IBM Healthcare Roadshow Eithne Reichert, RN, MN, PMP President, RWI Informatics Informatics...

IBM Healthcare RoadshowEithne Reichert , RN, MN, PMP

President, RWI Informatics

Informatics Consultant,

Saskatchewan, Canada

Email: [email protected]

Lorraine Fernandes, RHIA

Global Healthcare Ambassador

IBM Software Group

San Francisco,, USA

Email: [email protected]

© 2009 IBM Corporation

Building a smarter planet

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



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Global Health Care State: Inefficiencies from Fragmented Data

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A unified view of patients & providers A unified view of patients & providers improves processes & increases efficienciesimproves processes & increases efficienciesA unified view of patients & providers A unified view of patients & providers improves processes & increases efficienciesimproves processes & increases efficiencies

Patient

Healthcare

Data

Patient

Symptoms

Treatment

Records

Family

History

Admission

History

Exam

Records

Prescription

History

Ambulatory

Data

Clinicians

…re-entering patient demographic

information is time consuming

& error prone

Health information

systems unable

to recognise

clinicians…multiple sources &

contact information is

outdated

…communication is not

timely

or consistent

as a result

Costs continue

to increase…simply implementing new

systems does not solve

the problem

System adoption

is slow…clinicians continue to ‘hunt

& peck’ for information,

waste 20-40% of their time

… lack of complete information

affects decision making,

treatment & outcomes

Registration systems

are not connectedClinicians don't

have access

to all information



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.

Strategies are similar

4



5

How Does Canada & Australia Compare?

CanadaCanada AustraliaAustraliaYear Started 2001 2005 when NEHTA formed

Priorities Common architecture and core services

Foundation infrastructure. Health Identifier, Standards and Snomed

Privacy Provincial and Federal Privacy commissioners with well established policy

Currently no privacy bill for PCEHR. Health Identifier has clauses to prevent privacy commissions prior to PCEHR

Architecture Defined with HIAL, standards To be defined by NEHTA and finalised with PCEHR at a national level. High level architecture released. State level – working on architecture

Certification Started in 2010 Certification for accessing Health Identifier

Funding $CAN 1.6B to date flow through to Provinces and Projects

$467 Million over 2 years for PCEHRNational infrastructure and Community based infrastructure has been funded. No funding at state levels to date.

Outcomes Clinical adoption and outcomes impact now being addressed

Citizens and Providers have a Health Identifier. National Authentication Service and Snomed available. Adoption levels currently low

Weaknesses Later emphasis on adoption and impact on clinical outcomes.

Slow movement towards eHealth – 6 years building. Lack of roadmap to achieve integration.



6

Canada – Health Care Governance

Source: Canada Health Infoway

• 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



7

Linking Information across Jurisdictions implementations


Architecture allows some variability in implementation

EHR SOLUTION (EHRS)

EHR INFOSTRUCTURE (EHRi)

EHR ViewerEHR ViewerPoint of ServicePoint of Service

ApplicationApplication

Point of ServicePoint of Service


HealthHealth

InformationInformation

DataData

WarehouseWarehouse

EHREHR

Data &Data &

ServicesServices

AncillaryAncillary

Data &Data &

ServicesServices

RegistriesRegistries

Data &Data &

ServicesServices

Longitudinal Record ServicesLongitudinal Record ServicesEHR SOLUTION (EHRS)

EHR INFOSTRUCTURE (EHRi)

EHR ViewerEHR ViewerPoint of ServicePoint of Service


HealthHealth


DataData

WarehouseWarehouse

EHREHR

Data &Data &

ServicesServices

AncillaryAncillary

Data &Data &

ServicesServices

RegistriesRegistries

Data &Data &

ServicesServices

Longitudinal Record ServicesLongitudinal Record Services

Health Information Access LayerHealth Information Access Layer

Diagnostic

Hospital

Emergency

Specialist

Clinic

Homecare

Clients / PatientsClients / Patients

Community Care

Center

Emergency

Services

Pharmacy

Laboratory

Health Information Access LayerHealth Information Access Layer

Diagnostic

Hospital

Emergency

Specialist

Clinic

Homecare

Clients / PatientsClients / Patients

Community Care

Center

Emergency

Services

Pharmacy

Laboratory



Canada EHR Projects



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Canadian Progress



Starting on the Path

The Building Blocks:

