EHRS Blueprint Presentation

Infoway Architecture Update
March 2006
Solution Architecture Group
1
Outline
Introducing Infoway
EHRS Blueprint Scope
Business Context
Clinical/Work Process Architecture
System Architecture
Information Architecture
Integration & Deployment Options
Potential Applications
Summary & Conclusion
2
What Does Infoway Do?
End User Adoption & Innovation & Adoption

Setting the Future $60M
Direction
The Electronic Health Interoperable EHR

Record $175M
Drug Laboratory Diagnostic

Public
Domain Repositories & Information Information Imaging TeleHealth
Health Systems
Healthcare Systems Systems Systems $150M
$220M $100M
Applications $185M $150M
Cross Program Client, Provider & Location Registries

Foundation $110M
Components
Infostructure
Architecture &
Standards $125M
3
EHRS Blueprint Scope
EHRS BLUEPRINT V1.0 ADDRESSED BUSINESS CONTEXT

(Mission, objectives, stakeholders, benefits)
WORK PROCESS INFORMATION SYSTEM TECHNOLOGY
Blueprint V1 Blueprint V1
Conceptual Blueprint V2
Blueprint V2 Blueprint V2
Logical Blueprint V2 Blueprint V2 Blueprint V2
Physical
EHR Implementations across Canada
4
Architecture Perspectives
Business
Architecture
Clinical
Potential
Work Process
Applications
Architecture
CONTEXT
Integration &
System
Deployment
Architecture
Models
Information
Architecture
5
Business
Architecture
Clinical
Potential
Work Process
Applications
Architecture
CONTEXT
Integration &
System
Deployment
Architecture
Models
Information
Architecture
6
Business Context
7
Healthcare Industry Ministry
of Health
Elected
Government
Planning & Provides $

Resources
Planning & Tax

Resources $$$
Health Authority Health Authority Health Authority
Homecare
Community Emergency
Care Center Services
Tax Payer
Providers
Clients/Patients
Pharmacy
Specialist Clinic
Hospital
Emergency Laboratory
Diagnostic
8
International Industry: IT Spending Comparisons
IT spending as a % of total expenditures

Financial Services 12.1
Government 5.7
Telcos 5.5
Worldwide Health Providers 4.2
Transportation 3.3
Utilities 2.7
Textiles 2.2
Manufacturing 1.9
Petroleum 1.7
Pulp & Paper 1.6
Canadian Healthcare 1.4
Food & Bev 1.2
SOURCE: Gartner Group – as reported in the Health Services Restructuring Commission’s (www.hsrc.gov.on.ca) report: Ontario Health Information Management Action Plan, June 1999
9
Mean Hospital: IT spending in Canada <2%
Canadian IT budgets as a % of total

hospital budget
less than 1% 25
1-1.4% 27
1.5-1.9% 27
2-2.4% 12
2.5% or more 10
0 5 10 15 20 25 30
SOURCE: 2003 Report on I.T. in Canadian Hospitals: Top issues, applications and vendors. Canadian Healthcare Technology, 2003. CIHI NHex 2002 (Hospital Expenditures)
10
Why an EHR?
The World of Healthcare
is Changing…
The Old World The New World

Provider-focused Patient & family-focused
Illness Wellness
Site-of-care Continuum of care
Episode Management Disease Management
Supply Management Demand Management
Solitary decision making Collaborative, evidence-based decisions
Efficiency Effectiveness
De-centralized, generalized care Centralized, specialized care
11
Why an EHR?
The World of Healthcare
is Changing…
The changes in healthcare require

significant capability from the
health infostructure, capability
which does not fully exist today
12
The Timing Has Never Been Better!
WILL CONVERGENCE CAPACITY

