Laboratory IT Initiatives in Saskatchewan HL7 Regina Conference - June 7, 2001

1. Laboratory IT Initiatives in SaskatchewanHL7 Regina Conference - June 7, 2001 • Presentation Purpose is to discuss use of HL7 V3, not the Lab Standard itself • Vision for Electronic Test Requisition and Result Reporting • Provincial, not in-hospital/lab • presentation emphasis on CONTENT, not FORMAT • CONTENT: • HL7 V3 Reference Information Model • Use of Registries for content quality control • Strategy & Schedule • Leverage from British Columbia’s work on LOINC & HL7 • Saskatchewan is reviewing the BC Standard and identifying areas of “difference” for resolution • Areas of difference include use of registries and associated governance models (e.g. assignment of new LOINC codes) • Partnership through the Western Health Information Collaborative (WHIC) & CIHI

2. Directory Metadata Regional Clinical Data Repository Access Protocols Access Laboratory IT Initiatives in SaskatchewanVISION Registries to Support Identifiers for Clients, Providers, Lab Facilities/Organizations and Lab Test Identifiers & Nomenclatures Provincial Laboratory - Reference & Public Health Lab Feeder Systems Tele-Homecare Provincial Laboratory Telemedicine Laboratory Specific Data & Messaging Standards Health “region” Regional Clinical Data Repository Community Pharmacy Feeder Systems Lab Feeder Systems Pharmacy Laboratory Physician Clinic Feeder Systems ER MPI/ADT Clinic Management Interfaces OC Radiology Lab Pharmacy Speech Path LTC Env Health Hospital Feeder Systems LTC Facility Feeder Systems Home Care Immunization Community Clinic Feeder Systems Health “region” Tele-Homecare

3. Role Relationship Act Relationship 0..* 0..* 0..* 0..* 0..* 1 0..* 1 1 0..* 1 1 1 1 HL7 RIM Core Classes Employee-employer Patient-provider Practitioner-provider Practitioner-certifier Entity Role Participation Act Test Compendium & Result Nomenclature Registries Referral Transportation Supply Procedure Condition Node Consent Observation Medication Act complex Financial act Guarantor Healthcare provider Insurer Military person Notary public Organization Living Subject Material Place Health Chart Provider Registry (WHIC) Service Recipient Registry (CIHI) Laboratory Registry Management System

4. Laboratory IT Initiatives in SaskatchewanUse of REGISTRIES for Data Content Overall Business Process Model: Registry Management Infrastructure • (Laboratory) Facility Registry • contains contact data for all Medical Laboratories in Saskatchewan • Planning for development internal to Saskatchewan? or WHIC? • a web-based Registry Management System associated with Laboratory Licensing • will require an “owner”, likely Lab Licensing/Quality Assurance • Service Recipient Registry • contains index of all identifiers used by all Sask stakeholders for all patients • Planning for development being led by CIHI and involves provinces, territories and Health Canada “jurisdictions • will require HL7 messages to be balloted • will require an “owner” not yet identified • Test Compendium Registry contains data for all Medical Tests done by all Labs in Saskatchewan • contains an index for all nomenclatures used by all Labs in Sask for Orders and Tests as well as LOINC codes for these tests • a web-based Registry Management System associated with Laboratory Licensing - a possible WHIC collaboration? • will require an “owner”, likely Lab Licensing/Quality Assurance • Service Provider Registry • contains index of all identifiers used by all Sask stakeholders for all Providers (individuals) • Planning for development being led by WHIC • will require HL7 messages to be balloted • will require an owner not yet identified Strong Link

5. Laboratory IT Initiatives in SaskatchewanTACTICAL PLANS & STATUS • Project Deliverables - Design Phase: • Overall Business Data Model: Registry Management Infrastructure Service Recipient Registry There a 19 publicly funded jurisdictions that issue health cards with unique identifiers in Canada. There are an unknown number of internal (shadow) identifiers assigned by health delivery organizations, and an unknown number of identifiers issued by private 3rd party payors. One person may have several current identifiers presented during one or more care episodes. • Stakeholder Organization • (e.g. Health Registration, SDH,....) • Sask Unique Id • Organization Name • Contact Data • Recipient Person/Organization Xref • WHIC Unique (Person) Id • WHIC Unique (Organization) Id • Person/Organization Id • Recipient Person • WHIC(?) Unique Id • Person Name • Person Data

6. Laboratory IT Initiatives in SaskatchewanTACTICAL PLANS & STATUS • Project Deliverables - Design Phase: • Overall Data Model: Registry Management Infrastructure Service Provider Registry Coming in the fall of 2002. • Stakeholder Organization • (e.g. ProvLab, SDH, Regenstrief, SNOMED....) • Sask Unique Id • Organization Name • Contact Data • Provider Roles • (e.g. Physician, Pharmacist, Nurse, Dentist, Lab Tech....) • WHIC Unique Id • Role Name • Role Data • Provider/Role/Organization Xref • WHIC Unique (Person) Id • WHIC Unique (Role) Id • Sask Unique (Orgaization) Id • (local) Provider Id • (local) Provider Data • Provider Person • WHIC Unique Id • Person Name • Person Data

