Meeting the Challenge; Creating Collaborative Harmonization for Canadian Drug Information Systems

1. Meeting the Challenge; Creating Collaborative Harmonization for Canadian Drug Information Systems eHealth 2013 May 28, 2013

2. Welcome! Panelists Lynne Zucker, VP Clinical Systems Integration, Canada Health Infoway Paul Caines, CIO & Chief Privacy Officer, NL Centre for Health Information Justin Bates, VP Pharmacy Affairs, Canadian Ass. of Chain Drug Stores Bonnie Cochrane, VP Clinical Information Programs and Quality, NL Centre for Health Information

3. Faculty/Presenter Disclosure • Faculty: Lynne Zucker • Relationships with commercial interests: NIL • Faculty: Paul Caines • Relationships with commercial interests: NIL • Justin Bates • Relationships with commercial interests: NIL • Faculty: Bonnie S. Cochrane • Relationships with commercial interests: NIL

4. Now that you know us...........................................

6. AGENDA 15:30 – 15:35 Welcome and introductions Bonnie 15:35 – 15:55 Setting the Context Lynne 15:55 – 16:15 DIS Harmonization; How did we Get Here? Paul 16:15 – 16:30 DIS Harmonization; Pharmacy Industry Perspective Justin 16:30 – 16:45 Harmonized Message Set with Impacts Paul 16:45 – 16:50 Summary Bonnie 16:50 – 17:00 Q&A; Close

7. Panel Session Objectives Introduce diverse perspectives related to challenges, complexities and opportunities faced implementing provincial Drug Information Systems (DIS) in Canada Provide an overview of the identified need & opportunity for a broad & inclusive national multi-stakeholder partnership to tackle the challenges and opportunities Describe ongoing work toward the achievement of Harmonization By sharing lessons learned, provide an understanding of the evolutionary nature of this work, necessary for optimal benefits realization for the DIS and beyond, while setting the stage for the future.

8. Setting the Context Lynne Zucker

9. Program Activity Summary (December 31, 2012) 386 active and completed projects with an estimated value of $2.10 billion as at December 31, 2012

10. Drug Information System Programs • Shared common objectives among all major stakeholders: • Reducing adverse drug events • Provide the best possible medication history to support clinical decision making across the health system

11. Fitting the Pieces Together JURISDICTIONAL INFOSTRUCTURE Common Services Registries Data & Services EHR Data & Services Communication Bus ClientRegistry Drug Information System Domain and Shared EHR Repositories Domain and Shared EHR Repositories Domain and Shared EHR Repositories HIAL ProviderRegistry HIAL LocationRegistry HIAL TerminologyRegistry HIAL Inter-Jurisdiction:EHR PCSStandards HIAL HIAL EMR Pharmacy System Hospital System POS-6 EHR Viewer Consumer Systems POINT OF SERVICE SYSTEMS

12. Benefits Evolve with System Maturity Early Benefits Long-Term Benefits

13. Estimated Access to Drug Information Systems (DIS)* * Original source: National Impacts of Generation 2 Drug Information Systems Technical Report, September 2010. Numbers in table above updated September 2012.

14. Standards • Drug Information Systems use many standards • Architecture • Messaging Standards • Terminology

15. In Spite of the Standards…. The Drug Information Systems in place across Canada make use of these standards, however, each jurisdiction had to adapt to balance many requirements: • legacy systems already in production • needs of clinical stakeholders • level of EMR use • legislation and policy requirements • capabilities of vendors • optionality included in the standards • procurement of commercial components The resulting variety of models and approaches has resulted in a variation in requirements between provinces. This creates a challenge for companies that need to manage streamlined, national solutions that can interact with multiple DIS environments.

16. E-Prescribing Harmonization • In addition to harmonization for pharmacy systems, there is also work underway to align e-Prescribing approaches for Electronic Medical Records (EMR) and other prescriber systems • First pass identification of jurisdiction variances and targeted reduction of 50% • Creation of jurisdiction message sets – libraries to support more plug and play capabilities • This work is to be completed in collaboration with the pharmacy harmonization initiatives.