• Public wants more • Better infrastructure
accessibility • More mature
• Health Authorities application
recognize benefits technologies
• Increased financial
pressures
• Healthcare
professionals
embracing technology CAPABILITY
• Willingness to • Political will
collaborate
• Funding is now available
• Infoway mandated to pursue investments
13
EHRS Blueprint:
Key Definitions
14
EHR
An Electronic Health Record (EHR) provides each individual in Canada with a
secure and private lifetime record of their key health history and care within the
health system. The record is available electronically to authorized health providers
and the individual anywhere, anytime in support of high quality care.
This record is designed to facilitate the sharing of data – across the continuum of
care, across healthcare delivery organizations and across geographies.
15
EHR Solution
The EHR Solution is a combination of people,
organizational entities, business processes, systems,
technology and standards that interact and exchange
clinical data to provide high quality and effective
healthcare.
16
EHR Infostructure
The EHR Infostructure is a collection of common and reusable
components in the support of a diverse set of health information
management applications. It consists of software solutions for the EHR,
data definitions for the EHR and messaging standards for the EHR.
17
EHRS Outcomes
Providers Researchers & Health
• Relevant data, granular Surveillance
• Real time Professionals
• Rapid access from multiple • Appropriately summarized data
locations, anywhere, anytime
• Anonymized
• Decision support
• Clinical reference data
• Designed for analysis:
• Guidelines & protocols • Statistical sampling
• Common terms & codes • Trends
• Outbreak detection
• Case management & workflow Authoritative,
• Outcome analysis
• Safety reliable, secure,
• Regional
• Improved quality of care private
• Pan-Canadian
• Regulation & accountability
Payer/Payee
Patient/Public/Clients • Relevant data to adjudicate claim
• Convenient, relevant access to • Workflow management
accredited health information
• Access to relevant personal health
information Public Sector Health Managers
• Safety • Registry solutions & initiatives
• Improved quality of care • Objective analysis of results & benefits
• Management reports
• Funding & resource allocation
• Policy
18
Key EHRS Architecture Concepts
EHR SOLUTION (EHRS)
EHR INFOSTRUCTURE (EHRi)

EHRS
Locator
Ancillary Health EHR Registries

Data & Information Data & Data &
Services Data Services Services
Warehouse
Longitudinal Record Services
Health Information Access Layer
Point of Service Point of Service

Application EHR Viewer
Application
19
EHRS Blueprint Recommended Approach:
A Pan-Canadian EHR Service
EHR SOLUTION (EHRS) EHR SOLUTION (EHRS)
EHR INFOSTRUCTURE (EHRi) EHR INFOSTRUCTURE (EHRi)
Health Health
Ancillary EHR Registries Ancillary EHR Registries
Information Information
Data & Data & Data & Data & Data & Data &
Data Data
Services Services Services Services Services Services
Warehouse Warehouse
Longitudinal Record Services Longitudinal Record Services
Health Information Access Layer Health Information Access Layer
Point of Point of Point of Point of

Service Service EHR Viewer Service Service EHR Viewer
Application Application Application Application
EHRS EHRS EHRS EHRS EHRS EHRS EHRS
20
EHR Infostructure: Conceptual Architecture
JURISDICTIONAL INFOSTRUCTURE
Registries Data Ancillary Data EHR Data Data

& Services & Services & Services Warehouse
Client
Registry Outbreak PHS Shared Drug Diagnostic Health
Laboratory
Management Reporting Health Record Information Imaging Information
Provider
Registry
Location
Registry Business EHR Message Normalization
Rules Index Structures Rules
Terminology Longitudinal Record Services

Registry
Security Mgmt
Privacy Data Configuration
Data
Common Services
HIAL
Communication Bus
Radiology
Public Health Pharmacy Lab System Hospital, LTC, Physician
Center EHR Viewer
Services System (LIS) CCC, EPR Office EMR
PACS/RIS
Public Health Pharmacist Radiologist Lab Clinician Physician/ Physician/ Physician/

Provider Provider Provider Provider
POINT OF SERVICE
21
Guiding Principles for EHRS
• Patient-centric • Leverage legacy systems & solutions

• Mass customized views of all clinical data • Design for phased rollout with near
• Value add for the provider term results
• Timely, accurate information • Scalable
• Enable sharing at local, regional, • Extensible to support future growth

cross-jurisdictional • Cost-effective
• Interoperable, integrated • Secure & private
• Standards based • Allow for innovation & competition
• Replicable solution – patterns, components • Comprehensive
22
Generations of EHR Capabilities
Full Gen 5
The Mentor
Gen 4
The Colleague
Functionality Gen 3
The Helper
Gen 2
The Documentor
Gen 1
The Collector
Minimal
1993 1998 2005 2010 2015+
End of 2009
Source: Gartner (December 2005)
Availability of Products
23
A Few Misconceptions About EHR Solutions
Misconception Reality
• A person’s health data is in only one • EHR: an integrated service covering
physical EHR all available EHR Solutions; a client’s
• All data for a person must be in the record is seen as coming from a single
EHR to have value and generate integrated EHR
adoption • Quality, safety & effectiveness
• A jurisdiction is a province/territory enhanced with only subsets of clinically
relevant data available for sharing
• The EHR is a data warehouse to
• Any geo-political entity mandated to
support research and surveillance
govern the operation of an EHR
Solution
• The EHR: an information support
service available to caregivers in the
daily context of care provision work
activities
24
Business/Clinical Scope
25
EHRS Serving Healthcare Service Delivery
Health Health
Data & Data Data & Data & Data & Data Data & Data &
Warehouse Warehouse
Point of Service Poin of Service Point of Service Point of Service

