EMPI and the EHR: The Canadian Experience Eithne Reichert

1. EMPI and the EHR:The Canadian ExperienceEithne Reichert Presentation to Informing Healthcare July 13, 2006

2. Introduction Canada Health care funded and managed by each jurisdiction/province Canada Health Infoway nationally funding strategic EHR investments and standards development, adoption and use Most jurisdictions have created technical project departments to implement the components for EHR services & integration for clinicians Canada Health care funded and managed by each jurisdiction/province Canada Health Infoway nationally funding strategic EHR investments and standards development, adoption and use Most jurisdictions have created technical project departments to implement the components for EHR services & integration for clinicians

3. Agenda Based on topics covered so far � I will try t focus on things that have not been covered or need further clarification from Canadian experience. I will start with national framework, purposes of the EMPI, outcomes expected, Sk experience and challenges and lessons learned. I want to cover your interests that I understand to be: privacy concerns Technology concerns outcome and performance concerns value add for cost identifier options Based on topics covered so far � I will try t focus on things that have not been covered or need further clarification from Canadian experience. I will start with national framework, purposes of the EMPI, outcomes expected, Sk experience and challenges and lessons learned. I want to cover your interests that I understand to be: privacy concerns Technology concerns outcome and performance concerns value add for cost identifier options

4. Integrating heterogeneous systems Health care no matter what country or system, has disparate systems of care delivery. Some of these are automated and some are not, most do not talk to one another or even know they are managing the care of the same patient. Most of the organizations cannot afford to replace or start over � most want to leverage systems that are already in place. Each of these points of care delivery have different business process and data capture. How can we expect to provide continuity of care without some changes in how to support the care systems? Health care no matter what country or system, has disparate systems of care delivery. Some of these are automated and some are not, most do not talk to one another or even know they are managing the care of the same patient. Most of the organizations cannot afford to replace or start over � most want to leverage systems that are already in place. Each of these points of care delivery have different business process and data capture. How can we expect to provide continuity of care without some changes in how to support the care systems?

5. Canadian Health Care Health Care challenges is that the provinces have the money for health care so Infoway sets direction, funds strategic investments � as with Infoway and the EHR development Each province is slightly different in geographical , cultural and size � some are primarily French, some are primarily English, most are a multi-cultural environment. Infoway has developed a structure to support provinces to develop similar EHR services. There are different approaches, platforms, directions, priorities, timeframes.Health Care challenges is that the provinces have the money for health care so Infoway sets direction, funds strategic investments � as with Infoway and the EHR development Each province is slightly different in geographical , cultural and size � some are primarily French, some are primarily English, most are a multi-cultural environment. Infoway has developed a structure to support provinces to develop similar EHR services. There are different approaches, platforms, directions, priorities, timeframes.

6. This is the conceptual architecture for infostructure. Registries, Domains, Public health surveillance and data warehouse; HIAL components and longitudinal services Point of services should not need to know what is happening behind the application This architecture was tested with the Life of Lamberts case studies for care delivery and decision supportThis is the conceptual architecture for infostructure. Registries, Domains, Public health surveillance and data warehouse; HIAL components and longitudinal services Point of services should not need to know what is happening behind the application This architecture was tested with the Life of Lamberts case studies for care delivery and decision support

7. EHRS Blueprint: Pan-Canadian EHR Service Speed Real-time on read requests: response time under 2 seconds Near real-time on updates Legal Assumption - Exchanges of clinical patient information between systems will be achievable at reasonable speeds while applying consent policies as part of privacy and confidentiality rules and regulations Scalable From growth in number of source systems From growth in point-of-care usage From growth in territory coverage From growth in surveillance usage From growth in administrative usage Reliable (High Availability) Redundancy: Power, Network, Servers (Application & Database), Disks Healthy economic balance in HIS vendor industry It is possible to maintain healthy business dynamics in the HIS vendor industry while insuring the uptake of a central source of EHR data in all provinces; Speed Real-time on read requests: response time under 2 seconds Near real-time on updates Legal Assumption - Exchanges of clinical patient information between systems will be achievable at reasonable speeds while applying consent policies as part of privacy and confidentiality rules and regulations Scalable From growth in number of source systems From growth in point-of-care usage From growth in territory coverage From growth in surveillance usage From growth in administrative usage Reliable (High Availability) Redundancy: Power, Network, Servers (Application & Database), Disks Healthy economic balance in HIS vendor industry It is possible to maintain healthy business dynamics in the HIS vendor industry while insuring the uptake of a central source of EHR data in all provinces;

8. EHRS Serving Healthcare Service Delivery This infostructure needs to support service delivery process We are just at the point of testing that this will work � most of the provinces are deploying sllghtlly differently depending on many variables � but the standards development will start allowing systems to request information as people need to travel to sites for care � move to other locations or travel across Canada, This infostructure needs to support service delivery process We are just at the point of testing that this will work � most of the provinces are deploying sllghtlly differently depending on many variables � but the standards development will start allowing systems to request information as people need to travel to sites for care � move to other locations or travel across Canada,