17. Canadian Stakeholders Coming Together • Challenges facing our provinces are not unique – other jurisdictions have discovered there is no simple answer • In June 2012, a group of stakeholders came together – public sector jurisdictions and private sector pharmacies and vendors to try a different approach to achieve harmonization necessary for success • Fellow panelists going to share not only the issues and opportunities but also how this approach has built stronger buy in and participation in achieving a common resolution

18. May 2013 Pharmacy Harmonization“How did we get here?”A provincial perspective

19. Reminder… JURISDICTIONAL INFOSTRUCTURE Common Services Registries Data & Services EHR Data & Services Communication Bus ClientRegistry Drug Information System Domain and Shared EHR Repositories Domain and Shared EHR Repositories Domain and Shared EHR Repositories HIAL ProviderRegistry HIAL LocationRegistry HIAL TerminologyRegistry HIAL Inter-Jurisdiction:EHR PCSStandards HIAL HIAL EMR Pharmacy System Hospital System POS-6 EHR Viewer Consumer Systems POINT OF SERVICE SYSTEMS

20. A Complex Environment • Many vendors …with legacy products • Many jurisdictions …with legacy environments …diverse , complex stakeholder groups …many different starting points • Other complex ingredients in our ‘regimes’: • Standards: international considerations, different jurisdictional implementations, etc • Business processes, service desk interactions, on-call protocols… Jurisdictional variances expected

21. NL Standards History • Fully involved in development of pan-Cdn standard • Made sense to adopt broad implementation of standard - Adopt next generation after PEI - Build in flexibility through variances - Others adopted a narrower standard, but maintained more rigidity • Working with vendor community Good work done; we are building on that

22. A Dynamic Environment Since NL go-live: • Core Drug system has evolved - Version 1.3 to 1.6.5 • All POS systems have evolved - Kroll: 8.3 to 9.2 - Telus: Assyst to Ubik (new platform) • Conformance process has evolved • Major Client Registry upgrade • Clearer shared understanding among partners BUT - core standard - and protocols - have (essentially) remained the same!

23. Time is Right for Harmonization Discussion • Critical mass of implementations • Different stakeholders now “speak the same language” • Vendors: DIS, POS, etc • Technical, clinical, standards, management, etc • Operational processes (conformance, training, etc) • March 2013 harmonization forum • Go-forward approach needs further work… • …but such a conversation was not possible even 2 years ago! Standards are a success: they have gotten us to this point Can build on

24. DIS HarmonizationPharmacy Industry PerspectiveJustin BatesMay 2013

25. CACDS • We are the voice and advocate of our members who: • Operate more than 6,500 neighbourhood pharmacies across Canada and provide pharmacy and other core healthcare products and services; • Focus on wellness, treatment and prevention; • Ensure fulfillment of almost 70% of Canadian prescriptions each year; • Employ more than half a million Canadians, including 75% of pharmacists practicing in neighbourhood pharmacies across Canada; • We engage stakeholders in dialogue about our industry, our people and our role in providing quality neighbourhood-based healthcare products and services.

26. CACDS Members • Pharmacy retailers • Independent Banners • Grocery • Mass Merchandisers • Corporate • Represent pharmacy software vendors • 120+ organizations in the supply chain

27. Background • Pharmacy organizations are partners in making eHealth work in a cost effective framework • Provincial eHealth agencies, software vendors, and pharmacy organizations are working collaboratively to learn from experience to date and: • Design a truly pan-Canadian system that can be adopted across all jurisdictions • Focus on health outcomes and clinical value • Pharmacy software vendors and the NL Centre for Health Information began to work together in the Spring of 2012 to address the need for national harmonization • CACDS become involved to bring the industry perspective and help drive change

28. Overview • Goal is to mesh past and current harmonization efforts into a new multi stakeholder group • Canada Health Infoway, provinces, pharmacy retailers, CACDS and pharmacy software vendors • Develop priority areas • Inaugural meeting held in Toronto in June 2012 • Established an executive committee to oversee efforts • NL Center for Health Information and pharmacy software vendors co-developed harmonized message set • Harmonized message set presented to all stakeholders in Feb 2013 • Proposal simplifies DIS with a reduced message set with a focus on clinically relevant messages • Pharmacy supports a basic DIS with harmonized national message set that includes: • e-Prescribing – harmonize regulations for e-signature • Adverse Drug Reaction Reporting

29. Guiding Principles • eHealth must drive positive patient outcomes • Must provide additional value added information to assist healthcare professionals improve health outcomes • Support a minimal set of standard messages – simplify solution to: • Decrease implementation time for PMS vendors and DIS, thereby; • Decrease time for patients to realize benefits of a well designed and implemented solution • Lower bandwidth burden to allow for: • Implementable solution across different provincial IT infrastructures • Reasonable message response times

30. Guiding Principles Continued • eHealth should complement existing processes and workflow • The workflow of healthcare professionals and retailer operations varies, and cannot be dictated by technology • Messages should be designed and implemented with the flexibility to accommodate for different healthcare professional workflow choices, and the evolving role of pharmacists and technicians in community practices • Best practice guidelines need to be developed • Boards, colleges and associations should be involved in guidelines. National guidelines (NAPRA) preferable • Must be informed throughout development by stakeholders with practical experience in developing and implementing eHealth solutions