EHR Viewer EHR Viewer
Homecare Homecare
Community Care Emergency Community Care Emergency

Center Services Center Services
Clients/Patients Clients/Patients
Specialist Pharmacy Specialist Pharmacy

Clinic Clinic
Hospital Laboratory Hospital Laboratory

Emergency Emergency
Diagnostic Diagnostic
26
Public Health Business Requirements
• Focuses on managing health status of populations

• Managed and executed through complex network of public/private organizations acting at different
levels of the health system (Federal, Provincial/Territorial, Regional, Local, Individual)
• Involves:
• Research & analysis to identify/define population health programs
• Surveillance activities to detect and pro-actively react to potential population health problems
• Application of health programs to prevent the appearance and/or dissemination of preventable diseases
• Active management of communicable disease outbreaks
• Active management of the delivery of health services to individuals in the context public health related
programs
• Current focus limited to:
• Surveillance and detection (focused on human health-related diseases)
• Outbreak Management
• Public Health Alert Management
• Disease Information Dissemination
• Immunization Management
• Communicable Disease Case Management
27
Integrating Public Health in the Architecture
New services required to support:

• Surveillance & Detection: introduces a formal business need for the Health information
data warehouse introduced in V2
• Outbreak Management: requires the addition of a new category of service called Ancillary
Services where a specific service is introduced to address outbreak management
• Disease Information Dissemination: introduces the need for a formal terminology registry
system that would maintain information about diseases and other key terminologies
required for many services of the EHRi
• Terminology registry would go beyond simply maintaining to allow for maintenance, dissemination of education, etc.
associated with diseases
• Public Health Alert Management

• Public health disease alert reporting requires use of specific applications also positioned as ancillary services
• Public health alerts dissemination relies on terminology registry and HIAL Alerts and Notification services
• Immunization Management
• Immunization programs and their management requires a specific application that would live under the ancillary
services category
• Delivery of immunisation would be tracked by the drug information domain as part of the EHR
• Communicable Disease Case Management

• Delivery of health services in relation with the treatment of a CD case would be tracked by the shared health record and
other domains as part of the EHR
• Management of a CD case from the perspective of the public health specialists involved in detection and tracking would
require a specific application that would live under the ancillary services category
28
Integrating Public Health in the Architecture
Some Public Health business requirements can be sustained by the

existing services of the EHR Infostructure
• Public Health Alert Management: HIAL and LRS to provide for mechanism to help with
detection & reporting on communicable diseases
• Immunization Management: Drug Information Domain is the home of immunisation
information as part of the core clinical data in client’s health records. HIAL and LRS to
provide mechanisms to communicate the data and coordinate its location and access within
the EHRi
• Communicable Disease Case Management: CD Cases, from the perspective of the EHR
are treated like any other health delivery encounter
29
EHRS Serving Public Health Service Delivery
JURISDICTIONAL INFOSTRUCTURE Immunization
“Registry“
Client
Laboratory
Provider
Registry
Case
Reference Management
Management
Location
Rules Index Structures Rules PHS Data
Terminology Warehouse
Longitudinal Record Services Services
Registry
Content &
Alert Notification Security &
Messaging Knowledge
Services Privacy Services
Management Security Mgmt
Data
Common Services
HIAL
Communication Bus
PHS Systems
Operational data
Radiology Hospital,
PHS Other PH Pharmacy Lab System Physician
CM OM AM IM* Center Community, EHR Viewer
A System(s) System (LIS) Office EMR
PACS/RIS etc… EPR
Public Health Surveillance Portal
Pharmacist Radiologist Lab Clinician Physician/ Physician/ Physician/