Identification of Clients, Providers

Drugs

Labs

DI Images

10



11

Connecting Information - Unified Patient Record for the PCEHR

11

Local Care Centre

Social Services General Practitioner

Urgent Care

Hospital

PharmacyDiagnostics

Record Locator Service / EMPI / Patient Registry

Local Care Centre

First:

Last:

City/Cntry:

Treatment:

Visit:

Colm

Heaney

London, Eng

Arthroscopy

CCR

08/2008

Social Services

First:

Last:

City/Cntry:

Treatment:

Visit:

Colum

Heaney

Manchester, Eng

Immunization

Records

05/1980

General Practitioner

First:

Last:

City/Cntry:

Treatment:

Visit:

Colm

Heaney

Manchester, Eng

History &

Physical

09/1987

Urgent Care

First:

Last:

City/Cntry:

Treatment:

Visit:

Coln

Heany

London, Eng

Penicillin

Allergy

11/1997

Hospital

First:

Last:

City/Cntry:

Treatment:

Visit:

Colm

Heaney

London, Eng

Myocardial

Infarction

04/2008

Diagnostics

First:

Last:

City/State:

Treatment:

Visit:

Colm

Heanie

London, Eng

CT Scan

04/2008

Mental Health

First:

Last:

City/Cntry:

Outcome:

Visit:

Colum

Heaney

Manchester, Eng

Disability

Approval

06/2008

Pharmacy

First:

Last:

City/Cntry:

Prescription:

Visit:

Coln

Heany

Manchester, Eng

Coumadin 2mg

04/2008

Mental Health

Health Record

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

Name: Colm Heaney City/Country: London, Eng

Yes

Yes

No

Yes

Yes

Yes

No

Yes

Visit Date: Name: Treatment / Prescription: Consent:



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

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Accuracy using a UHI alone Accuracy using a UHI alone is insufficientis insufficient to meet to meet identification requirementsidentification requirements

Accuracy using a UHI alone Accuracy using a UHI alone is insufficientis insufficient to meet to meet identification requirementsidentification requirements



1313

How It Works…


POINT OF SERVICE

Ancillary DataAncillary Data

& Services& Services

Registries DataRegistries Data


EHR DataEHR Data


DataData

WarehouseWarehouse

OutbreakOutbreak

ManagementManagement

PHSPHS

ReportingReporting

SharedShared

Health RecordHealth Record

DrugDrug


DiagnosticDiagnostic

ImagingImagingLaboratoryLaboratory

HealthHealth


Hospital, LTC,Hospital, LTC,

CCC, EPRCCC, EPR

PhysicianPhysician

Office EMR Office EMR EHR ViewerEHR Viewer

Physician/

Provider

BusinessBusiness

RulesRules

EHREHR

IndexIndex

MessageMessage

StructuresStructures

NormalizationNormalization

RulesRules

Security MgmtSecurity Mgmt

DataDataPrivacy DataPrivacy Data ConfigurationConfiguration

Physician/

Provider

Physician/

Provider

Lab SystemLab System

(LIS)(LIS)