31. Process Moving Forward • eHealth Ontario developed a national template to collect feedback to the harmonized message set proposal • Pharmacy industry meetings with each province to discuss harmonized proposal • Develop national chart that identifies by province: • Alignment • Partial Alignment • Requires Further analysis • Establish a SME Task Force to work on a group of messages • Develop proposal for proposed changes to SCWG • Integrate other harmonization efforts with e-prescribing and EMR

32. May 2013 Harmonized Message Set With Impacts

33. Disclaimer • NL metrics, examples used • …but the principles are the same for all

34. NL - Current Context JURISDICTIONAL INFOSTRUCTURE Common Services Registries Data & Services Communication Bus EHR Data & Services ClientRegistry HIAL Domain and Shared EHR Repositories Drug Information System Domain and Shared EHR Repositories Domain and Shared EHR Repositories ProviderRegistry HIAL LocationRegistry HIAL TerminologyRegistry HIAL HIAL HIAL Inter-Jurisdiction:EHR PCSStandards EMR Pharmacy System Hospital System POS-6 EHR Viewer Consumer Systems POINT OF SERVICE SYSTEMS

35. NL - Current Context • Pharmacy deployed as an EHR application • Thru a HIAL • Real-time client registry integration • Business processes support this integration • EG Real time identity issue follow-up; on-call protocols

36. Messaging – NL Current Status • Large number of messages • 82 in NL • Many are similar • Eg abort, cancel • Extensive processes to build, sustain • Value, but a cost: significant per-transaction overhead • Great example of where we have learned • Time is right to step back more methodically

37. Proposal • 27 areas for increased harmonization • Messages (19) • Reminder: NL currently has 82 • Business practice • Conformance, training approaches • Ongoing: system availability, service levels • Data, terminology

38. Impact of proposed message set (NL) • Aligned: • Fully: 11 • Partially: 6 • Further Analysis required: 9 • Gap: 1

39. Example - Dispense • Current - separate messages for dispense of: • Drugs • Devices • OTCs • professional services • Proposed: one dispense message

40. Example - Query • Current: 18 query messages • Includes broad and narrow payloads • Reality – with variances, there are more than 18… • Proposed: 3 query messages • Broader messages

41. Why? • Fewer messages (and more harmonized processes) to: • Build, document, test, optimize, conform, maintain, troubleshoot, etc…. • …Across multiple jurisdictions • Each with some level of per-message variance • (ie reality is that there are currently more than 18…) • …Across each jurisdiction’s very complex technical environments • …For each POS vendor–each with its own operation ..but still deliver the value; MUST deliver same content

42. More Benefits • Shift interoperability burden to HIAL • From POS software • HIAL designed to enable interoperability • Reduces overhead • Currently significant per-transaction overhead • Testing (development, UAT, conformance, etc) • Simplifies environment • Facilitates communication • Clarifies boundaries • Can still maintain flexibility

43. Challenges of harmonization • Notable effort • Requires work on multiple fronts • POS/jurisdiction/DIS-backend • Has to be “right” • Will still have sustainability challenges • Hopefully fewer/”better” ones! • May increase load for some transactions

44. Jurisdictional Benefits Summary • Harmonization brings benefits (simplification, etc) • Systems are evolving anyway • Why not make the evolution in a harmonized way? • Won’t be easy • Aligned themes: • Minister Aglukkaq: “ putting (ehealth) into action is hard” • Peake (innovation): effective>efficient>improving>cutting>…. • Topol: “needs to be a changing of the guard” Time to accelerate the change!

45. May 2013 Summary

46. Summary – Key Messages The vision of this partnership is to simplify our very complex systems, to ensure optimal value is realized The value to be realized is value to the health system, care providers and patients We need this broad and inclusive partnership, which is collaborative and focused to achieve success The work we are doing is part of an ongoing evolution; we are making progress. Are we there yet? ……..the evolution continues!

47. Panel Session Objectives Introduce diverse perspectives related to challenges, complexities and opportunities faced implementing provincial Drug Information Systems (DIS) in Canada Provide an overview of the identified need & opportunity for a broad & inclusive national multi-stakeholder partnership to tackle the challenges and opportunities Describe ongoing work toward the achievement of Harmonization By sharing lessons learned, provide an understanding of the evolutionary nature of this work, necessary for optimal benefits realization for the DIS and beyond, while setting the stage for the future.

48. THANK YOU