
EHR Infostructure IP (EHR I-IP)
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Client
Registry
Ancillary Data
& Services
EHR Data
& Services
Data
Warehouse
INFOSTRUCTURE INTEROPERABILITY PROFILE
Outbreak
Management
PHS
Reporting
Shared
Health Record
Drug
Information
Diagnostic
Imaging
Health
Information
Laboratory
Provider
Registry
Location
Registry
Terminology
Registry
Business
EHR
Rules Infostructure
Index
IP
Message
Structures
Normalization
Infostructure
Rules
Services Catalogue
Generic Interface
Specification
Longitudinal Record Services
Security Mgmt
Data
HIAL
Privacy Data
Configuration
Common Services
Communication Bus
• Third class of deliverables normative; specify inner workings within EHR Infostructure to
orchestrate and process transactions
• Express sequencing of activities to process transactions
• Express expected capabilities of services within an EHRi to process transactions
POINT OF SERVICE
64
Architecture Perspectives
Business
Architecture
Clinical
Work Process
Architecture
Potential
Applications
CONTEXT
Integration &
Deployment
Models
System
Architecture
Information
Architecture
65
EHR Infostructure: Services Drill-Down
JURISDICTIONAL INFOSTRUCTURE
Ancillary Data
& Services
Registries Data
& Services
Client
Registry
Outbreak
Management
EHR Data
& Services
PHS
Reporting
Shared
Health Record
Drug
Information
Diagnostic
Imaging
Data
Warehouse
Health
Information
Laboratory
Provider
Registry
Location
Registry
Business
Rules
EHR
Index
Message
Structures
Terminology
Registry
Normalization
Rules
Longitudinal Record Services
Security Mgmt
Data
Privacy Data
Configuration
Common Services
HIAL
Communication Bus
Public Health
Services
POINT OF SERVICE
Public Health
Provider
Pharmacy
System
Pharmacist
Radiology
Center
PACS/RIS
Radiologist
Lab System
(LIS)
Lab Clinician
Hospital, LTC,
CCC, EPR
Physician/
Provider
Physician
Office EMR
Physician/
Provider
EHR Viewer
Physician/
Provider
66
EHR Infostructure: Standards Based Connectivity
JURISDICTIONAL INFOSTRUCTURE
Ancillary Data
& Services
HIAL
Provider
Registry
HIAL
Location
Registry
EHR Data
& Services
Data
Warehouse
Outbreak
Management
PHS
Reporting
Shared
Health Record
Drug
Information
Diagnostic
Imaging
Laboratory
HIAL
HIAL
HIAL
HIAL
HIAL
HIAL
Business
Rules
EHR
Index
Message
Structures
HIAL
Client
Registry
HIAL
Registries Data
& Services
Terminology
Registry
Health
Information
Normalization
Rules
Longitudinal Record Services
HIAL
HIAL
Security Mgmt
Data
HIAL
Privacy Data
Configuration
Common Services
HIAL
Communication Bus
EHR SCP
Standards
EHR IP
EHR IP Standards
EHR IP
EHR IP Standards
EHR IP
EHR IP Standards
EHR IP
EHR IP
EHR IP Standards
EHR IP Standards
EHR IP
EHR IP Standards
EHR IP
EHR IP Standards
EHR IP
EHR IP
EHR IP
EHR IP
EHR IP
EHR IP
EHR IP
Public Health
Services
Pharmacy
System
Radiology
Center
PACS/RIS
Lab System
(LIS)
Hospital, LTC,
CCC, EPR
Physician
Office EMR
EHR Viewer
POINT OF SERVICE
Public Health
Provider
Pharmacist
Radiologist
Lab Clinician
Physician/
Provider
Physician/
Provider
Physician/
Provider
67
EHR Infostructure: Communication Bus
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Ancillary Data
& Services
EHR Data
& Services
Data
Warehouse
COMMUNICATION BUS
MESSAGING
Transformation
Services
Routing
Services
Encrypt/Decrypt
Services
En/Decoding
Services
Parser
Services
Serialization
Services
HIAL
PROTOCOL
App Protocol
Services
Communication bus
Network Protocol
Services
POINT OF SERVICE
68
EHR Infostructure: Common Services
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Ancillary Data
COMMON
& Services
EHR Data
& Services
SERVICES
PRIVACY & SECURITY
INTEROP
Interoperability
Services
Identity Protection
Services
Anonymization
Services
Consent Directives
Mgmt Services
Search/Resolution
Services
Identity Mgmt
Services
User Authentication
Services
Encryption
Services
INTEGRATION
Access Control
Services
Secure Auditing
Services
Digital Signature
Services
Service Catalogue
Services
General Security
Services
Broker Services
SUBSCRIPTION
MANAGEMENT
Management
Services
Common Auditing
Services
Queuing Services
Alert/Notification
Services
CONTEXT
Pub/Sub
Services
Configuration
Services
Log Mgmt
Services
Policy Mgmt
Services
Exception/Error
Handling Services
Mapping Services
HIAL
Caching Services
Data
Warehouse
GENERAL
Security Mgmt
Data
Privacy Data
Configuration
Services
Session Mgmt
Services
POINT OF SERVICE
69
EHR Infostructure: Longitudinal Record Services
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Ancillary Data
& Services
EHR Data
& Services
Data
Warehouse
LONGITUDINAL RECORD SERVICES
DATA
Business
Rules
EHR
Index
Message
Structures
Normalization
Rules
Longitudinal Record Services
Key Mgmt
Services
Data
Services
ETL
Services
Replication
Services
BUSINESS
Data Quality
Services
Normalization
Services
HIAL
Domain Business Components
(Registries, EHR, Domains, User, Context)
EHR Index
Services
Business Rules
Services
Orchestration
Services
Assembly
Services
POINT OF SERVICE
70
EHR Infostructure: Longitudinal Record Services
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Ancillary Data
& Services
The EHR Index maintains a sequential list of all events that affect the clinical
picture of a client. It also provides the location where the data relevant to each
event is kept in the EHRi. It can be used to retrieve the history of events for a
client or to trace the information about a specific event.
