Title: The Canadian Electronic Health Records Strategy for Better Care Delivery
1The Canadian Electronic Health Records Strategy
for Better Care Delivery
- David A. Koff MD
- McMaster University, Hamilton
- ZHE FENG MD
- Sunnybrook Health Science Centre, Toronto
2Geographic Specificities
Average distance that people have to travel to
reach the nearest specialist living in the same
province or territory. Specialists tend to be
found in urban areas. Rural and northern
residents must travel considerable distances to
see specialists.
gt 100 km
3Definitions
- Telehealth is the use of communications and
information technology for clinical care,
education and healthcare services at a distance. - Telemedicine is the use of communication and
information technologies to provide or support
clinical care at a distance. - Teleradiology is the electronic transmission of
diagnostic imaging studies from one location to
another for the purposes of interpretation and/or
consultation. - Teleradiology represents 90 of telemedicine
activity. - More and more telehealth transactions include
transmission of images.
4Numerous projects
- All Provinces and Territories involved in
Telehealth. - Over 100 active telehealth programs.
- Many of those programs have to include medical
images. - Heterogeneous networks and multi-vendor programs
and telecommunications services.
5A few examples
- Health Infostructure Atlantic Project
- Interprovincial Integration of Images and
Information (TELE-i4) - Images shared within the 4 Atlantic Provinces
- North Network
- 80 sites through northern and central Ontario
- Alberta Wellnet
- Integrated system-wide health information
- Provincial PACS project.
6Electronic Health Record
- Canada is focusing its efforts in improving
healthcare by implementing an interoperable
electronic health records.
7What is an EHR ?
- An electronic health record provides each
individual in Canada with a secure and private
lifetime record of their health history. - Electronic health record systems provide
authorized healthcare professionals with rapid
access to patient information anywhere anytime. - Today, only 9 of Canadians have an electronic
health record.
8Canada Health Infoway
- Canada Health Infoway
- Launched mid-2001, Infoway is an independent
federally funded agency that works with the 10
provinces and 3 territories to invest in
electronic health records projects. - Mission
- To foster and accelerate the development and
adoption of electronic health information systems
to have an interoperable EHR in place across 50
percent of Canada by the end of 2009 and all
Canadians covered by 2016.
9Canada Health Infoway
- Infoway acts as a strategic investor
- invests with partners and funds 50 or more of
the cost of a project - is involved in project planning
- monitors progress of projects and quality of
deliverables gated strategy links reimbursement
to achievement of milestones.
10Infoways Investment Programs
End-user Adoption and Setting the Future Direction
Innovation Adoption - 60m
The Electronic Health Record
Interoperable EHR - 175m
Laboratory Information Systems150m
Public Health Systems100m
Diagnostic Imaging Systems310
Drug Information Systems185m
Domain Repositories and Healthcare Applications
Telehealth150m
Cross Program Components
Client, Provider and Location Registries - 135m
Architecture and Standards
Infostructure - 25m
11Infostructure
End-user Adoption and Setting the Future Direction
Innovation Adoption - 60m
The Electronic Health Record
Interoperable EHR - 175m
Laboratory Information Systems150m
Public Health Systems100m
Diagnostic Imaging Systems310
Drug Information Systems185m
Domain Repositories and Healthcare Applications
Telehealth150m
Cross Program Components
Client, Provider and Location Registries - 135m
Architecture and Standards
Infostructure - 25m
12Infostructure
- Development of common solution architecture and
standards to ensure interoperability of EHR. - Provide to hospitals and vendors the business and
technical guidelines - Toolkits technical and business knowledge (case
studies, templates, plans, reports, etc) - EHRS Blueprint, including the Privacy and
Security requirements.