Public Health Providers Provider Provider Provider
POINT OF SERVICE
30
Telehealth Business Requirements
• Telehealth: the use of information & communication technologies to deliver health

services in contexts where the providers and clients are in separate locations
• Telecommunication infrastructure is a pre-requisite
• Telehealth solutions enable health service delivery channels:
Tele-consultations Tele-education Tele-homecare Tele-triage
Videoconferencing Videoconferencing Active or passive Centralized call centers

stations, communication stations used for monitoring of remote to offer first line delivery
enabled medical training/education patients for pre-/ of service to clients as
devices post-op procedures, part of primary care and
chronic diseases emergency response
management, etc
• Scheduling solutions – a key enabler required for the effective use of telehealth service delivery
• EHR Infostructures support telehealth applications as per any other Point-of-Service Application
31
EHRS Serving Telehealth Scheduling

Client
Laboratory
Provider
Registry
Location

Registry
Security Mgmt
Data
Common Services
HIAL
Communication Bus
Patient End-user Referring Attending

Info Info Physician Physician
Site Site
Event Clinical
TSA History Profile
Database
Video
Scheduling
Session Physician/ Physician/
POINT OF SERVICE Provider Provider
TSA APPLICATION
32
EHRS Blueprint: Tele-Consultation
Health Health
Data Data
Warehouse Warehouse
Live Video-Conferencing
Session
Local Electronic Telehealth Telehealth Local Electronic
Medical Record Application Application Patient Record
Tele-Consultation Devices Data
Lutselk’e, Edmonton,
NWT AB
33
EHRS Blueprint: Tele-Homecare
Health Health
Data Data
Warehouse Warehouse
Tele-Homecare Data Feed

Local Electronic Homecare Homecare
Medical Record Application Server Client Application
Tele-Consultation Devices
Montreal,
QC
Dieppe,
NB
34
EHRS Blueprint: Tele-Triage
Health Health
Data Data
Warehouse Warehouse
Patient Info End-user Info

Personal
Event Clinical Tele-Triage
History Profile Health Record
Application
Scheduling Video Session Application
EHR Viewer
Sault Ste-Marie,
Kingston, ON ON
London, ON Oshawa, ON
35
Clinical, Business &
Socio-economic Drivers
for EHR Solutions
36
Why is Value Created by an EHR Solution?
• Healthcare professionals make clinical decisions based on knowledge

• Better knowledge translates to better care
• Knowledge starts with accurate, relevant clinical information
• The EHR creates the capability to share relevant clinical information
• The 5 Rs of the EHR:
• The right information
• About the right client
• Available to the right person
• In the right place
• At the right time
37
How Is Value Delivered By An EHR?
The value of the EHR for clients, families and their providers
increases with the completeness of the information contained as well
as the level of standardization of the data
Point of
greatest value
Extent of the Care
Continuum Involved
(PCP office, Hospital, Long a
Term Care Homecare, etc.) Are
l
ra
fer
l Re
ra
atu
N
a
A re
a re
lC
ca
Lo
# of Data Domains Included

(Encounter Summaries, Lab, DI, Drugs, etc.)
38
Why Pursue The EHR: Circle of Care
Homecare
Clinic Emergency Services
Community Pharmacy
Care Center
Specialist Clinic Laboratory
Hospital Diagnostic
Emergency
39
Why Pursue The EHR: Benefits
Homecare
Community Pharmacy
Care Center
QUALITY SAFETY
ACCESSIBILITY
Hospital Diagnostic
Emergency
40
The EHR is a Key to a
Renewed Health System!
EHR solutions provide an

opportunity to
• Improve the quality, safety,
accessibility and timeliness of care for
Canadians
• Support more informed healthcare
decision making, research and
management
• Improve the efficiency of the healthcare
system and reduce costly duplication
• Maximize return on IT investments
• Achieve standards based solution
allowing interoperability
41
EHR Key Clinical & Business Requirements
• Life-long longitudinal record of clinical data

• Allowing private and secured access to data made available in EHR
• Focused on clinically relevant data shared beyond organizational boundaries
• Support for accurate, complete, timely delivery of information
• Shared across multiple organizations, jurisdictions
• Adaptive to the future of healthcare delivery in the 21st Century
• Requiring ongoing governance and operations management with 24/7 high
availability service
• Affordable in relation to complexity and size of integration challenges (connecting large
numbers health points of service)
• Scalable to allow continuous, extensive growth of clinical and $ ROI
• More POS applications sourcing data to EHR
• More users accessing and using data from EHR
• Allowing natural growth of capabilities towards Generation 3 and beyond
42
Different Approaches To
Achieving EHR
43
EHR: How Do We Do This?
Sharing Information From Multiple Systems
Homecare
Community Pharmacy
Care Center
INTEGRATED VIEW
Clients/Patients
Hospital Diagnostic
Emergency
44
Methods of Sharing EHR Information
The “Big Database Broadcast to all or The “Big Index in Use of a