EHR Data
& Services
Data
Warehouse
LONGITUDINAL RECORD SERVICES
DATA
EHR INDEX
Event ID (Instance ID of an
Business
Rules
event)
EHR
Index
Parent Folder ID
Focal Class Type
Message
Structures
Normalization
Rules
Longitudinal Record Services
Key Mgmt
Services
Data
Services
ETL
Services
Replication
Services
Focal Act Subject (Client ECID)
Focal Act Author (Provider)
Focal Act Service Delivery Location
Focal Act Timestamp
BUSINESS
Data Quality
Services
Normalization
Services
FocalHIAL
Act Status
Focal Act Language
Focal Act Type:
• Act Mood (e.g. Order Request)
• Act Class Code (type of class, e.g. Lab order)
• Act Code (Class value, e.g. CBC)
Focal Act Source ID (ID provided by POS)
Domain Business Components
(Registries, EHR, Domains, User, Context)
EHR Index
Services
Business Rules
Services
Orchestration
Services
Assembly
Services
Focal Act Template ID
Focal Act Data Location ID (URI)
POINT OF SERVICE
71
EHR Infostructure: EHRS Locator Data
CROSS-JURISDICTIONAL INFOSTRUCTURE
•
•
•
•
•
EHRS
Locator
EHRi Client ID (resolved ECID)
CR instance ID (OID root)
EHRi instance ID (which instance of an EHRi)
EHRi URI (the URI to access the HIAL)
Optimized for performance
• Information type (drug, lab, DI) (derived from HL7 act classes)
• First created date
• Last updated date
JURISDICTIONAL INFOSTRUCTURE
EHR SOLUTION (EHRS)
EHR SOLUTION (EHRS)
EHR INFOSTRUCTURE (EHRi)
EHR INFOSTRUCTURE (EHRi)
Health
Information
Data
Warehouse
Ancillary
Data &
Services
EHR
Data &
Services
Registries
Data &
Services
Longitudinal Record Services
Health
Information
Data
Warehouse
Ancillary
Data &
Services
Point of
Service
Application
Registries
Data &
Services
Longitudinal Record Services
Health Information Access Layer
Point of
Service
Application
EHR
Data &
Services
Health Information Access Layer
EHR Viewer
Point of
Service
Application
Point of
Service
Application
EHR Viewer
POINT OF SERVICE
72
Centralized Service Approach
CROSS-JURISDICTIONAL INFOSTRUCTURE
EHRS
Locator
JURISDICTIONAL INFOSTRUCTURE
EHR SOLUTION (EHRS)
EHR SOLUTION (EHRS)
EHR SOLUTION (EHRS)
EHR INFOSTRUCTURE (EHRi)
EHR INFOSTRUCTURE (EHRi)
EHR INFOSTRUCTURE (EHRi)
Health
Information
Data
Warehouse
Ancillary
Data &
Services
EHR
Data &
Services
Registries
Data &
Services
Longitudinal Record Services
Health
Information
Data
Warehouse
Ancillary
Data &
Services
Point of Service
Application
Registries
Data &
Services
Longitudinal Record Services
Health Information Access Layer
Point of Service
Application
EHR
Data &
Services
Health
Information
Data
Warehouse
Ancillary
Data &
Services
Point of Service
Application
Point of Service
Application
Registries
Data &
Services
Longitudinal Record Services
Health Information Access Layer
EHR Viewer
EHR
Data &
Services
Health Information Access Layer
EHR Viewer
Point of Service
Application
Point of Service
Application
EHR Viewer
POINT OF SERVICE
Jurisdiction
Jurisdiction
Jurisdiction
A
B
C
73
Distributed Service Approach
CROSS-JURISDICTIONAL INFOSTRUCTURE
EHRS Locator Synchronization
EHRS
Locator
EHRS
Locator
JURISDICTIONAL INFOSTRUCTURE
EHR SOLUTION (EHRS)
EHR SOLUTION (EHRS)
EHR SOLUTION (EHRS)
EHR INFOSTRUCTURE (EHRi)
EHR INFOSTRUCTURE (EHRi)
EHR INFOSTRUCTURE (EHRi)
Health
Information
Data
Warehouse
Ancillary
Data &
Services
EHR
Data &
Services
Registries
Data &
Services
Longitudinal Record Services
Health
Information
Data
Warehouse
Ancillary
Data &
Services
Point of Service
Application
Registries
Data &
Services
Longitudinal Record Services
Health Information Access Layer
Point of Service
Application
EHR
Data &
Services
Health
Information
Data
Warehouse
Ancillary
Data &
Services
Point of Service
Application
Point of Service
Application
Registries
Data &
Services
Longitudinal Record Services
Health Information Access Layer
EHR Viewer
EHR
Data &
Services
Health Information Access Layer
EHR Viewer
Point of Service
Application
Point of Service
Application
EHR Viewer
POINT OF SERVICE
Jurisdiction
Jurisdiction
Jurisdiction
A
B
C
74
EHRS Locator: LRS Integrated Approach
CROSS-JURISDICTIONAL INFOSTRUCTURE
EHRS
Locator
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Ancillary Data
& Services
EHR Data
& Services
Data
Warehouse
Client
Registry
Provider
Registry
Location
Registry
Terminology
Registry
Business
Rules
EHR
Index
Message
Structures
Normalization
Rules
Longitudinal Record Services
HIAL
POINT OF SERVICE
75
LRS Integrated Services Approach
CROSS-JURISDICTIONAL INFOSTRUCTURE
Client Registry Synchronization
JURISDICTIONAL INFOSTRUCTURE
EHR SOLUTION (EHRS)
EHR SOLUTION (EHRS)
EHR SOLUTION (EHRS)
EHR INFOSTRUCTURE (EHRi)
EHR INFOSTRUCTURE (EHRi)
EHR INFOSTRUCTURE (EHRi)
Health
Information
Data
Warehouse
Ancillary
Data &
Services
EHR
Data &
Services
Registries
Data &
Services
Longitudinal Record Services
Health
Information
Data
Warehouse
Ancillary
Data &
Services
Point of Service
Application
Registries
Data &
Services
Longitudinal Record Services
Health Information Access Layer
Point of Service
Application
EHR
Data &
Services
Health
Information
Data
Warehouse
Ancillary
Data &
Services
Point of Service
Application
Point of Service
Application
Registries
Data &
Services
Longitudinal Record Services
Health Information Access Layer
EHR Viewer
EHR
Data &
Services
Health Information Access Layer
EHR Viewer
Point of Service
Application
Point of Service
Application
EHR Viewer
POINT OF SERVICE
Jurisdiction
Jurisdiction
Jurisdiction
A
B
C
76
EHR Infostructure: EHR Data Domain Services
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Ancillary Data
& Services
EHR Data
& Services
Shared
Health Record
Drug
Information
Diagnostic
Imaging
Data
Warehouse
Laboratory
SHARED HEALTH RECORD
DATA
Key Mgmt
Services
HIAL
Data
Services
BUSINESS
Domain Business Components
(Registries, EHR, Domains, User, Context)
Normalization
Services
Business Rules
Services
EHRi Interoperability
Services
Assembly
Services
POINT OF SERVICE
77
EHR Infostructure: EHR Viewer
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Ancillary Data
& Services
EHR Data
& Services
Data
Warehouse
EHR VIEWER
EHRi Interoperability
Services
Data
Services
EHR Viewer
Business Objects Components
Normalization
Services
Business Rules
Services
End-user
Navigation Services
End-user
Display Services
HIAL
EHR Viewer
POINT OF SERVICE
Physician/
Provider
78
EHR Infostructure: Client Registry
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Ancillary Data
& Services
EHR Data
& Services
Data
Warehouse
Client
Registry
Provider
Registry
Location
Registry
Terminology
Registry
HIAL
POINT OF SERVICE
79
EHR Infostructure: Why A Client Registry?
