UPDATE Adoption of standards to share diagnostic imaging information in the pan-Canadian EHR

1. UPDATEAdoption of standards to share diagnostic imaging information in the pan-Canadian EHR DICOM Standards Committee – December 4, 2008 Eugene Igras

2. Agenda • Sharing DI data in the pan-Canadian EHR context • Adoption of standards in the DI Domain • Issues to be addressed • 2008 Events • Conclusion

3. Infoway Diagnostic Imaging Program • Vision Foster and accelerate the development and adoption of DI solutions to assist healthcare providers in acquisition, collection, storage, management, distribution and viewing patient radiology reports and images (any study, any time, any where) regardless of where the DI tests were conducted and/or the reports transcribed. • Strategy • Build on existing standard-based PACS / RIS capabilities • Use IHE XDS/XDS-I Integration Profiles to: • Implement Registry & Data Repository (or multiple Repositories) • Enable interoperability with the EHR components, including: • Clinical Viewer • Health Information Access Layer (privacy & security, consent management) • Registries (Client, Provider, Site and Terminology) • Ensure privacy and security of DI information

4. Value Proposition • Improve Access to Services • Provide timely access to DI information irrespective of where the images were acquired and/or the report transcribed • Provide access to a longitudinal record of patient DI history • Improve timeliness and continuity of care • Enable real-time collaboration and clinical consultations • Improve training opportunities • Improve Productivity & Contain Costs • Increase patient throughput, reduce patient transfers and wait times • Provide capabilities for Radiologists to share workload across the region • Reduce DI exams by reducing avoidable retakes • Improve Quality of Care • Improve quality of DI information (accuracy, completeness, consistency) • Reduce radiation exposure • Reduce medical errors

5. Common Approach • Adherence to Infoway DI Program vision • Leverage existing RIS and PACS as operational film-less solutions • Consolidation of DI data into DI Repository (DI-r) or multiple Repositories • Seamless sharing of DI data among authorized users • Provide access to a longitudinal record of patient DI history • Conformance & Compliance to Standards • Architecture: EHRS Blueprint v2 • Privacy & Security: Jurisdictional privacy protection legislation Privacy & Security Requirements & Architecture ISO/IEC 17799 • Content & Messaging: HL7 v2.x and v3, CDA, DICOM • Terminology: SNOMED CT & other terminology standards • IHE Integration Profiles: XDS/XDS-I - to support DI data sharing PIX/PDQ – to support patient identity/CR with HL7 v3 ATNA – to support security Other IHE Radiology and IT Profiles • Electronic Business & Internet Standards

6. EHRS Blueprint v2 Privacy & Security Privacy Legislation HealthcareContent, Messaging, Terminology HL7/CDA, DICOM, SNOMED CT LOINC, ICD-10-CA… Internet Standards HTML/XML, HTTP,PDF, JPEG, MIME, UTF-8 … Electronic BusinessStandards ebXML, Web Services Standards used in DI Domain • An array of standards address DI Requirements in Canada IHE Integration Profiles XDS/XDS-I, PIX/PDQ, ATNA…

7. Longitudinal Record Services Scope of the XDS Affinity Domain in the EHR Context 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 ProviderRegistry BusinessRules EHRIndex MessageStructures NormalizationRules LocationRegistry TerminologyRegistry Security Mgmt Privacy Data Config Services HIAL Public HealthServices PharmacySystem RadiologyCenterPACS/RIS Lab System(LIS) Hospital, LTC,CCC, EPR PhysicianOffice EMR EHR Viewer Pharmacist Radiologist Lab Clinician Physician/Provider Physician/Provider Physician/Provider Public Health Provider POINT OF SERVICE

8. Infoway and IHE • Leverage and implement IHE integration profiles • DI domain • Co-authored XDS-I content supplement • Funded development of XDS-I MESA tool set • Declared XDS/XDS-I as a pan-Canadian Standard (“Stable for Use”) • Implement XDS/XDS-I in current DI projects across Canada • Client Registry • Authored a change proposal to IHE PIX/PDQ to support HL7 v3 messaging • EHR Infostructure • Completed a review of IHE ITI integration profiles for consideration as pan-Canadian standards • Coordinate with IHE to avoid duplication • Leverage IHE technical committees to develop new profiles and/or propose changes to existing profiles e.g. support for v3 messaging • Leverage MESA tools for conformance testing • Provide resources to IHE International through IHE Canada