Lab Clinician

RadiologyRadiology

CenterCenter

PACS/RISPACS/RIS

Radiologist

PharmacyPharmacy

SystemSystem

Pharmacist

Public HealthPublic Health

ServicesServices

Public Health

Provider

Longitudinal Record ServicesLongitudinal Record Services

HIALHIALCommon ServicesCommon Services

ProviderProvider

RegistryRegistry

LocationLocation

RegistryRegistry

TerminologyTerminology

RegistryRegistry

ClientClient

RegistryRegistry

I need to know what

information is available for

Mr. R. Smith as he is a new

patient referred to me

Drug ProfileVisit History

Laboratory Diagnostic Imaging

Patient Info End-User Info

Clinical View



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® Provider

as 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



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

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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 individual

source 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



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

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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 individual

source 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 surveillance

and document repository

18



19

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

Manual ReviewLowestPossibleScore

LowestPossibleScore

HighestPossibleScore

HighestPossibleScore

Don’tLinkDon’tLink

LinkLink

LowestThreshold

UpperThreshold

Should be Linked

Should not be Linked



Lessons Learned

Implementations and Directions

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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 records

and outcome measurement

An EHR starts with a An EHR starts with a solid foundationsolid foundation for patient identification for patient identificationAn EHR starts with a An EHR starts with a solid foundationsolid foundation for patient identification for patient identification

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Challenges for projects and programs

Technical Technical ChallengesChallenges

Organisational Organisational ChallengesChallenges

• 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

Business Process Business Process ChallengesChallenges

• 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?

• 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



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Building an EHR: Lessons Learned

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

BusinessBusiness 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

TechnicalTechnical


Building a smarter planetImplementation timeframes can be fairly quick….

JUNE

2004 2005

JULY AUG SEPT OCT NOV DEC JAN FEB MAR APRIL MAY JUNE JULY AUG SEPT OCT NOV DEC JAN

Phase IPhase I Phase IPhase I

Phase IIPhase II Phase IIPhase II

Phase IIIPhase III PIIIPIII PIIIPIII

Phase IV

Scoping & PlanningScoping & Planning Funding

Approval

Funding

Approval

Data

Analytics

Data

Analytics

Requirements/

Specifications

Requirements/

Specifications

ImplementationImplementation

Data

Quality

Message

Testing

Production +

GO

LIVE

GO

LIVE

2006

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25

Know the business….

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



Understand the Data Use and Reuse – Data Governance Downstream

OriginalID Data

Lab

Client Registry

EMR

Referral

Portal

Drugs

Consent

Error - Patient presents sister’s health card

Information shared broadly and instantly

Need to Audit data back to a specific point of time

Need consistent validation & correction

PACS



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……



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Implementation Words of Wisdom…

Never underestimateNever underestimate the importance of the importance of data quality at the data quality at the foundation of your foundation of your EHR initiativesEHR initiatives

Never underestimateNever underestimate the importance of the importance of data quality at the data quality at the foundation of your foundation of your EHR initiativesEHR initiatives

Understand Understand downstream impactsdownstream impactsof data use & re-useof data use & re-use

Understand Understand downstream impactsdownstream impactsof data use & re-useof data use & re-use

Allow adequate timeAllow adequate time & resources to & resources to address governance address governance & accountability& accountability

Allow adequate timeAllow adequate time & resources to & resources to address governance address governance & accountability& accountability

Understand Understand impact of impact of patient & provider patient & provider misidentification for misidentification for shared datashared data

Understand Understand impact of impact of patient & provider patient & provider misidentification for misidentification for shared datashared data



So where to Next?

Opportunities and Future Directions

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Building a smarter planetCollaborate: Client Care Team & Communities of Practice -

Source – Primary Health Care Project

NurseNurse

EducatorEducatorPharmacistPharmacist

SpecialistSpecialistPhysicianPhysician

TherapistTherapist

Nurse Nurse PractitionerPractitioner

ProgramProgram

Client & FamilyClient & Family



Manage: Chronic Disease Solutions


Building a smarter planetIntegrate: Tele-HealthTele-Consultation, Tele-Home Care, Tele-Triage



Create Access: Patient Portals - What Canadians Say: Functions Most Likely to Use

33




Launch Public Awareness Campaign

34




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Start somewhere and get going…..it is a longer path than you may imagine…..

Questions /Comments???



Thank you.

36

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