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Ancillary Data
& Services
EHR Data
& Services
Data
Warehouse
Client
Registry
Provider
Registry
Location
Registry
Terminology
Registry
Has Mr. Lambert had any ER
visits since I’ve last seen him
one year ago?
HIAL
Patient
Info
End-user
Info
Visit
History
Drug
Profile
Laboratory
Diagnostic
Imaging
POINT OF SERVICE
EHR Viewer
Physician/
Provider
EHR VIEWER
80
EHRi Client Registry: The Challenge
EMPI
1: A 123 Robert Lambert 1 Main St
1: B 456 Bob Lambert 1 Main St
1: C 789 Robert Lambert 1 Main St
1: C 987 Robert Lambert 1 Main St
2: B 444 Robert Lambert 2 Elm St
Pharmacy
Lab
???
A
B
C
123 Robert Lambert 1 Main St
456 Bob Lambert 1 Main St
444 Robert Lambert 2 Elm St
789 Robert Lambert 1 Main St
987 Robert Lambert 1 Main St
81
EHRi Client Registry: What Data?
Name
Birthdate
Gender
The generation (or sourcing)
of the EHRI Client Identifier
(ECID) is a service offered
by the Client Registry.
Address
Phone
SIN
ULI
ECID
The ECID is the foundation
for interoperability both
locally and across EHR
Infostructures.
Static, natural
person identity
information
Dynamic, natural
person identity
information
Static, artificial
person-identifying
information
MDR ID
Lab ID
Dynamic, artificial
person-identifying
information
Eligibility status
Coverage details
Core system data
about the person
82
EHRi Client Registry: Interoperability Pattern
JURISDICTIONAL
ECID: J1 Root ID. Client ID
ECID: J2 Root ID. Client ID
Client
Registry
J1
Client
Registry
J2
Active synchronization
of travelling clients only
Client
Registry
J1/2
Client
Registry
J1.1
Applications
Applications
REGIONAL
83
EHR Infostructure: Provider Registry
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Ancillary Data
& Services
EHR Data
& Services
Data
Warehouse
Client
Registry
Provider
Registry
Location
Registry
Terminology
Registry
HIAL
POINT OF SERVICE
84
EHR Infostructure: Why A Provider Registry?
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Ancillary Data
& Services
EHR Data
& Services
Data
Warehouse
Client
Registry
Provider
Registry
Location
Registry
Terminology
Registry
Have any new test results been
published for me?
HIAL
Patient
Info
End-user
Info
Visit
History
Drug
Profile
Laboratory
Diagnostic
Imaging
POINT OF SERVICE
EHR Viewer
Physician/
Provider
EHR VIEWER
85
Provider Registry: Data Sources
JURISDICTIONAL
Doctors
Unlicensed
Providers
Dentists
EHR SCP Standards
Provider Registry
Provider
Registry
EHR SCP Standards
Provider Registry
Applications
Applications
Applications
REGIONAL
86
Standards-based
Solutions: What Does
It Mean?
87
Interoperable EHR Solutions: Key Architectural Requirements
Standardized
Architecture
Standardized
Interfaces
Standardized
Data Structures
Standardized
Data Vocabularies
(encoding rules)
Standards-based
Solutions
Standardized
Functional Behaviour
88
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
89
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 Infoway Knowledge Way
• Business-driven
• Adoption of existing standards where ever possible
• http://knowledge.infoway-inforoute.ca
90
Principles for Establishing Pan-Canadian EHR Standards
• Standards initiatives to be driven by the business of healthcare with a
clearly defined business need
• Existing standards work must be leveraged wherever possible and
practical with an approach that includes adoption, or adaptation of
existing standards, before development
• Health Level 7 V3 messaging standard required for all new message
development related to EHR
• Infoway investments predicated on a commitment to implement
pan-Canadian EHR standards
• Standards to be established, tested, refined and evaluated within the
context of early adopter implementations
• Infoway will support early adopter investment projects that have the
establishment of pan-Canadian standards as their goal
91
Principles for Establishing Pan-Canadian EHR Standards
• Establishing standards is an evolutionary process and will not be
perfect the first time; implementation of standards that are not fully
balloted may be needed
• Infoway is committed to supporting Canada’s leadership role in
influencing EHR international standards
• Infoway will work with other countries undertaking similar EHR
initiatives to leverage their work and bring synergies to the projects as
they move toward internationally balloted standards
• Infoway will partner with CIHI, HL7 Canada, IHE Canada and other
standards organizations in the establishment of pan-Canadian EHR
standards
• Establishment of pan-Canadian EHR standards is coordinated via an
open, transparent and inclusive Stakeholder Collaboration Process as
defined by our stakeholders
92
Standards Collaboration Process (SCP)
•
Pan-Canadian EHR Standards Advisory Committee
PAN-CANADIAN
DEVELOPMENT
Telehealth
Lab
Interoperable
EHR
Diagnostic Imaging
Drugs
Registries
Infostructure/EHR
The EHR Standards Collaboration
Process will establish panCanadian standards for Infoway
investments through collaboration
and consensus
EHR Standards Steering Committee
Expert Working Groups
•
The EHR Standards
Collaboration Process includes
those jurisdictions, standardsrelated organizations, healthcare
professionals and vendors that
will build, operate and use an
interoperable EHR
GOVERNANCE
STRATEGIC COLLABORATION/COORDINATION
•
An integral element of and key
requirement for the establishment
of a pan-Canadian interoperable
Electronic Health Record (EHR)
Infostructure
Pan-Canadian Standards working groups
93
Pan-Canadian EHR Standards: Status
Pan-Canadian Standards
Groups
•
•
•
•
•
•
•
Drugs
Client Registry
Provider Registry
DI/Tele-radiology
Laboratory
Clinical Terminology
iEHR Technical Standards
(coming soon)
• iEHR Clinical Standards
(coming soon)
• Public Health (coming soon)
Program Projects
Health Surveillance
Telehealth
Lab
Diagnostic Imaging
Drugs
Registries
Interoperable EHR
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
EHRS Blueprint V1
EHR Data Definition & Standards
Standards Collaboration Process
Standards Tactical Plan
Artefacts Repository
Telehealth ISO Interoperability
Telehealth CCHSA Accreditation