9. DI Projects Across Canada • Most provinces in Canada • Have deployed digital DI modalities and PACS/RIS solutions • Have completed architecture for DI Repository (or multiple Repositories) integrated with the EHR • Plan to deploy interoperable EHR / DI solutions • All DI Solutions • Span multiple health regions, hundreds of hospitals, and DI clinics • Integrate multi-vendor PACS / RIS environment • Are designed to handle • Multiple patient identification domains and EMPI services • Multiple security domains • Millions of exams per year (e.g., Alberta: over 4.5 million) • Provide services to thousands of users (e.g. Alberta: over 15,000)

10. XDS – Actors and Transactions Patient Identity Source • Feeds identity of known patients to Document Registry Patient Identity Feed • Stores and maintains metadata • Creates and maintains links to documents • Supports document search (query) • Enforces policies at the time of registration Query Registry Document Registry Document Consumer • Initiates search (query) • Initiates retrieval of documents Register Document Set Provide & Register Document Set Document Source Document Repository Retrieve Document • Submits document sets • Creates and submits documents description (metadata) • Stores documents & metadata • Creates & maintains document URI (Uniform Resource Identifier) • Forwards metadata for registration • Supports document retrieval

11. XDS-I – Actors and Transactions Patient Identity Source • Feeds identity of known patients to Document Registry Patient Identity Feed • Receives, stores & maintains metadata • Creates and maintains document index • Supports document search (query) • Enforces policies for registration Query Registry Document Registry Document Consumer Imaging Document Consumer Register Document Set • Initiates search and retrieval of documents Provide & Register Document Set Retrieve Document Document Repository Imaging Document Source • Initiates retrieval of DICOM objects referenced within the manifest WADO Retrieve • Stores documents and metadata • Enhances metadata with document URIs to enable retrieval • Forwards the enhanced metadata for registration • Supports document retrieval Retrieve Images Retrieve Presentation States Retrieve Reports Retrieve Key Imaging Note Retrieve Evidence Documents • Creates text / PDF report and/or imaging manifest documents • Submits document sets with document description (metadata) • Supports retrieval of DICOM objects

12. Real-world Systems vs. XDS-I Actors Patient Identity Source Document Registry Document Consumer Imaging Document Consumer Document Repository Imaging Document Source Mod PACS Mod • DI Repository (DI-R) • Stores and maintains a lifetime record of relevant DI data including • Images and reports • Key image notes, image processing results & overlay information • Presentation states and other evidence documents • Serves as shared operational PACS for greenfield sites • Supports 2-3 Million exams per year • Delivers DI data to consumer over a network • Facilitates seamless sharing of DI information • Maintains quality and integrity of data Mod RIS Mod DI-R Mod PACS Mod Mod

13. Real-world Systems vs. XDS-I Actors Mod PACS Mod Patient Identity Source Document Registry Document Consumer Imaging Document Consumer Document Repository Imaging Document Source Mod DI-R PACS Mod RIS Mod Mod EMR Viewer

14. Issues To Be Addressed (1) • How to ensure interoperability of XDS-based systems with other solutions that handle discrete data (e.g., Lab, Drug)? • How does an XDS Registry for DI evolve into and/or co-exist with other indexing scheme? • How to ensure other XDS/XDS-I consumers (e.g., EMR) adopt Document Consumer actor capabilities to access DI content? • How to provide document sharing capabilities across multiple affinity domains? • How to ensure data quality attributes (e.g., accuracy, completeness, integrity) are maintained/preserved in a data sharing environment? • How to provide a uniform clinical terminology given a multitude of terminology schemes and vocabularies? • How does a jurisdiction approach XDS Affinity Domain policies for consumers that are “associated “with the Affinity Domain (GP, Specialist) but not “in” the Affinity Domain? 14

15. Issues To Be Addressed (2) • Synchronization of shared radiology studies • Radiology study split • Radiology study attribute changes • Deletion of a study component (e.g. radiology image) • Standardized representation of DI study in the XDS Affinity Domain • A single manifest • Multiple manifests • Standardized use of XDS Affinity Domain attributes and metadata • Division of responsibilities between PACS and DI-r • Data synchronization between local PACS systems and DI-r • Linking of documents from multiple repositories and support for consultation workflows including creation of new objects