7. Laboratory IT Initiatives in SaskatchewanTACTICAL PLANS & STATUS • Project Deliverables - Design Phase: • Overall Data Model: Registry Management Infrastructure (Laboratory) Facility Registry • Stakeholder Organization • (e.g. ProvLab, SDH, RHD, PAHD,....) • Sask Unique Id • Organization Name • Contact Data • Laboratory Facility QA/Licensing Events • Sask Unique Id • Event Id • Event Data • Laboratory Facility • (e.g. ProvLab, SDH Laboratory....) • Sask Unique (Organization) Id • Sask Unique Facility Id • Facility Name • Contact Data

8. Laboratory IT Initiatives in SaskatchewanRegistry Design • Project Deliverables - Design Phase: • Overall Data Model: Registry Management Infrastructure About 200 Labs in Saskatchewan are publicly owned and regulated by the Saskatchewan College of Physicians & Surgeons and are licensed by Saskatchewan Health. There are almost 230 Physician Office Labs in Saskatchewan. Saskatchewan needs to build a Registry Management System according to the guidelines of the HL7V3 RIM. This may be a feeder system to the WHIC Provider (Organization) Registry. It must, however, be closely tied to the Test Compendium Registry for licensing and information management purposes. (Laboratory) Facility Registry • Stakeholder Organization • (e.g. ProvLab, SDH, RHD, PAHD,....) • Sask Unique Id • Organization Name • Contact Data • Laboratory Facility QA/Licensing Events • Sask Unique Id • Event Id • Event Data • Laboratory Facility • (e.g. ProvLab, SDH Laboratory....) • Sask Unique (Organization) Id • Sask Unique Facility Id • Facility Name • Contact Data

9. Laboratory IT Initiatives in SaskatchewanTACTICAL PLANS & STATUS • Project Deliverables - Design Phase: • Overall Data Model: Registry Management Infrastructure Test Result Nomenclature Registry Test Compendium Registry • Saskatchewan Lab Nomenclatures • Sask Unique Id • Organism, Outcome Name • Stakeholder Organization • (e.g. ProvLab, SDH, Regenstrief, SNOMED....) • Sask Unique Id • Organization Name • Contact Data • Provincial Test • Sask Unique Id • Order Name • Business Rules • Test Xref by Organization • Sask Unique (Test) Id • Sask Unique (Org) Id • Test Name • Test Code • Business Rules • Nomenclature Xref by Organization • Sask Unique (Nom) Id • Sask Unique (Organization) Id • Name

10. Laboratory IT Initiatives in SaskatchewanRegistry Design • Project Deliverables - Design Phase: • Overall Data Model: Registry Management Infrastructure • Several grouping levels of this data are required: • 1. Laboratory Licence Test Group • 2. A Test Panel/Battery (for both Orders & Instruments) • 3. A Named Test • 4. A specific Test/Result (LOINC) • HL7 refers to “Act Relationship”: • “A relationship between two acts. This includes numerous relationships, such as “part-of” relationships, which allow both temporal and non-temporal groupings of instances of acts. Examples include batteries of tests or longitudinal guidelines” Test Compendium Registry • Provincial Test • Sask Unique Id • Order Name • Business Rules • Stakeholder Organization • (e.g. ProvLab, SDH, Regenstrief, SNOMED....) • Sask Unique Id • Organization Name • Contact Data • Test Xref by Organization • Sask Unique (Test) Id • Sask Unique (Org) Id • Test Name • Test Code • Business Rules

11. Laboratory IT Initiatives in SaskatchewanRegistry Design • Project Deliverables - Design Phase: • Overall Data Model: Registry Management Infrastructure Test Result Nomenclature Registry These Nomenclatures are also being addressed for Public Health Surveillance. The proposed data structure would allow any required cross-reference between local, provincial and national identifiers. • Stakeholder Organization • (e.g. ProvLab, SDH, Regenstrief, SNOMED....) • Sask Unique Id • Organization Name • Contact Data • Saskatchewan Lab Nomenclatures • Sask Unique Id • Organism, Outcome Name • Nomenclature Xref by Organization • Sask Unique (Nom) Id • Sask Unique (Organization) Id • Name

12. Laboratory IT Initiatives in SaskatchewanAction Plan Schedule for Registry Development & Implementation Provider Registry (WHIC) Service Recipient Registry (CIHI) Lab Data Standards Business Design Laboratory Registry Management System Populate the Lab/Test Compendium & Result Registries Test Compendium & Result Nomenclature Registries WHIC Collaboration?