13The Use of Standards
- Teleradiology
- Standards and Guidelines for Teleradiology - CAR
- ACR Technical Standards for Teleradiology - ACR
- Integration
- IHE (Integrating the Healthcare Enterprise)
- Diagnostic Imaging Data
- DICOM
- JPEG and JPEG 2000
- TIFF
- BMP
- Electronic Health Information
- HL7 v3
- CCR (Continuity of Care Record) - ASTM
International - Multimedia Conferencing
- ITU-T H.323/H.320 for video and audio
- ITU-T T.120 for data
14The Use of Standards
- Launched in 2006, the Standards Collaborative is
a new Canada-wide coordination structure created
to support and sustain health information
standards in Canada. - Housed at Infoway, the Standards Collaborative
will be responsible for the implementation,
support, education, conformance, and maintenance
for EHR standards currently being developed by
Infoway.
15The Use of Standards
- The Standards Collaborative also encompasses
several standards initiatives formerly managed by
the Canadian Institute for Health Information
(CIHI) - Partnership for Health Information Standards,
- HL7 Canada,
- Canada's participation in DICOM (Digital Imaging
and Communications in Medicine) and, - in conjunction with the Canadian Standards
Association (CSA), the secretariat to the
Canadian Advisory Committee to ISO/TC 215.
16Client, Provider and Location Registries
End-user Adoption and Setting the Future Direction
Innovation Adoption - 60m
The Electronic Health Record
Interoperable EHR - 175m
Laboratory Information Systems150m
Public Health Systems100m
Diagnostic Imaging Systems310
Drug Information Systems185m
Domain Repositories and Healthcare Applications
Telehealth150m
Cross Program Components
Client, Provider and Location Registries - 135m
Architecture and Standards
Infostructure - 25m
17Client, Provider and Location Registries
- Answers to the need to accurately identify
patients, health professionals and healthcare
facilities - Client Registries contain patient health
identification number and demographic
information. - Provider Registry identification of doctors,
pharmacists, dentists, nurses, etc - Service Delivery Location Registry hospital,
clinics, physician offices.
18Drug Information Systems
End-user Adoption and Setting the Future Direction
Innovation Adoption - 60m
The Electronic Health Record
Interoperable EHR - 175m
Laboratory Information Systems150m
Public Health Systems100m
Diagnostic Imaging Systems310
Drug Information Systems185m
Domain Repositories and Healthcare Applications
Telehealth150m
Cross Program Components
Client, Provider and Location Registries - 135m
Architecture and Standards
Infostructure - 25m
19Drug Information Systems
- All data concerning a patients medication
history prescribed and dispensed drugs,
allergies, ongoing drug treatment. - Drug and drug-interaction checks performed
automatically and added to the patients' drug
profiles in their Electronic Health Record (EHR).
- Provide physicians and pharmacists with data to
support appropriate and accurate prescribing and
dispensing.
20Laboratory Information Systems
End-user Adoption and Setting the Future Direction
Innovation Adoption - 60m
The Electronic Health Record
Interoperable EHR - 175m
Laboratory Information Systems150m
Public Health Systems100m
Diagnostic Imaging Systems310
Drug Information Systems185m
Domain Repositories and Healthcare Applications
Telehealth150m
Cross Program Components
Client, Provider and Location Registries - 135m
Architecture and Standards
Infostructure - 25m
21Laboratory Information Systems
- To allow clinicians to view laboratory results
and reports from all hospital, community and
public health laboratories. - The results will be linked to patients'
Electronic Health Records (EHR).
22Diagnostic Imaging Systems
End-user Adoption and Setting the Future Direction
Innovation Adoption - 60m
The Electronic Health Record
Interoperable EHR - 175m
Laboratory Information Systems150m
Public Health Systems100m
Diagnostic Imaging Systems310
Drug Information Systems185m
Domain Repositories and Healthcare Applications
Telehealth150m
Cross Program Components
Client, Provider and Location Registries - 135m
Architecture and Standards
Infostructure - 25m
23Diagnostic Imaging Systems
- Digital Image Repositories
- Electronic distribution of DI results to all
facilities, referring community physicians and
specialists over reliable networks (all studies,
any time, any where). - Shared DI Repository scaleable to 1.5 million
studies/year (single/multi jurisdiction or large
regions) integrated with IHE-compliant RIS
solution(s).
