April 26, 2006 Dennis Giokas Chief Technology Officer Canada Health Infoway Inc.

1. Standards at Infoway Overview for HITSP April 26, 2006 Dennis Giokas Chief Technology Officer Canada Health Infoway Inc.

2. Outline Introducing Infoway Key Definitions Key Clinical and Business Requirements Solution Architecture Standards for Interoperability Standards Landscape Infoway Standards Collaborative Standards Projects Challenges and Lessons Learned 2

3. Canada Health Infoway • Mission To foster and accelerate the development and adoption of electronic health information systems with compatible standards and communications technologies on a pan-Canadian basis, with tangible benefits to Canadians. To build on existing initiatives and pursue collaborative relationships in pursuit of its mission. • Vision A high-quality, sustainable and effective Canadian health care system supported by an infostructure that provides residents of Canada and their healthcare providers timely, appropriate and secure access to the right information when and where they enter into the healthcare system. Respect for privacy is fundamental to this vision. • Goal Infoway’s plan is to have an interoperable electronic health record in place across 50 percent of Canada (by population)by the end of 2009. Shared Governance Facilitates Collaboration Canada Health Infoway is an independent not-for-profit organization, whose Members are Canada’s 14 federal, provincial and territorial Deputy Ministers of Health.

4. “Write code &build modules” “Invest, advise & monitor” Infoway’s Role – Strategic Investor Infoway focuses on initial investment in a solution & its deployment. Our unique role is in providing strategic leadership. Intervener Developer Strategic Investor Funder “Work alongside & take over if needed” “Fund & ignore” • Invests with Partners • Involved in project planning • Monitorsprogress of projects and quality of deliverables • Gated funding manages risk Infoway is Not • A Granting Agency • A Venture Capital Fund • A builder, direct implementer or holder of proprietary solutions Leadership in setting strategic direction and standards for EHR deployment across Canada An active partner, contributing to all aspects of the projects, while establishing a broad knowledge & experience base across Canada

5. 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. 5 © 2006 Canada Health Infoway Inc.

6. EHR Key Clinical & Business Requirements • Patient centric, life-long longitudinal record of clinical data • Support for accurate, complete, timely delivery of information • Allowing private and secured access to data made available in the EHR • Focused on clinically relevant data shared beyond organizational boundaries • Shared across multiple organizations, jurisdictions • Scalable to allow continuous, extensive growth of clinical information with a ROI • More POS applications sourcing data to EHR • More users accessing and using data from EHR • Towards more physician order entry and decision support • Interoperable, integrated • Standards based

7. High Level View of the Solution Architecture 7 © 2006 Canada Health Infoway Inc.

8. EHR Infostructure The EHR Infostructure is a collection of common and reusable components in the support of a diverse set of health information management applications. It consists of software solutions to support integration with the EHR, data definitions for the EHR and messaging standards for integration and interoperability. 8 © 2006 Canada Health Infoway Inc.

9. Key EHRS Architecture Concepts EHR SOLUTION (EHRS) EHR INFOSTRUCTURE (EHRi) EHRSLocator Longitudinal Record Services HealthInformationDataWarehouse AncillaryData &Services EHRData &Services RegistriesData &Services Health Information Access Layer (HIAL) Point of ServiceApplication EHR Viewer Point of ServiceApplication

10. EHRS In Canada Federated Databases, Peer-to-Peer, Message Based EHR SOLUTION (EHRS) EHR SOLUTION (EHRS) EHR INFOSTRUCTURE (EHRi) EHR INFOSTRUCTURE (EHRi) Longitudinal Record Services Longitudinal Record Services HealthInformationDataWarehouse HealthInformationDataWarehouse AncillaryData &Services EHRData &Services RegistriesData &Services AncillaryData &Services EHRData &Services RegistriesData &Services Health Information Access Layer (HIAL) Health Information Access Layer (HIAL) Point of ServiceApplication Point of ServiceApplication EHR Viewer EHR Viewer Point of ServiceApplication Point of ServiceApplication EHRS EHRS EHRS EHRS EHRS EHRS EHRS

11. StandardizedArchitecture StandardizedInterfaces Standards-based Solutions StandardizedData Structures StandardizedData Vocabularies StandardizedFunctional Behaviour 11 © 2006 Canada Health Infoway Inc.

12. 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 systems integration 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 Standards Infoway’s role is to set standards and requirements for robust, interoperable products and outcomes

13. Longitudinal Record Services Common Services Communication Bus JURISDICTIONAL INFOSTRUCTURE Ancillary Data& Services EHR Data& Services DataWarehouse Registries Data& Services OutbreakMgmt PHSReporting SharedHealth Record DrugInformation DiagnosticImaging Laboratory HealthInformation ClientRegistry HIAL ProviderRegistry HIAL HIAL HIAL HIAL HIAL HIAL HIAL LocationRegistry BusinessRules EHRIndex MessageStructures NormalizationRules HIAL TerminologyRegistry HIAL HIAL Security Mgmt Privacy Data Configuration HIAL HIAL HIAL EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP Public HealthServices PharmacySystem RadiologyCenterPACS/RIS Lab System(LIS) Hospital, LTC,CCC, EPR PhysicianOffice EMR EHR Viewer Public Health Provider Pharmacist Radiologist Lab Clinician Physician/Provider Physician/Provider Physician/Provider POINT OF SERVICE EHR Infostructure: Standards Based Connectivity EHR SCP Standards