9. Infoway & Initiate Initiate is the standard solution for the provincial EMPI/Client Registry British Columbia � 12 Million UPI records Ontario � 20 Million UPIs, possibly multiple tiers Saskatchewan, Manitoba, Newfoundland, Nova Scotia, New Brunswick using Initiate Quebec has more restrictive laws for centralizing health information, partnership with Initiate services Expertise was shared across projects Standards, tools, documents, knowledge Over all, Initiate Hub has been integral to patient identification for the EHR strategies Initiate is the standard for all of Canada where the volume of residents make sense (Arctic and PEI considered too small � and may end up with a clinical system instead) Quebec has invested in a system over years and the privacy laws are much more restrictive for centralizing data � therefore may be more of a partnership with the existing software vendor. We have Canadian lessons learned every 6 months and most of use keep in touch and share findings and knowledge and deliverablesInitiate is the standard for all of Canada where the volume of residents make sense (Arctic and PEI considered too small � and may end up with a clinical system instead) Quebec has invested in a system over years and the privacy laws are much more restrictive for centralizing data � therefore may be more of a partnership with the existing software vendor. We have Canadian lessons learned every 6 months and most of use keep in touch and share findings and knowledge and deliverables

10. EMPI: The Identity Challenge across systems Every system uses different names, histories, identifiers The EMPI algorithm provides a top of the line science to leverage the data versus imposing a specific standard on sourcesEvery system uses different names, histories, identifiers The EMPI algorithm provides a top of the line science to leverage the data versus imposing a specific standard on sources

11. Why does an EMPI help? Clinically Patients are sick and need to be cared for first; many are elderly Patients do not always come to the hospital with all their identification Patients have to go to different places for treatment Patient information is stored in different files Technically Names can be misspelled, errors on numbers Different cultures and languages Different systems collect different attributes for different purposes Different methods of identifying patients Different platforms, message versions The argument is usually that we just need to apply an identifier to everyone and life would be easy = but it is not that easy Clinical and Technical barriers require sophisticated science to support the diversityThe argument is usually that we just need to apply an identifier to everyone and life would be easy = but it is not that easy Clinical and Technical barriers require sophisticated science to support the diversity

12. How the EMPI contributes to the EHR How is care improved? Right person, right information Promotes integration and interoperability between systems Access to linked information that may not be available usually Improved patient safety is an outcome as all relevant information is correctly linked and managed Imagine �..how the clinical treatment would be enhanced if information about the patient was routinely available before the person was even seen by a physician �..even simple information such as, the person was in a specific hospital just recently or recent xray images So how the EMPI works When I was a critical care nurse � I always wondered why we had to spend critical time investigating and questioning family for health history. Often we had no information available for the person, sometimes just a name and age. When you have a history for one person and nothing for another, I can tell you that the care is different. When we were able to link the hospitals in a city together � all of a sudden we had real time access that a chart was available at another site � and we could ask for the consult or discharge info to be sent over � or even to find out who the physician was would help the care process. With the Drug system SK has just implemented medication profile from different sources are pulled together through a common identifier and data integration. Clinicians will never go back to no info. If critical info was available routinely, patient care would be greatly enhanced � sometimes we do not even know what piece of info would helpSo how the EMPI works When I was a critical care nurse � I always wondered why we had to spend critical time investigating and questioning family for health history. Often we had no information available for the person, sometimes just a name and age. When you have a history for one person and nothing for another, I can tell you that the care is different. When we were able to link the hospitals in a city together � all of a sudden we had real time access that a chart was available at another site � and we could ask for the consult or discharge info to be sent over � or even to find out who the physician was would help the care process. With the Drug system SK has just implemented medication profile from different sources are pulled together through a common identifier and data integration. Clinicians will never go back to no info. If critical info was available routinely, patient care would be greatly enhanced � sometimes we do not even know what piece of info would help

13. The EMPI & Registry is key to the electronic record With the infostructure � the linking of patient records through the EMPI and data attributes will support lab and images and consultants Primary Health Care requires this level of integration to the point of service � where the clinicians are With the infostructure � the linking of patient records through the EMPI and data attributes will support lab and images and consultants Primary Health Care requires this level of integration to the point of service � where the clinicians are

14. What Data ? Data attributes in the EMPI can be as extensive as desired. You need to understand which of the data attributes you want to assign a weight to The algorithm is set based on the data provided from your sources and name types found in the data load. The weight is configured to meet your needs for manual review Data attributes in the EMPI can be as extensive as desired. You need to understand which of the data attributes you want to assign a weight to The algorithm is set based on the data provided from your sources and name types found in the data load. The weight is configured to meet your needs for manual review

15. Different Deployment Models: Tiered vs Central Multiple deployment models � tiered or notMultiple deployment models � tiered or not

16. EMPI Project developed into a Program Jurisdiction Home of publicly funded universal health care Multiple ethnic origins: English, Irish, French, German, Ukrainian, Russian, Middle Eastern, Oriental, and Native Indian No single identifier � 80% covered with health number Health care delivered by regional health authorities � groups of hospitals, ambulatory care, community clinics, mental health, therapies, home care and continuing care agencies Regional implementations of same registration systems for multiple sites Implemented software into testing in July, Go Live with messaging with 7 sources by March Standardized business processes, data elements, and messaging Additional sources added, additional facilities added within source Data errors 0.23% from 5% Interfaces to RIS/PACS central repository Lab Results to follow

