IBM Healthcare Roadshow

1. IBM Healthcare Roadshow Eithne Reichert , RN, MN, PMP President, RWI Informatics Informatics Consultant, Saskatchewan, Canada Email: rwi@sasktel.net Lorraine Fernandes, RHIA Global Healthcare Ambassador IBM Software Group San Francisco,, USA Email: lfernand@us.ibm.com

2. Agenda • Australian Health Reform – Challenges and Opportunities • Comparison to Canadian approach for national EHR services • Starting on the Path – Building Blocks • Technical & Business Architecture & Standards • Identification requirements to support Integration of Records • The Canadian experiences and lessons learned • Continuing on the Path • Access to More Information, Chronic Disease Management, Integration to Point of Service • Opportunities for future • Questions / Discussion

3. Global Health Care State: Inefficiencies from Fragmented Data Registration systemsare not connected …re-entering patient demographic information is time consuming& error prone … lack of complete information affects decision making,treatment & outcomes FamilyHistory ExamRecords Patient Symptoms Patient Healthcare Data Health information systems unableto recognise clinicians AdmissionHistory Costs continueto increase …simply implementing new systems does not solve the problem …multiple sources & contact information is outdated …communication is not timelyor consistentas a result TreatmentRecords AmbulatoryData PrescriptionHistory System adoptionis slow Clinicians …clinicians continue to ‘hunt& peck’ for information,waste 20-40% of their time Clinicians don'thave accessto all information A unified view of patients & providers improves processes & increases efficiencies 3

4. Strategies are similar • Australia The future health system is to be powered by the smart use of data and enabled by the electronic flow of essential information between individuals and the health professionals from whom they seek care and advice. There should be a passionate commitment to measure and improve health and performance outcomes. PCEHR is the core infrastructure element to enable the quick and seamless exchange of patient-controlled, high priority healthcare information. • Canada A high quality, sustainable and effective Canadian health care system supported by an infrastructure that provides residents of Canada and their health care providers timely, appropriate and secure access to the right information when and where they enter into the health care system. Respect for privacy is fundamental to this vision.

5. How Does Canada & Australia Compare?

6. Canada – Health Care Governance • Health care is delivered locally by health authorities (multiple hospitals) and community physicians and providers • Health care is mostly funded by each province (state) to the delivery organisations • Standards & directions are developed nationally. EHR projects funded nationally if fit within the standards and directions Source: Canada Health Infoway

7. Linking Information across Jurisdictions implementations EHR SOLUTION (EHRS) EHR SOLUTION (EHRS) EHR INFOSTRUCTURE (EHRi) EHR INFOSTRUCTURE (EHRi) HealthInformationDataWarehouse HealthInformationDataWarehouse AncillaryData &Services EHRData &Services RegistriesData &Services AncillaryData &Services EHRData &Services RegistriesData &Services Longitudinal Record Services Longitudinal Record Services Health Information Access Layer Health Information Access Layer Point of ServiceApplication Point of ServiceApplication Point of ServiceApplication EHR Viewer EHR Viewer Homecare Homecare Community Care Center Community Care Center Emergency Services Emergency Services Clients / Patients Clients / Patients Specialist Clinic Specialist Clinic Pharmacy Pharmacy Hospital Emergency Hospital Emergency Laboratory Laboratory Diagnostic Diagnostic Architecture allows some variability in implementation Source: Canada Health Infoway

8. Canada EHR Projects

9. Canadian Progress

10. Starting on the Path The Building Blocks: Identification of Clients, Providers Drugs Labs DI Images

11. Connecting Information - Unified Patient Record for the PCEHR Social Services General Practitioner General Practitioner Social Services First: Last: City/Cntry: Treatment: Visit: Colum Heaney Manchester, Eng Immunization Records 05/1980 First: Last: City/Cntry: Treatment: Visit: Colm Heaney Manchester, Eng History & Physical 09/1987 Urgent Care Local Care Centre Colm Heaney London, Eng Arthroscopy CCR 08/2008 First: Last: City/Cntry: Treatment: Visit: Record Locator Service / EMPI / Patient Registry Local Care Centre Urgent Care Health Record First: Last: City/Cntry: Treatment: Visit: Coln Heany London, Eng Penicillin Allergy 11/1997 Name: Colm Heaney City/Country: London, Eng Visit Date: Name: Treatment / Prescription: Consent: 08/2008 06/2008 04/2008 04/2008 04/2008 11/1997 09/1997 05/1980 Colm Heaney Colum Heaney Colm Heanie Colm Heany Colm Heaney Colm Heany Colm Heaney Colum Heaney Arthroscopy CCR Disability Approval CT Scan Coumadin 2mg Myocardial Infarction Penicillin Allergy History & Physical DTaP, IPV, PCV, Rota Yes Yes No Yes Yes Yes No Yes Mental Health First: Last: City/Cntry: Outcome: Visit: Colum Heaney Manchester, Eng Disability Approval 06/2008 Hospital Mental Health Hospital First: Last: City/Cntry: Treatment: Visit: Colm Heaney London, Eng Myocardial Infarction 04/2008 Diagnostics Pharmacy Pharmacy Diagnostics Colm Heanie London, Eng CT Scan 04/2008 First: Last: City/State: Treatment: Visit: First: Last: City/Cntry: Prescription: Visit: Coln Heany Manchester, Eng Coumadin 2mg 04/2008 11