CeRx (formerly Rx5) HL7 V3 Messaging
Client Registry
Provider Registry
IRIS (Infoway Reference
Implementation Suite)
Laboratory Nomenclature & Messaging
NeCST: electronic claims messaging
EHR Clinical Terminology Integration
EHR Profiles for Interoperability
between DI, Registries & Consumers
EHR Blueprint Evolution Project
Privacy & Security Architecture Project
94
EHR Infostructure: Standards-based Connectivity
JURISDICTIONAL INFOSTRUCTURE
Ancillary Data
& Services
EHR Data
& Services
Data
Warehouse
HIAL
Registries Data
& Services
HIAL
Architecture Standards
HIAL
Data Messaging Standards
HIAL
HIAL
HIAL
• Provider Registry iIn ballot)
• EHR Data Model
• Pharmacy CeRx (in ballot)
• EHR Services Model
• Laboratory (in Planning)
• EHR Interoperability Profiles
• Diagnostic Imaging/Teleradiology (in planning)
HIAL
• Terminology
Standards
HIAL Clinical Messaging (in planning)
• iEHR
HIAL
• EHR Use Cases
HIAL
HIAL
• CTI project (underway)
EHR SCP
Standards
HIAL
• Client Registry (in ballot)
HIAL
• EHRS Blueprint
HIAL
• iEHR Technical Standards(in planning)
• Terminology
implemented
in data
• Public
EHR IP
EHR IP
EHR IP
EHR IPHealth Services
EHR IP Standards
EHR IP
messaging
standards
EHR IP Standards
EHR IP Standards
EHR IP Standards
IP Standards
EHR IP Standards
EHR IP Standards
• Public EHR
Health
Surveillance
Standards
EHR IP
POINT OF SERVICE
Public Health
Provider
EHR IP
Pharmacist
EHR IP
Radiologist
EHR IP
Lab Clinician
EHR IP
Physician/
Provider
EHR IP
Physician/
Provider
EHR IP
EHR IP Standards
EHR IP
Physician/
Provider
95
Service-oriented
Architecture (SOA):
What Does It Mean?
96
Level of Encapsulation Can Vary:
Five Normal Forms of Encapsulated Software
1
2
3
4
5
External access
Other data
Own data
Encapsulated software
Programmatic interface
Overloaded,
incomplete; any data
One complete
function; any data
Own data only
Exclusive data
Opaque data
Source: Gartner
97
SOA as an Enabler
Applications of SOA in EHRi Solutions
• Repurposed legacy applications to offer services as part of
SOA-based EHR Infostructure
• New breed of services to enable coordinated transactions in an EHR
Infostructure (e.g. Longitudinal Record Services)
• Use of commercially available solutions to enable components of
EHR Infostructure
Two Degrees of Separation
• Services exposed outside of an EHRi in the form of supported EHR
Interoperability Profiles for an entire Infostructure perceived as a
single system with transactional services
• Services within an EHR Infostructure to optimize scalability,
maintainability and functional flexibility
98
First Degree: The EHR Service
JURISDICTIONAL INFOSTRUCTURE
ClientGet Client ID
RegistryResolution
Get Outbreak
Case Data
PHS
Reporting
Outbreak
Management
Provider
Registry
Location
Registry
EHR SERVICE
Ancillary Data
& Services
Registries Data
& Services
List CD Report
Events
Shared
Health Record
Business
Rules
EHR
Index
List Service
Terminology
Registry Delivery
Locations
Message
Structures
Data
Warehouse
Get DI Report
Health
Information
Laboratory
Stream DI Image
Normalization
Rules
List Laboratory Orders
Get Laboratory Result
Longitudinal Record Services
List Medications
Get Encounter
Summary
HIAL
List DI Results
Diagnostic
Imaging
List Laboratory
Results
List Encounter
Events
Get Provider
Information
Drug
Information
EHR Data
& Services
Get Clinical
Dashboard
Security Mgmt
Data
Get Client
Demographic
Common Services
Privacy Data
Configuration
Get Prescription
Communication Bus
Public Health
Services
POINT OF SERVICE
Public Health
Provider
Pharmacy
System
Pharmacist
Radiology
Center
PACS/RIS
Radiologist
Lab System
(LIS)
Lab Clinician
Hospital, LTC,
CCC, EPR
Physician/
Provider
Physician
Office EMR
Physician/
Provider
EHR Viewer
Physician/
Provider
99
Second Degree: Inside The EHR Infostructure
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
CR
Services
Client
Registry
PR
Provider
Services
Registry
LR
Location
Services
Registry
Terminology
Terminology
Registry
Services
Ancillary Data
& Services
Detection
Outbreak
& Reporting
Services
Services
Outbreak
PHS
Management
Business
Rules
Rules
Services
A&A
Services
HIAL
Reporting
EHRi SERVICES
Shared Health
Record Services
Shared
Health Record
EHR Data
& Services
Drug
Services
Drug
Information
DI
Services
Diagnostic
Imaging
EHR
Message
Normalization
EHR Index
Index
Structures
Rules
Orchestration
Services
Services
Longitudinal Record Services Normalization
Services
Brokering
Services
Consent
Services
Session
Services
Data
Warehouse
Lab
Services
Health
Information
Laboratory
Assembly
Services
Security Mgmt
Privacy Data
Logging
Data
Services
Configuration
Common Services
Communication Bus
EHR IP
Any
Point-of-Service
Application
POINT OF SERVICE
100
Functioning Principles
101
Functioning Principles/Rules
• Home/no-home EHR
• Level of parameterization
• EHRi Identifier Management
• Primary Purpose for EHRi repositories
• EHR Index
• Other uses of the HIAL (POS to POS)
• EHRS Locator
• Multilingual capabilities
• POS to EHRi interface
• Runtime environment
• Level of transparency of EHR to
POS applications
• Performance principles – targets
• Transaction scope
• Error Handling
• Trust Models valid for an EHRi
• Consent
• Normalization
• Authentication & Authorization
• Auditing, logging, use of logs
• OIDS as a principle
• HL7 V3 (Messaging and templates)
• Prospective Events
• POS Integration environment
102
Architecture Perspectives
Business
Architecture
Clinical
Work Process
Architecture
Potential
Applications
CONTEXT
Integration &
Deployment
Models
System
Architecture
Information
Architecture
103
EHRi Conceptual Data Model
Governance
• High-level model representing
generalized concepts
• Event driven model to represent instances of
clinical service impacting a patient record
Role
• Broad range of event typing – governance,
people playing roles, delivery, environment,
resource
Event Linkage
Event
• Derived from the Canadian conceptual health
data model (CCHDM)
• Aligned and mapped to HL7 V3 RIM
• Mapped against several local and
international EHR data models – Quebec,
Alberta, Ontario, Australia, etc.