13. Laboratory IT Initiatives in SaskatchewanUse of REGISTRIES for Data Content • Project Deliverables - Design Phase: • Overall Business Process Model: Ordering and Result Reporting Enter Order /Retrieve Results (Physician, Lab) Prepare & Mail Specimen (Lab, Clinic) Lab Web Portal Lab Web Portal Lab Web Portal Receive Sample /Retrieve Order /Do Test /Record Results (Laboratory) Other JurisdictionRegistries HL7 Saskatchewan Registries Enter Order /Retrieve Results (Physician, Lab) HL7 Prepare & Mail Specimen (Lab, Clinic) HL7 HL7 HL7

14. Laboratory IT Initiatives in SaskatchewanScenarios of Possible Laboratory Transactions – manual systems using Web portal Dr. Smith orders CBC on John Doe via Web portal – info verified by Web application using registries. John Doe goes to LittleTown Lab – at Lab reception, info retrieved by Web application and collection recorded - sample numbered. Sample taken to LittleTown Lab bench – info retrieved by Web application, sample processed and result recorded by Web application. Added info verified using registries. Dr. Smith looks for John Doe result on Web and finds it. Dr. Smith sends John Doe to Dr. Jones, a specialist. Dr. Jones looks on the Web portal for past lab test results for John Doe and finds the CDC result.

15. Laboratory IT Initiatives in SaskatchewanScenarios of Possible Laboratory Transactions – computer systems using messaging Dr. Brown orders cholesterol on Mary Doe from his practice management system – info verified by messaging to registries. Mary Doe goes to Somewhere Bleeding Station –info retrieved and collection recorded by messaging - sample numbered. Sample arrives at BigLab – info retrieved by LIS application through messaging, sample processed and result sent through messaging. Added info verified using registries. Dr. Brown looks for Mary Doe result on his PMS and finds it along with a cholesterol fractionation done because cholesterol was high.

16. Laboratory IT Initiatives in SaskatchewanScenarios of Possible Laboratory Transactions - mixed Doctor uses the Web, but the Collection Point/Lab uses a computer system with messaging. Lab test was done rurally using Web applications but is being found by another physician because the patient became sick when visiting town. The city physician has a practice management system. Assumes the order and results exist in a central database or directory share by Web apps and HL7 messaging.

17. Laboratory IT Initiatives in SaskatchewanScenarios of Possible Laboratory Transactions – validation early Dr. White attempts to place an order and finds that the patient does not exist in the registry with the ID given to the doctor. He finds a ‘Richard Robin’, address in townA, in the registry, while he knows his patient as ‘Dick Robin’, address in townB. The patient confirms that he is the same person. Doctor changes his system to ‘Richard’ and the registry to the address in townB. When patient arrives to have sample collected there is no problem with name or birth date. Lab calls organism ‘E.coli’. System consults registry for agreed name ‘Escherichia coli’. Referral lab goes to registry to retrieve its name ‘E COLI’ before further lab work on the organism. Assumes that all messages are validated before sending using the registries.

18. Laboratory IT Initiatives in SaskatchewanScenarios of Possible Laboratory Transactions - help Dr. Farout wants to order a very unusual test. His system does not list it, but he finds and orders it via the Web site rather than his PMS. The patient goes to a collection center and they do not have the test on their system either. They use the Web site to find what has to be collected and where it must be sent. The lab does not do this test without prior agreement with the physician on the merit of the circumstances. They decide to substitute another test and do the ordered test only if the substitute has an abnormal result. The lab cancels the ordered test and result (as normal) the substitute test with a comment. The physician uses the comment info to access a paper on this group of tests and their interpretation on the Web portal.

19. Laboratory IT Initiatives in SaskatchewanScenarios of Possible Laboratory Transactions – Completely Local An intern orders a test on a patient in hospital directly into the hospitals LIS. Collection and reporting are also entirely within the LIS. The whole transaction can be reported to a central directory or database with a series of HL7 messages after the fact. The LIS will have to have the standards to make valid messages ‘after the fact’. Alternatively, the hospital may use messaging to communicate between separate ward, collection and lab systems. A lab might even have a number of separate specialized lab systems rather than a single LIS and use messaging for input and output.

20. Laboratory IT Initiatives in SaskatchewanScenarios of Possible Laboratory Transactions – Incomplete testing Dr. Black instructs a patient to go to a local hospital for a lab test and orders the test on the Web. The patient decides he feels better and will not go for the test. At some point, the central system can notify Dr. Black that his patient did not have the test done and cancel the order. Or… Before this, the patient may feel bad again and go to Dr. Green. The physician orders the same test and gets a message that there is an order with collection pending. There are many ways to resolve this situation depending on the physicians.

21. Laboratory IT Initiatives in SaskatchewanAction Plan Schedule for Laboratory Message and Data Standard Development & Implementation WHIC CIHI CIHI Lab Data Standards HL7 Message Specification Lab Data Standards HL7 Message Balloting WHIC Lab Data Standards HL7 Message Specification Lab Data Standards Business Design

22. Laboratory IT Initiatives in Saskatchewan3rd Party Laboratory, Hospital & Practice Management System Impacts • HL7 Compliance with: • Laboratory Test Order & Results & Associated Messages • Service Recipient Look-up, Add & Change Messages • Service Provider Look-up, Add & Change Messages • Test Compendium Look-up Messages, (Add & Change?) • Result Nomenclature Look-up Messages, (Add & Change?) • Network Security Compliance CIHI Lab Data Standards HL7 Message Specification Lab Data Standards HL7 Message Balloting WHIC Lab Data Standards HL7 Message Specification Lab Data Standards Business Design