12. Sole reliance on National or State Identifiers needs to be considered…. • Unique Health Identifiers don’t provide total solution • Governance considerations are significant • Human and business processes can affect capture and use • Implementation and back-porting to legacy records costs are high • Identifiers easily associated with personally identifiable health information provides increased opportunity for privacy breaches Accuracy using a UHI alone is insufficient to meet identification requirements 12 12

13. How It Works… Longitudinal Record Services Common Services Ancillary Data& Services EHR Data& Services DataWarehouse Registries Data& Services OutbreakManagement PHSReporting SharedHealth Record DrugInformation DiagnosticImaging Laboratory HealthInformation ClientRegistry ProviderRegistry BusinessRules EHRIndex MessageStructures NormalizationRules LocationRegistry TerminologyRegistry Security MgmtData Privacy Data Configuration HIAL I need to know what information is available for Mr. R. Smith as he is a new patient referred to me Patient Info End-User Info Public HealthServices PharmacySystem RadiologyCenterPACS/RIS Lab System(LIS) Hospital, LTC,CCC, EPR PhysicianOffice EMR EHR Viewer Visit History Drug Profile Laboratory Diagnostic Imaging Public Health Provider Pharmacist Radiologist Lab Clinician Physician/Provider Physician/Provider Physician/Provider Clinical View POINT OF SERVICE Source: Canada Health Infoway 13

14. Use of the EHR Identification Registries Across Canada • Eight out of nine larger provinces using IBM® Initiate® Patient as the provincial EMPI/Client Registry • Smaller provinces and territories using clinical systems • Two provinces also using IBM® Initiate® Provideras the provider registry • Nova Scotia, Alberta • Six of eight provinces actively integratingEHR with client registry for real timepatient identification • Four of eight provinces integrate clientregistry with Provincial PACS • Five of eight provinces integrate client registry with provincial Lab results

15. British Columbia: The First Implementation… British Columbia is the westernmost of Canada's provinces Health services primarily delivered through six integrated networkscalled regional health authorities Ethnically diverse population with significant Asian and Aboriginal citizens 2009 estimatedpopulation 4,420,000 15

16. Current status of British Columbia: IBM® Initiate® Patient Links patient identity data from multiple sources 3 regional health authorities and the Ministry’s legacy Client Registry System using HL7 v3.0 message Includes 6 contributing sources and 8 million unique person records Enables data quality remediation Manage linkages and duplicates across 12 million individualsource records Manages EHR IDs and changes across receiving systems Multiple integration points Source of identity authentication for lab results contributed by two Health Authorities to the Provincial lab information system 16

17. Saskatchewan: Home of publicly funded universal health care:Province funds 90%of health care services Health services primarily delivered through 11 integrated networks called regional health authorities Multiple ethnic origins: English, Irish, French, German, Ukrainian, Russian, Middle Eastern, Oriental,and significant Aboriginal population Many communities borderingAlberta and Manitoba 2009 population 985,000 17

18. Current status of SCI: IBM® Initiate® Patient Links patient identity data from multiple sources 11 regional health authorities, the Saskatchewan Cancer Agency,the provincial insurance registry Includes 80 facilities and 2.3 million unique person records Enables data quality remediation Manage linkages and duplicates across 5 million individualsource records Manages EHR IDs and changes across receiving systems Multiple integration points Source of identity authentication for provincial PACS,lab results, and drug repositories Future integration with public health surveillanceand document repository 18

19. Should be Linked Should not be Linked LowestPossibleScore HighestPossibleScore Don’tLink Manual Review Link LowestThreshold UpperThreshold How IBM® Initiate® Patient Helped AddressClient Identification Challenges • Very good algorithm tweaked to your specific demographics • Excellent recognition of duplicates – even hard to find ones • Consistent data linkage matching across sources • Ability to query at point of service against all records • System recognises manual review & intervention when required as higher authority • Ability to be flexible in the configuration settings and business requirements to manage sources uniquely • Application is easy to use, easy to train users