People
• More detailed views available – transactional
views, domain views
Place
Capability
Resource
Environment
104
Architecture Perspectives
Business
Architecture
Clinical
Work Process
Architecture
Potential
Applications
CONTEXT
Integration &
Deployment
Models
System
Architecture
Information
Architecture
105
HIAL Integration Layer:
Evolutionary Path
106
Interim State: No EHR Services (Undesirable)
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Drug
Information
System
Repository
DR API
CR API
Client
Registry
EHR Data
& Services
HL7 (CR)
Search/Resolve
CR API
HL7 v3 (CeRx)
Client Registration
1) Search client
2) Create new client
3) Update existing client
PATIENT ENCOUNTER
Client Registration
1) Search client
2) Create new client
3) Update existing client
Pharmacy Profile
4) Request drug profile
5) Request DUR
6) Enter new prescription
CR API
Each Jurisdiction Infostructure level
system uses patient and other
required strong identifiers (e.g.
provider, encounter) based on
point-of-service generated IDs
(e.g. MRNs). The CR-EMPI source
systems make the CR-EMPI aware
of client identifiers. The Point-ofService applications and
Infostructure systems query the
CR EMPI for these identifiers in
order to access data within any
Infostructure System. The level of
queries and maintenance of MRNs
in the EMPI is not scalable to
hundreds or thousands of Point-ofService systems. There are
performance issues accessing
CR/EMPI for every Drug system
interaction.
Pharmacy Profile
4) Request drug profile
5) Request DUR
6) Enter new prescription
DR API
HL7 v3 (CeRx)
CR API
Pharmacy
System
EHR Viewer
DR API
HL7 (CR)
Pharmacist
Physician
POINT OF SERVICE
107
Interim State: HIAL Without LRS
The Client Registry system
“determines” a global unique ID
(EHR ID) for patients. The Drug
Informaton System (DIS) will
use the EHR patient ID to store
prescribing and dispensing data.
Point-of-Service applications
query the Client Registry and
obtain the EHR patient ID and
will use this ID as a token
throughout the entire business
transaction. This model
eliminates the need for
communication between the
DIS and CR and reduces the
transactions to the CR to one
per business transaction.
JURISDICTIONAL INFOSTRUCTURE
EHR Data
& Services
Search/
Resolve
Get EHR ID
HL7
(CR)
Drug
Information
System
Repository
HIAL
Client
Registry
Client Registration
1) Search client
2) Create new client
3) Update existing client
HIAL
Registries Data
& Services
HL7 v3 (CeRx)
HIAL
Pharmacy Profile
4) Request drug profile
5) Request DUR
6) Enter new Prescription
Determine
EHR Client ID
Security Mgmt
Data
Privacy Data
Configuration
Common Services
HIAL
Pharmacy
System
HL7
HL7
EHR IP
PATIENT ENCOUNTER
Client Registration
1) Search client
2) Create new client
3) Update existing client
EHR IP
Communication Bus
EHR Viewer
Pharmacy Profile
4) Request drug profile
5) Request DUR
6) Enter new prescription
Pharmacist
Physician
POINT OF SERVICE
108
Interim State: HIAL Without LRS
JURISDICTIONAL INFOSTRUCTURE
EHR Data & Services
Search/Resolve
Get EHR ID
HL7
(CR)
Business Components
Determine
EHR Client ID
CR API
DR API
Data Access
Longitudinal Record Services
EHR
Index
HL7 v3 (CeRx)
Drug
Information
System
Repository
HIAL
Client
Registry
Client Registration
1) Search client
2) Create new client
3) Update existing client
HIAL
Registries Data
& Services
Pharmacy Profile
4) Request drug profile
5) Request DUR
6) Enter new Prescription
Security Mgmt
Data
The Client Registry determines
a global unique ID (EHR ID) for
patients. The DIS will use the
EHR patient ID to store
prescribing and dispensing
data. EHR services will use the
CR to map any local MRN found
within transactions to the
corresponding EHR client ID.
The POS applications do not
necessarily have to be aware of
the EHR client ID or they can
continue to provide this ID
themselves after querying the
CR (compatible with prior
model).
Privacy Data
Configuration
Common Services
HIAL
Pharmacy
System
HL7
HL7
EHR IP
PATIENT ENCOUNTER
Client Registration
1) Search client
2) Create new client
3) Update existing client
EHR IP
Communication Bus
EHR Viewer
Pharmacy Profile
4) Request drug profile
5) Request DUR
6) Enter new prescription
Pharmacist
Physician
POINT OF SERVICE
109
Target State: Full Featured EHR Infostructure
JURISDICTIONAL INFOSTRUCTURE
Ancillary Data
& Services
Registries Data
& Services
Client
Registry
Outbreak
Management
EHR Data
& Services
PHS
Reporting
Shared
Health Record
Drug
Information
Diagnostic
Imaging
Provider
Registry
Location
Registry
Business
Rules
EHR
Index
Message
Structures
Terminology
Registry
Normalization
Rules
Longitudinal Record Services
Security Mgmt
Data
The client, provider, location
registries and EHR Services
Data
determine (respond with)
Warehouse
global unique ids for patient,
providers, encounters and other
required strong identifiers.