14. Principles for Establishing Pan-Canadian EHRS Standards • Infoway has created Principles for Establishing pan-Canadian EHRS • Standards to provide guidance in the adoption of standards-based solutions • 11 Principles – accessible via the Infoway Knowledge Way • Business-driven • Adoption of existing standards where ever possible • HL7 V3 for all new message development • Establishment of pan-Canadian EHR standards is coordinated via an open, transparent and inclusive Stakeholder Collaboration Process as defined by our stakeholders • International collaboration and balloting of standards work • http://knowledge.infoway-inforoute.ca

15. Canadian Standards Community Standards Organizations • Standards DevelopmentOrganizations (SDOs) • Licensing and Maintenance • Certification and Conformance • Approval and Endorsement • Integrators • Funders & Investors Complexity of the Standards Landscape

16. Infoway Standards Projects 8 1- Need Identification & Business Definition 1 7 2- Options Analysis & Selection Decision 3- Development & Stable for Use Decision 6 Standards Selection Decision Point (e.g. Use existing, adapt, develop) 4- Test/Pilot & Approval 2 5- Training/Education 5 3 6- Implementation 4 7- Conformance Stable for Use decision point (optional) Final Approval decision point 8- Maintenance & Support Note: Process is not linear Program Projects Standards Collaborative

17. Infoway Standards Collaborative Scope • Infoway will be home for development, ongoing operations, SDO liaisons, and pan-Canadian collaboration and coordination of standards • Includes collaboration and coordination functions of HL7 Canada, Partnership, ISO (as shared with Canadian Standards Association), DICOM Liaison • Scope is standards within Infoway’s mandate for the EHR and eClaims standard (NeCST) • Type of standards include: Messaging, Vocabulary and Interoperability Profiles

18. Conformance for pan-Canadian Standards Definition of Conformance • Conformance includes the development of pan-Canadian standards business requirements, the conformance testing against these business requirements, and certification. Scope • Functional, message level interoperability, privacy and security, usability • Infoway and the eHealth Collaboratory will share responsibilities for conformance on pan-Canadian Standards • Infoway (Standards Collaborative) will undertake the development of business requirements, including the development of conformance statements, for the pan-Canadian approved standards; • The eHealth Collaboratory (Collaboratory) will undertake the building of the conformance testing environment, the development of the testing processes and will undertake the actual conformance testing against the established business requirements.

19. Infoway Standards Collaborative Functional Model CTO Governance Group Director Standards Collaboration Process SDO Secretariat & Liaison Support, Conformance, Maintenance Education, Training, Events Standards Development • Strategy • Development • Investment oversight • Approvals – Investment deliverables • Compliance (gated funding) • Benefits Evaluation • Adoption • Complete to approval • Test/pilot • Stds. Maintenance • Implementation support • Conformance/Certification • Change Management • SNOMED • LOINC • Others terminologies • Structural codes for iEHR • OIDs • Artifacts repository • Training artifacts • Training services • Train-the-trainer • Marketing/Communications • Partnership • HL7 Canada education • IHE Canada education • HL7 Inc. • IHE • ISO • SNOMED • LOINC • DICOM • HL7 Canada • IHE Canada • CAC/Z295 • Distribution and Rights Management • HISCs Example – not meant to represent any organizational model

20. Standards Collaboration Process (SCP) • The EHR Standards Steering Committee which leads and approves pan-Canadian EHR information standards within the context of Infoway investment programs • The EHR Standards Advisory Committee which recommends information standards for approval by the EHR Standards Steering Committee and coordinates and guides the activities of pan-Canadian Standards Groups • A number of pan-Canadian Standards Groups that guide the standards requirements of individual Infoway programs • An expert group of resources available to provide cross-program technical and subject matter expertise in standards

21. Architecture Standards EHRS Blueprint EHR Use Cases EHR Data Model EHR Services Model EHR Interoperability Profiles Data & Messaging Standards eClaims (Primary Care, Oral, Vision, Chiro/Physio) HL7 v3 (complete) Client Registry HL7 v2.4 & HL7 v3 (complete) Provider Registry HL7 v3 (in ballot) Drug Information Systems HL7 v3 (in ballot) Laboratory HL7 v3 (in development) Diagnostic Imaging/Teleradiology DICOM, IHE (complete) iEHR Clinical Messaging HL7 v3 (in development) iEHR Technical Standards (in planning) Public Health Standards HL7 v3 (in development) Clinical Terminology Strategy (complete) Terminology Standards (SNOMED, LOINC, ICD10-CA, CCI) Standards Portfolio

22. Standards Projects – Typical Deliverables • Standards Specifications • Messaging schemas • Codesets • IHE Profiles • Business Requirements • Use Cases Implementation Guide Training, Marketing Materials; White Papers; Project Governance Artifacts (project reports, decision criteria)

23. Lessons Learned & Key Challenges • Standards Collaboration Process is a success! • Stable for Use Standards and Selected Standards Strategies in 1 year • Active engagement and collaboration across the country and internationally • Needed additional decision points along the Standards Life Cycle • Appropriate level of detail and amount of information to make decisions is different for different committees • Translating between technical and business “speak” • Stakeholder and expert overburden • Being very clear and specific on what decisions and words mean • E.g. select vs adopt vs mandate • Standards readiness – for test/pilot, for implementation projects • Policy and EHR implementation issues versus standards issues • One strategy or one development methodology doesn’t fit all

24. Thank you! Website: www.infoway-inforoute.ca E-mail: dgiokas@infoway-inforoute.ca

25. Client Registry

26. Provider Registry

27. CeRx (Drug)

28. Cross Enterprise Document Sharing for Imaging EHR Interoperability Profile (XDS-I)

29. Laboratory

30. Public Health Surveillance

31. iEHR Standards Project

32. Clinical Terminology Integration Project