16. Terminology & Classification Systems Current & Future State Current State Future State • Content & Format • Registry entries - ebXML • Terminology/Codes • To be standardized • Document Sharing • Document Registry • Content & Format • Images & Manifests - DICOM • Reports - DICOM SR, HL7 CDA R2 • Terminology/Codes • Adopted / Adapted / developed • Harmonized with pan-Canadian Terminology • Content & Format • Images & Manifests - DICOM • Reports - DICOM SR, HL7 CDA R2 • Terminology/Codes • Implementation-specific • Storage & Retrieval • DI-rs • Doc Repositories Normalization • Content & Format • Images - DICOM • Reports - DICOM SR, Text, PDF • Discrete Data • Terminology/Codes • DICOM (SNOMED CT, LOINC) • ICD-10CA, ICD-PSC • HL7 v3 • Content & Format • Images - DICOM • Reports - DICOM SR, Text, PDF • Discrete Data • Terminology/Codes • DICOM (SNOMED RT, LOINC) • ICD-10/10CA • CCI • HL7 v2.x and v3 HIAL POS Information Systems HIS EMR / Viewer RIS PACS • Content & Format • Images – DICOM • Discrete Data • Terminology/Codes • DICOM (SNOMED RT, LOINC) • ICD-9/10 • HL7 v2.x • Content & Format • Images – DICOM • Discrete Data • Terminology/Codes • DICOM (SNOMED CT, LOINC) • ICD-10-CA • HL7 v3 CT MRI US X-Ray Acquisition Modalities 16

17. Patient Provider and Delivery Site Procedure Requestor, Facility Request Recipient, Service Delivery Site Request Request Priority Indicator Clinical Reason for Request Request Status Consent Details Procedure Modality Anatomical Site, Position, Laterality, View Aspect Contrast Medium Specimen Details Preparation Instructions Procedure Performance Details Procedure Substitution Details Clinical Status Clinical Synopsis Problem/Diagnosis Observation Adverse Reaction Alert Severity (of problem, diagnosis or allergic reaction) DI Study Study & Series Details Image Instances Report Authorship, Review, Approval Interpretation, Findings, Comments Evidence Terminology Standardization: Candidate Data Entities Source: Diagnostic Imaging Data Specification; http://www.nehta.gov.au

18. XDS-I Metadata Attributes - Sample

19. XDS-I Value Proposition • Integrates information • Eliminates fragmentation of data captured and recorded in stand-alone systems through integration of data across organizations and systems • Improves quality of DI information (accuracy, completeness, consistency) • Addresses patient privacy and data security in a comprehensive and consistent manner • Improves Access • Provides timely access (anywhere, anytime) to DI information irrespective of where the images were acquired and the reports transcribed • Provides access to a longitudinal record of patient DI history • Improves timeliness and continuity of care • Enables collaboration among care providers • Improves training opportunity • Improves Productivity • Increases patient throughput, reduces patient transfers and wait times • Provides capabilities for Radiologists to share workload across the Affinity Domain • Reduces DI exams by reducing avoidable retakes • Improves Quality of Care • Reduces radiation exposure • Reduces medical errors

20. 2008 Events • Infoway Partnership Conferences • April 2008 (Toronto) • October 2008 (Montréal) • Standards Collaborative Working Groups • SCWG 1 - Population Care • SCWG 2 - Individual Care • SCWG 3 - Managing the Healthcare System • SCWG 4 - Medication Management • SCWG 5 - Labs & Diagnostics • SCWG 6 - Infostructure & Architecture • SCWG 7 - Non-clinical Registries • SCWG 8 - Privacy & IT Security Services • SCWG 9 – Clinical Terminology • Project team meetings

21. Conclusion • IHE XDS-I is aligned with the pan-Canadian EHR architecture and accepted as the right approach to achieving seamless sharing of DI documents within the EHR • Declared a pan-Canadian Standard “stable for use” • All Provinces recognize the value of consolidating DI data in domain repositories • DI projects across Canada adopt XDS-I • There are still outstanding issues to be addressed by: • Infoway invested DI projects • Infoway Standards Collaborative (Standards Collaborative Working Groups) • IHE Canada / IHE • Vendor community

22. Thank you! Infoway Standards Collaborative Contact: Grant Gillis (ggillis@infoway-inforoute.ca) Infoway Solution Architecture Group Contact: Eugene Igras (eigras@infoway-inforoute.ca)