Health All
Laboratory
Infostructure systems
use these
Information
unique IDs to store clinical data
about a person. The EHR
Services will map any local ID
to the corresponding EHR ID.
The Domain services (DIS,
DI, Lab) systems rely on the
EHR Services to ensure that
the necessary EHR IDs are
provided with every transaction.
Privacy Data
Configuration
Common Services
HIAL
Communication Bus
Public Health
Services
POINT OF SERVICE
Public Health
Provider
Pharmacy
System
Pharmacist
Radiology
Center
PACS/RIS
Radiologist
Lab System
(LIS)
Lab Clinician
Hospital, LTC,
CCC, EPR
Physician/
Provider
Physician
Office EMR
Physician/
Provider
EHR Viewer
Physician/
Provider
110
EHRS Infostructure:
Deployment Models
111
Client
Registry
Provider
Registry
Laboratory
Repository
REGION 1
DI
Repository
Drug
Repository
Larger size Jurisdictions
• Provincial Client and Provider and
Location Registries
REGION 2
Shared
Health Record
Longitudinal Record Services
DI
Repository
• Provincial Lab, Drug Repositories
and HIAL
Shared
Health Record
• Supra-regional LRS, Shared Health
Record and DI Repositories and
EHR Viewer
Longitudinal Record Services
Common Services
HAIL
• EHRS Locator across regions
Communication Bus
EHR
Viewer
EMR
Medium size Jurisdictions
• Provincial Client and Provider and Location
Registries
• Provincial Lab, Drug, DI, Shared Health
Record, LRS, HIAL and EHR Viewer
• EHRS Locator across Provinces
CIS
REGIONAL/
JURISDICTIONAL
CIS
• Local EMR, CIS and other applications
• Local EMR, CIS and other
applications
EHR
Viewer
Client
Registry
EMR
Provider
Registry
Shared
Health Record
Laboratory
Repository
Drug
Repository
DI
Repository
Longitudinal Record Services
Common Services
HAIL
Communication Bus
LOCAL
LOCAL/REGIONAL
REGIONAL/
JURISDICTIONAL
Large & Medium Deployment Models
CIS
EHR
Viewer
EMR
112
Small Jurisdictions
PROVINCIAL
Client
Registry
Provider
Registry
DI
Repository
Shared
Health Record
Drug/Lab
Longitudinal Record Services
Common Services
HIAL
Communication Bus
LOCAL
CIS
EHR Viewer
EMR
•
Provincial Client, Provider & Location Registry
•
integrated hospital CIS solution fulfilling the roles of the Provincial EHR Services, Laboratory and Drug services
•
Provincial DI Service
•
Provincial HIAL & EHR Viewer
•
Local physician office systems & other CIS connect as POS Systems
113
Model 1: Single EHR Infostructure
PROVINCIAL
Registry & Data Services
Client
registry
Provider
Registry
EHR Data & Services
Location
registry
Terminology
Registry
Drug
Information
EHR Data & Services
Shared
Health Record
Business
Rules
EHR
Index
Message
Structures
Diagnostic
Imaging
Laboratory
Normalization
Rules
Longitudinal Record Services
Security Mgmt
Data
Privacy Data
Configuration
Common Services
HIAL
Communication Bus
Public Health
Services
POINT OF SERVICE
Public Health
Provider
Pharmacy
System
Pharmacist
Radiology
Center
PACS/RIS
Radiologist
Lab System
(LIS)
Lab Clinician
Hospital, LTC,
CCC, EPR
Physician/
Provider
Physician
Office EMR
Physician/
Provider
EHR Viewer
Physician/
Provider
114
Model 2: Shared EHR Infostructure
PROVINCIAL
Registry & Data Services
Client
registry
Provider
Registry
Location
registry
REGIONAL
EHR Data & Services
Terminology
Registry
Drug
Information
REGION 1
Shared
Health Record
Diagnostic
Imaging
Business
Rules
EHR
Index
Message
Structures
…
REGION 2
Laboratory
Normalization
Rules
Shared
Health Record
Diagnostic
Imaging
Business
Rules
Longitudinal Record Services
EHR
Index
Shared
Health Record
Laboratory
Message
Structures
Normalization
Rules
Longitudinal Record Services
Security Mgmt
Data
Privacy Data
Configuration
Common Services
HIAL
Communication Bus
Public Health
Services
POINT OF SERVICE
Public Health
Provider
Pharmacy
System
Pharmacist
Radiology
Center
PACS/RIS
Radiologist
Lab System
(LIS)
Lab Clinician
Hospital, LTC,
CCC, EPR
Physician/
Provider
Physician
Office EMR
Physician/
Provider
EHR Viewer
Physician/
Provider
115
Model 3: Distributed EHR Infostructures
PROVINCIAL
Registry & Data Services
Client
registry
Provider
Registry
REGIONAL
Location
registry
EHR Data & Services
Terminology
Registry
Drug
Information
REGIONAL
EHR Data & Services
POINT OF
SERVICE
REGIONAL
EHR Data & Services
POINT OF
SERVICE
Region 1
EHR Data & Services
POINT OF
SERVICE
Region 2
Region X
Least leverage
No
solution
Most leverage
Different
specification
Different
standards
Specification
& standards
Data
model
Business
process
Business
rules
User
Interface
Same
solution
Use shared
service
Reuse drives down cost, accelerates timelines, reduces risk and enables interoperability
116
Deployment Decisions
Business choices?
• Who, where, when, what
EHR Data & Services
• Clinical value
• Adoption
Drug
PROVINCIAL
Registry & Data Services
Client
registry
Provider
Registry
Location
registry
Terminology
Registry
Information
Solution development choices?
• Services/functions
EHR
Data & Services
Shared
Health Record
Business
Rules
EHR
Index
Message
Structures
Normalization
Rules
•
•
•
•
Data persistence
Diagnostic
Laboratory
Communication
standards
Imaging
Data standards
Integration tooling
Evolution plan?
Longitudinal Record Services •
What functionality when
• EHR Service evolution path
Security Mgmt configuration choices?