20. Lessons LearnedImplementations and Directions

21. Benefits of client & provider identification for EHR services Building block for EHR communication Better identification through improved search and verification from different sources and consuming systems Better understanding of health care recipients & referral patterns between sources Improved health record - both paper & electronic Better duplicate identification & less duplicate creation Information more accurate and comprehensive in real time Assistance with management of paper health recordsand outcome measurement An EHR starts with a solid foundation for patient identification 21

22. Organisational Challenges Business Process Challenges Technical Challenges Challenges for projects and programs • Hard to influence changein other organisations and other people • Stakeholders may have to ‘choose’ to participate • Politics, opinions andvision issues • Requires large & diverse. working groups • Stakeholders are busy and involved in other needs • Who was going to managethe combined data? • It seems to be so hard – how can we make it easier/ quicker? • Data quality & integrity is affected by processes • Differences in collection & use of records within and across sources • Data quality role(s) within the organisation is lacking • Privacy is an issue when sharing data - how much, whom to share, for how long • Best practices & processes need to be confirmed regardless of standards • Clinical use of data may be different than departments who send data • Older systems, limited money for replacements • Each hospital & office may be managed independently • Common practice may not be used across organisations doing the same thing • ‘Integration’ knowledge &experience is limited • Limited interoperability platforms established • Network, firewalls, infrastructure connectivity issues

23. Need to understand business processes that generate datain messages so integration rules need context Integration knowledge& experience is evolving Need to work through and with standards & solutions Technically integrated environments need comprehensive testing Interoperability between systems has an overhead, regardless No single solution is going to fit all needs, technology cannot mandate business process Business Technical Building an EHR: Lessons Learned • Privacy concerns require education & discussion • Sensitivity with diagnostic & health data, in particular with mental health and infectious diseases • Real data is often requiredfor testing and trainingto manage decision-making on configuration • Best practice & data standards help stakeholder understanding of accountabilities and risks • Need for people who know – health info professionals, knowledge leaders

24. Implementation timeframes can be fairly quick…. 2004 2005 2006 JUNE JULY AUG SEPT OCT NOV DEC JAN FEB MAR APRIL MAY JUNE JULY AUG SEPT OCT NOV DEC JAN Phase I Phase I Scoping & Planning Funding Approval Phase II Phase II Data Analytics Requirements/ Specifications Phase III PIII PIII Implementation Data Quality Message Testing Phase IV GO LIVE Production + 24

25. Shared Information / Shared Accountability for Quality in the EHR • Know what you are wanting to do: • Clinical quality and patient safety may be different than financial • Support the business needs of source systems • Understand the business processes that may affect shared data • Understand issues and plan for data governance program • Align the fit with community EMRs and hospital systems needs • Consider the future: • EHR identification to the clinical strategies, PACS, Lab, & Drugs, chronic disease, patient information • Understand the downstream use of data sent Know the business….

26. Understand the Data Use and Reuse – Data Governance Downstream Referral Error - Patient presents sister’s health card Lab EMR Information shared broadly and instantly Need to Audit data back to a specific point of time Need consistent validation & correction Drugs Original ID Data PACS Portal Client Registry Consent

27. Evolving Standards Data & Message Standards provide a roadmap for implementation • Data integration quality is more than messaging; • Business process is key to quality • Continued work for integration and data quality of combined record • Implementation projects can challenge & evolve the standards • Accountability is imperative for data quality in the PCEHR • Small steps can go a long way! Start on the path……

28. Implementation Words of Wisdom… Never underestimate the importance of data quality at the foundation of your EHR initiatives Understand downstream impactsof data use & re-use Allow adequate time & resources to address governance & accountability Understand impact of patient & provider misidentification for shared data

29. So where to Next? Opportunities and Future Directions

30. Collaborate: Client Care Team & Communities of Practice - Physician Specialist Therapist Nurse Client & Family Nurse Practitioner Program Educator Pharmacist

31. Manage: Chronic Disease Solutions

32. Integrate: Tele-HealthTele-Consultation, Tele-Home Care, Tele-Triage

33. Create Access: Patient Portals - What Canadians Say: Functions Most Likely to Use Source: Canada Health Infoway

34. Launch Public Awareness Campaign Source: Canada Health Infoway

35. Start somewhere and get going…..it is a longer path than you may imagine….. Questions /Comments???

36. Thank you.