24Repository Current Status
22 shared PACS/Archive Solutions (DI-r)
Target
Planning
Completed
Implementation
25Benefits of DI-r
- Patient impact
- Improve report turnaround time
- Reduction in duplicate exams (132M/year in
Ontario) - Reduction in patient transfers
- Resources impact
- Improve radiologist productivity by 25-28
- Improve technologist productivity by 10-12
- Improve clinician productivity
26Benefits of DI-r
- Cost impact
- Reduction in film related costs (3.2-4 B)
- Reduction in stand alone versus shared PACS
system savings estimated at 40. - For the healthcare system
- Overall cost 7.4 Billion but delivers 9.1
Billion in benefits over 10 years.
27Diagnostic Imaging Systems
- Filmless working environment for all procedure
types (CT, MR, X-Ray, ultra-sound, etc.) - Implementation of IHE profiles and EHR
interoperability specifications (HL7/DICOM
standards for image acquisition and report
creation) - Use of optimal compression strategies for digital
images.
28Use of a shared XDS infrastructure to access
Radiology Reports and Images development of
XDS-I and related tools by IHE-Canada.
IHE Profiles
- Between Radiology and
- Imaging specialists
- Non-imaging clinicians
Hospital
PACS Y
Radiology -to-Radiology
Radiology -to-Physicians
PACS Z
Imaging Center
Physician Practice
29Image Compression
- Storage volume
- Even if the cost of storage is dropping, the
savings are largely surpassed by the increasing
amount of data. - The cost of operation remains high.
- 40 million diagnostic imaging exams are performed
annually in Canada. - With an average legal retention period of 7 years
upon provincial regulations. - Use of irreversible compression at 101 could
save M100 million per year.
30Image Compression
- and transmission times
- and if access to high bandwidth gets more
available in local hospital networks, it is still
premature to expect any health professional to
use 100 mbps connections on their computers. - EHR networks cannot support large medical images
and timely access to diagnostic images requires
adequate level of compression.
31Image Compression
- The Canadian Association of Radiologists
PACS/Teleradiology committee has accepted the
principle of irreversible (lossy) compression
for use in primary diagnosis and clinical review,
using DICOM JPEG or JPEG-2000 compression
algorithms, at specific compression ratios set by
image type. - Adoption conditional to the results of a large
scale evaluation study.
32Image Compression
- This study has been performed at Sunnybrook,
supported by a grant from Canada Health Infoway. - Prior to that, CHI had commissioned 2 literature
reviews and 2 legal assessments. - Radiologists have been enrolled from 9 out of 10
Canadian Provinces.
33Methodology
- Based on previous studies, our evaluation
resulted from the association of 2 accepted
methods - Objective measurement of diagnostic accuracy with
ROC analysis - Subjective image comparison with
original-revealed forced choice (JND)
34Methodology
- 3 readers per session, 23 sessions, more than 100
readers in total from all across Canada. - Had to read the images on the DICOM compliant,
calibrated workstation they use in their daily
activity. - The workstation had to be connected to the
Internet ideally. - The answers were filled on-line and directly
transferred to our server.
35Diagnostic Accuracy
GROUND GLASS OPACITY
36Comparison side-by-side
JPEG 2000 151 ORIGINAL
37Examples
JPEG 2000 201 ORIGINAL
PNEUMOTHORAX
38Examples
JPEG 2000 251 ORIGINAL
CALCIFICATIONS
39Results
For 18 anatomical regions/modalities, there was
no difference noted, but discrepancies were noted
in 3 occurrences.
40Results
41Results
42Results
43J2K vs. JPG
J2K 151
JPEG 151
Noticeable degradation
No noticeable degradation
Difference in performance is due to the fact that
JPEG 2000 has good spatial resolution and
discards the low energy high-frequency
coefficients during quantization.
44Recommendations
- Lossy compression can be used at the lowest
levels of compression tested, as there was no
significant loss of diagnostic information at
those levels. - No difference between Lossy JPEG and JPEG 2000 at
the lowest levels of compression.