Deployment
Privacy Data
Configuration
Data
• Provincial vs regional
Common Services
• Single Solution/many deployments
Communication Bus
HIAL
• Multiple solutions
Public Health
Services
POINT OF SERVICE
Public Health
Provider
Pharmacy
System
Pharmacist
Radiology
Center
PACS/RIS
Radiologist
Lab System
(LIS)
Lab Clinician
Hospital, LTC,
CCC, EPR
Physician/
Provider
Physician
Office EMR
Physician/
Provider
EHR Viewer
Physician/
Provider
117
Architecture Perspectives
Business
Architecture
Clinical
Work Process
Architecture
Potential
Applications
CONTEXT
Integration &
Deployment
Models
System
Architecture
Information
Architecture
118
EHR Infostructure Deployment
JURISDICTIONAL INFOSTRUCTURE
Ancillary Data
& Services
Registries Data
& Services
Client
Registry
Outbreak
Management
EHR Data
& Services
PHS
Reporting
Shared
Health Record
Drug
Information
Diagnostic
Imaging
Data
Warehouse
Health
Information
Laboratory
Provider
Registry
Location
Registry
Business
Rules
EHR
Index
Message
Structures
Terminology
Registry
Normalization
Rules
Longitudinal Record Services
Security Mgmt
Data
Privacy Data
Configuration
Common Services
HIAL
Communication Bus
•
Strategic planning
•
Testing (compliance)
•
Change management
•
System implementation
•
System development/integration
•
Education & training
•
EHR SCP message development
•
Operation & maintenance
119
EHRS Data: Value Enabler For Existing Applications
EHR Infostructure (EHRi)
EHR SOLUTION (EHRS)
EHR INFOSTRUCTURE (EHRi)
Health
Information
Data
Warehouse
Ancillary
Data &
Services
EHR
Data &
Services
Registries
Data &
Services
HIAL
EHR SCP
Standards
EHR SCP
Standards
ADT
CDR
EHR SCP
Standards
PMS
Rx
Lab
•
•
•
•
•
•
•
Client data
Provider data
Location data
Privacy data
Security data
Encounter data
Blood/allergy/
immunization data
• Encounter summaries
• Clinical notes
• Observations/
problems/conditions
• Orders/Results data
• Referrals data
• Lab data
• Pharmacy data
• Diagnostic Imaging
data
EHR SCP
Standards
EHR SCP
Standards
Chronic Disease Health Education
Health Prevention
Custom projects
Data Mining
DI
Data loading
Data feeds
Enhanced
presentation
Enhanced
presentation
Initial data load/
data feeds/integration
of systems
Hospitals/private clinics/
emergency/homecare/specialty
centers/LT care
Laboratories/pharmacy /
diagnostics
Self-care
Research/surveillance
120
End-User Perspective: EHR Viewer
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Client
Registry
Ancillary Data
& Services
Outbreak
Management
EHR Data
& Services
PHS
Reporting
Shared
Health Record
Drug
Information
Diagnostic
Imaging
Data
Warehouse
Health
Information
Laboratory
Provider
Registry
Location
Registry
Terminology
Registry
Business
Rules
EHR
Index
Message
Structures
Normalization
Rules
Longitudinal Record Services
Security Mgmt
Data
HIAL
Privacy Data
Configuration
Common Services
Communication Bus
Patient
Info
End-user
Info
Visit
History
Drug
Profile
Laboratory
Diagnostic
Imaging
POINT OF SERVICE
EHR Viewer
Physician/
Provider
EHR VIEWER
121
End-User Perspective: EMR Application
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Client
Registry
Ancillary Data
& Services
Outbreak
Management
EHR Data
& Services
PHS
Reporting
Shared
Health Record
Drug
Information
Diagnostic
Imaging
Data
Warehouse
Health
Information
Laboratory
Provider
Registry
Location
Registry
Terminology
Registry
Business
Rules
EHR
Index
Message
Structures
Normalization
Rules
Longitudinal Record Services
Security Mgmt
Data
HIAL
Privacy Data
Configuration
Common Services
Communication Bus
EMR
Database
Patient
Info
End-user
Info
Patient
History
Drug
Profile
Laboratory
Diagnostic
Imaging
POINT OF SERVICE
Physician
Office EMR
Physician/
Provider
EMR APPLICATION
122
EHRS Data: Enables New Classes of Applications
EHR Infostructure (EHRi)
•
•
•
•
•
•
•
Client data
Provider data
Location data
Privacy data
Security data
Encounter data
Blood/allergy/
immunization data
• Encounter summaries
EHR SOLUTION (EHRS)
EHR INFOSTRUCTURE (EHRi)
Health
Information
Data
Warehouse
Ancillary
Data &
Services
Health Information Access Layer
EHR SCP
Standards
?
?
Decision support
The Helper
The Mentor
EHR
Data &
Services
Registries
Data &
Services
EHR SCP
Standards
?
?
?
Automated workflow
Drug interactions
Abnormal results
EHR SCP
Standards
?
?
?
New applications
Patient monitoring
• Clinical notes
• Observations/
problems/conditions
• Orders/Results data
• Referrals data
• Lab data
• Pharmacy data
• Diagnostic Imaging
data
EHR SCP
Standards
?