17. Other Models of Implementation Can require Sources to send specific data attributes in a specific message format Sources comply with specifications as able Each facility rather than larger multi-hospitals as Sources Hub can manage differences for multiple sources Can maintain the insurance database attributes as well as the EMPI data attributes Used for generating identifier & appropriate assignment of identifier Can �go get� information in newer releases Can be a hospital based EMPI with more clinical data or a jurisdictional implementation with a subset for identification purposes Can be used for provider or organization identification Same functionality required � just different attributes

18. Very good algorithm tweaked to your specific demographics Excellent recognition of duplicates � even hard to find ones System recognizes manual review & intervention as higher authority Ability to be flexible in the configuration settings and business requirements to manage sources uniquely Data management tools/applications easy to use, easy to train users Consistent data linkage matching across sources Ability to query at point of service against all records � pulling composite record at point of care to reduce duplicates

19. Benefits with EMPI Better identification through improved search More complete and up to date information on composite view Better Duplicate Identification & less Duplicate Creation Better understanding of health care recipients & referral patterns between Sources Improved health record � paper & electronic Data quality currently >99% (less than 1% duplicate rate Assistance with management of paper Health Records and Outcome Measurement Death information available across Sources

20. Interoperability Initiate system becomes the center of the client or provider identification for other systems Integration options to and from Initiate are flexible and do not have to be the same for each system integration New version is providing more tools to configure system independently and provide more interoperability flexibility Encouraging PIX/PDQ or V3.0 Q-R query rather than pushing IDs out to other systems Some systems cannot accommodate sophisticated messaging We are starting to explore the new direction that Initiate is going = with services into integration and interoperability dimensions Though we do not have the experience of 7.0 we are encouraged by the responsiveness of Initiate development for IHE profiles, PIX, PDQ standards However there is not just one type of integration Messaging or API options Federation Synchronization Enhanced Composite ViewsWe are starting to explore the new direction that Initiate is going = with services into integration and interoperability dimensions Though we do not have the experience of 7.0 we are encouraged by the responsiveness of Initiate development for IHE profiles, PIX, PDQ standards However there is not just one type of integration Messaging or API options Federation Synchronization Enhanced Composite Views

22. Older registration systems, no money for replacements Systems were independent and were managed independently EMPI was first building block �Integration� knowledge/experience was limited Limited interoperability platforms established Network, firewalls, connectivity Hard to influence change in organizations Stakeholders had to �choose� to participate Project struggled with politics and EHR issues Required large & geog. dispersed working groups Stakeholders also involved in other initiatives Data Governance for business rules and combined record

24. Lessons Learned Privacy concerns require education & discussion Sensitivity with Cancer and Mental health sources May need to use real data for testing and training Best Practice & Data Standard Guidelines help stakeholder understand accountabilities and risks Health Record/Info Professionals Understand business process generating data in message Integration knowledge& experience is evolving Technical environments need to comprehensive testing Interoperability between systems has an overhead regardless Start somewhere with something

25. Governance, Accountability & Policy Need to work through as the system & integration evolves and as organizations involved understand the best solutions Who owns the data? What are the rules for use, disclosure, reuse? What are the service levels required for data integrity and integration? Who owns and needs to communicate the linkage decisions? What about Unlinks? Unmerges? Downstream consumer systems data synchronization? Governance & accountability not well understood in the beginning � but have time to work it through This si probably the most significant work that is not a �task� in implementation � most effective when EHR direction is establishedThis si probably the most significant work that is not a �task� in implementation � most effective when EHR direction is established

26. Need to have a strong Business program as well as Technical as the data is only as good as the source�s capture Shared accountability for data management; source�s have Initiate toolset as well Adoption of business rules for linkage decisions by central business/technical Integrity Unit Developing trust in the record management Very similar to Wales � with provincial identifiers for some but not all people. Also medical records numbers that most clinicians know, financial identifiers for billing purposes o We capture SK PHN, as well as other provinces identifier if available. Prison identifiers, First Nations identifiers, military, RCMP identifiers. Need to define direct and indirect identifiers to support appropriate model Very similar to Wales � with provincial identifiers for some but not all people. Also medical records numbers that most clinicians know, financial identifiers for billing purposes o We capture SK PHN, as well as other provinces identifier if available. Prison identifiers, First Nations identifiers, military, RCMP identifiers. Need to define direct and indirect identifiers to support appropriate model

27. Summary of Initiate Experience Initiate software core to the EHR blueprint Initiate software excellent for EMPI functionality, easily configurable, data management toolset There have been minimal production issues once implemented Initiate Services project resources were excellent, knowledgeable, comprehensive, timely and easy to work with Excellent implementation processes and customer support services Easy to phase in new Sources and new Types of Integrations

28. Questions? Discussion? Eithne Reichert ereichert@sasktel.net