45Results recommended values
CR/DR CT US MR NM MG
Angio 10-15 16-24
Body 20-30 JPEG 10-15 J2K 10 8-12 16-24 9-11
Breast 8-12 16-24 15-25
Chest 20-30 10-15
MSK JPEG 20-30 J2K 20 10-15 8-12 16-24
Neuro JPEG 8-12 J2K 8 16-24
Ped 20-30 10-15 8-12 16-24 9-11
46Public Health Systems
End-user Adoption and Setting the Future Direction
Innovation Adoption - 60m
The Electronic Health Record
Interoperable EHR - 175m
Laboratory Information Systems150m
Public Health Systems100m
Diagnostic Imaging Systems310
Drug Information Systems185m
Domain Repositories and Healthcare Applications
Telehealth150m
Cross Program Components
Client, Provider and Location Registries - 135m
Architecture and Standards
Infostructure - 25m
47Public Health Systems
- Solutions that support the identification,
management and control of infectious disease
cases and outbreaks that pose a threat to the
public's health. - In March 2004, taking into account the lessons
learned from the SARS outbreak and public concern
about the ability of public health authorities to
deal with emerging communicable disease threats,
the federal government assigned Infoway the task
of developing a communicable disease surveillance
system in partnership with the provinces and
territories.
48Telehealth
End-user Adoption and Setting the Future Direction
Innovation Adoption - 60m
The Electronic Health Record
Interoperable EHR - 175m
Laboratory Information Systems150m
Public Health Systems100m
Diagnostic Imaging Systems310
Drug Information Systems185m
Domain Repositories and Healthcare Applications
Telehealth150m
Cross Program Components
Client, Provider and Location Registries - 135m
Architecture and Standards
Infostructure - 25m
49Telehealth
- Electronic solutions that facilitate the delivery
of health information and services between
patients and providers regardless of distance. - Multiple projects based on
- Geographic (tele-education, home healthcare,)
- Cultural (First Nations, language minorities)
- Clinical (post cardiac surgery, wound care
assistance, telepsychiatry) - Management Models as well as Technology and
Standards
50Interoperable EHR
End-user Adoption and Setting the Future Direction
Innovation Adoption - 60m
The Electronic Health Record
Interoperable EHR - 175m
Laboratory Information Systems150m
Public Health Systems100m
Diagnostic Imaging Systems310
Drug Information Systems185m
Domain Repositories and Healthcare Applications
Telehealth150m
Cross Program Components
Client, Provider and Location Registries - 135m
Architecture and Standards
Infostructure - 25m
51Interoperable EHR
- Implementation of solutions that allow clinicians
to view and update an integrated patient-centric
health record anywhere at any time. - Supports EHR initiatives that demonstrate value
and benefits in a specific health practice domain
integrating information across multiple points of
service and multiple caregivers. - Commercially available integrated EHR solutions
will be deployed regionally or supra-regionally
to demonstrate interoperability, scalability and
replicability.
52Innovation Adoption
End-user Adoption and Setting the Future Direction
Innovation Adoption - 60m
The Electronic Health Record
Interoperable EHR - 175m
Laboratory Information Systems150m
Public Health Systems100m
Diagnostic Imaging Systems310
Drug Information Systems185m
Domain Repositories and Healthcare Applications
Telehealth150m
Cross Program Components
Client, Provider and Location Registries - 135m
Architecture and Standards
Infostructure - 25m
53Innovation Adoption
- Infoway supports initiatives that bring clinical
value and optimize the use of EHR - Knowledge portals
- Evidence-based medicine
- Computerized physician order entry and clinical
decision support systems. - Disease management solutions.
54Conclusion
- Canada started late in the implementation of a
nationwide Electronic Health Record, but has
developed a tremendous effort to get 50 of the
population covered by end of 2010 through a
number of initiatives supported by Canada Health
Infoway. - Well do our best to reach this goal.
55Conclusion