Custom projects
Data mining
Patients
123
Deployment Configurations:
COTS-based Solutions
124
COTS: CIS with Integrated Viewer
JURISDICTIONAL INFOSTRUCTURE
Ancillary Data
& Services
HIAL
Provider
Registry
HIAL
Location
Registry
PHS
Reporting
Services
Outbreak
Services
EHR Data
& Services
Drug
Information
System
Diagnostic
Imaging
HIAL
HIAL
CLINICAL INFORMATION SYSTEM
Shared
Health Record
EAI
HIAL
Client
Registry
HIAL
Registries Data
& Services
Terminology
Registry
Consent Management
Authentication/Acess Control
Auditing/Logging
Interoperability
General
Integration
Subscription
Context
Management
Laboratory
Laboratory Shared Health Record
Longitudinal Record Services
Communication Bus
EHR Viewer Server
EHR IP Transactions: Get, Put, List; Pan-Canadian
EHR Standards
EHR IP
EHR IP
EHR IP
EHR IP
EHR IP
EHR IP
EHR IP
Public Health
Services
Pharmacy
System
Radiology
Center
PACS/RIS
Lab System
(LIS)
Hospital, LTC,
CCC, EPR
Physician
Office EMR
EHR Viewer
Client
POINT OF SERVICE
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COTS: CIS with External Viewer
JURISDICTIONAL INFOSTRUCTURE
Ancillary Data
& Services
HIAL
Provider
Registry
HIAL
Location
Registry
PHS
Reporting
Services
Outbreak
Services
EHR Data
& Services
Drug
Information
System
Diagnostic
Imaging
HIAL
HIAL
CLINICAL INFORMATION SYSTEM
EAI
HIAL
Client
Registry
HIAL
Registries Data
& Services
Terminology
Registry
Consent Management
Authentication/Acess Control
Auditing/Logging
Interoperability
General
Integration
Subscription
Context
Management
Shared
Health Record
Laboratory
Laboratory Shared Health Record
Longitudinal Record Services
Communication Bus
EHR IP Transactions: Get, Put, List; Pan-Canadian
EHR Standards
EHR IP
EHR IP
EHR IP
EHR IP
EHR IP
EHR IP
EHR IP
Public Health
Services
Pharmacy
System
Radiology
Center
PACS/RIS
Lab System
(LIS)
Hospital, LTC,
CCC, EPR
Physician
Office EMR
EHR Viewer
Client
POINT OF SERVICE
126
COTS Based: EAI Centric
JURISDICTIONAL INFOSTRUCTURE
HIAL
Provider
Registry
HIAL
PHS
Reporting
Services
CIS:
Shared Health
Record &
Laboratory
Drug
Information
System
Diagnostic
Imaging
HIAL
HIAL
HIAL
EAI
HIAL
Location
Registry
Outbreak
Services
HIAL
Client
Registry
EHR Data
& Services
Ancillary Data
& Services
Registries Data
& Services
Terminology
Registry
Consent Management
Authentication/Acess Control
Auditing/Logging
Interoperability
General
Integration
Subscription
Context
Management
Communication Bus
EHR IP Transactions: Get, Put, List; Pan-Canadian
EHR Standards
EHR IP
EHR IP
EHR IP
EHR IP
EHR IP
EHR IP
EHR IP
Public Health
Services
Pharmacy
System
Radiology
Center
PACS/RIS
Lab System
(LIS)
Hospital, LTC,
CCC, EPR
Physician
Office EMR
EHR Viewer
Client
POINT OF SERVICE
127
EHRS Blueprint: In Summary
128
EHRS Blueprint As Design Pattern & Standard
Provides specifications for provider
organizations & the vendor community
to design and develop:
•
EHR infostructure
•
Interfaces to allow existing systems to
interoperate using EHR infostructure
•
New applications that take advantage of the
EHR infostructure to provide added value to
service providers, patients; to promote
wellness of Canadians
Provides design pattern & set of
standardized specifications that:
•
Provide flexibility to meet the variety found in
existing service delivery settings while
providing an ability for jurisdictions to evolve
their solution set, leveraging their current
investments in systems
•
Allowing the managed addition of contributors
to and users of Electronic Health Records
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From Concept to Implementation
Infoway’s interoperable EHR
investment program provides
the primary vehicle for
transitioning the Blueprint from
architecture to working
components through:
• partnering with jurisdictions ready
to build interoperability between
existing systems
• jurisdictions ready to incorporate
their registries and domain
repositories
CONCEPT
The second vehicle for
testing and refining the
Blueprint specifications is
adoption by the vendor
community and acquisitions
of “interoperable ready”
applications
This process will be the
test-bed for the EHRS
Blueprints specifications
• Major vendors have
incorporated the Infoway
architectural approach into
their product strategies
• Implementation guidelines will be
produced to assist others in
implementing these capabilities
• Elements of the EHRS Blueprint
specifications will be updated by
these project teams as the concepts
are tested and refined
• The Blueprint can provide the
framework for jurisdictions to
evaluate vendor provided
solutions and ensure they will
work with their evolving EHR
infostructures
IMPLEMENTATION
130
Maintaining the Blueprint as a
Pan-Canadian Standard
• Infoway understands the importance of having a
stable, managed specification for interoperability
•
Jurisdictions and provider organizations need to be
confident that their commitment to implementing EHR
infostructure is based on a sound specification that will
be maintained and managed
•
Implementations of the infostructure will reveal where
the specification needs to be adjusted to optimize
performance and ensure reliability
• For this reason, the EHRS Blueprint specifications
will be subject to the pan-Canadian Standards
Collaboration Process established by Infoway
•
Ensuring pan-Canadian participation in
requirements definition
•
Providing foreknowledge of the financial and change
management requirements to all affected groups
and organizations
•
Providing a scope and change-management model for
the Blueprint specifications themselves
131
The Architecture In Summary: EHR Repository
Concepts
Benefits
• Patient’s data is stored and accessed
from one logical EHR
• Interoperability, performance, scalability
• Patient’s longitudinal clinically relevant
information, authoritative & reliable
• Provider adoption, supports use cases
across continuum of care, timely and
accurate for provider
• EHR co-exists with provincial
domain repositories
• Preserves investments, does not
unnecessarily duplicate data
• EHR may be implemented at any
jurisdictional level
• Flexibility, configurable to local & provincial
needs
• EHR has a common definition
across Canada
• Cost effective, standards-based,
Interoperability
132
The Architecture In Summary: HIAL
Concepts
Benefits
• HIAL (Health Information Access Layer)
provides common way to interoperate with
EHR, registries, domain repositories
• Common and standards based is most cost
effective, secure & private; applications
focus on clinical logic vs. integration logic
• Provider applications interoperate through
HIAL to access EHRS
• Cost effective environment for broad set of
provider applications, standards based
integration
• Provides peer-to-peer trusted
communication and value-added common
services to enable interoperability across
the continuum of care and across
jurisdictions
• Secure & private, efficient, scalable, cost
effective and standard runtime environment,
responsive
133
The Architecture In Summary: EHRi
Concepts
Benefits
• Common standards will enable integration
& interoperability
• Reduces design, development, test &
operational costs
• Standard message data protocol for
external communications is HL7 V3
• True interoperability, international standard
will incent vendors
• Registries have common definition
across Canada
• Interoperability, cost, security & privacy
134
The Architecture In Summary: Applications
Concepts
Benefits
• Messages initiated by point-of-care
applications populate EHR with clinical
data
• Low cost and common model of integration,
secure and private, scalable, extensible,
preserves current investments
• Provider applications read data out of
the EHR via the HIAL in addition to
their operational data stores
• Mass customized views of data tailored to
provider needs, secure and private,
scalable, authoritative, reliable, responsive
• Use cases, business rules and
visualization of data is a function of the
point-of-care application
• Vendors compete and innovate, extensible,
value added services for providers
135
Thank you!
Website: infoway-inforoute.ca
E-mail:
rparker@infoway-inforoute.ca
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