in the Sky” a logical subset of the Sky” shared reference
systems information source
• All Point-of-Service • Replication of data • EHR Index or locator • POS systems
(POS) systems share from one system to service that holds populate it
same data store all other relevant/ links to all POS • POS systems or
participating POS systems where viewers reference it
systems information resides
• External to the
• Every POS • Each POS system “operational” store
system holds same interfaces to other
information systems
45
Key Factors Affecting How to Share
• Sharing creates some very profound issues & requirements

• Unique identification of clients, providers, service delivery locations, etc.
• Protecting privacy and confidentiality of patients and providers while
simultaneously not limiting the ability to deliver appropriate services
• Ensuring information is stored, shared securely
• Ensuring compatibility of how data is interpreted/understood
• Issues the same no matter which model is chosen to share patient
identified information
• Canadian governance model for healthcare means these issues are F/P/T
jurisdictional responsibilities – requirements vary
• People increasingly mobile, especially when considering long periods
of time
• Provider’s confidence in the mechanisms to enable sharing is crucial
46
The Integration Challenge
of EHR Solutions
47
Integrating Heterogeneous Systems
Homecare
Community Pharmacy
Care Center
Clients/Patients
Hospital Diagnostic
Emergency
48
Integrating Heterogeneous Systems: Hospital
Hospital Emergency Homecare
Finance, Electronic
Order/ Specialized
inventory, ADT Patient Pharmacy
Results Care
payroll Record
Community Pharmacy
Care Center
Human Clinical Data Radiology

Scheduling Laboratory Emergency
Resources Clients/Patients Repository PACS
Hospital Diagnostic
Emergency
49
Integrating Heterogeneous Systems: Hospital
Homecare
Clinic Clinic Emergency Services
Electronic
Accountiing/
Scheduling Medical
Billing
Record
Community Pharmacy
Care Center
Clients/Patients
Hospital Diagnostic
Emergency
50
Locations of Electronic Clinical Data Today: Number of
Systems to Integrate
Homecare
Community Pharmacy
Care Center
Canada has approximately

Clients/Patients40,000 systems
Hospital Diagnostic
Emergency
51
Integrating Health Information Systems: Key Challenges
• Protecting Privacy
• Governance, accountability & data custodianship
• Controlling access
• Managing & applying consent directives
• Controlling feeds and queries to the data
• Trust relationships & contracts
• Existence & availability of data
• Discovery capability
• Availability in electronic format
• Timeliness
• Harmonization
• Data structures (format)
• Vocabularies (encoding, normalization)
• Semantics
• Heterogeneous technology environments
• Number of organizations, connection points & systems
• Costs inherent to integration
52
EHRS Blueprint
Recommended Approach:
The Cost of Integration
As A Key Driver
53
Integrating Health Information Systems:
Point-to-Point Connectivity
SYSTEMS TO CONNECT
ApplApp
1 1 AppAppl
1 2
Costs basis
• Cost of one integration
Contracts • Simple = $32K; Medium = $95K;
App 1 App 1
Complex = $190K
2
SYSTEMS TO CONNECT
Futile approach
• 38,783 systems in Canada
ApplApp
1 App
1 1 AppAppl
1 2
• Simple = 4,527; Medium = 20,081;
Complex = 14,175
ApplApp
3 App
1 1 • 1.5 B integration points
6 • 183.928 B $CDN
SYSTEMS TO CONNECT
App 1 ApplApp
1 App
1 1 AppAppl
1 2 App 1
App 1 ApplApp
3 App
1 1 AppAppl
1 4 App 1
We need a different approach
12
Interfaces = N (N-1)
54
Hospital Networks Approach
SYSTEMS TO CONNECT
ApplApp
1 1 AppAppl
1 2
Costs basis
Contracts • Simple = $32K; Medium = $95K;
App 1 App 1
Complex = $190K
2 Hypothesis
SYSTEMS TO CONNECT
• 1,126 Hospital networks, each
ApplApp
1 App
1 1 AppAppl
1 2 includes 71 systems to integrate and
group (EAI) in 44 points of
integration
ApplApp
3 App
1 1
• 1,892 (44 x 43) integrations per
6 network totalling 2.1 M (1,126 x
SYSTEMS TO CONNECT 1,892) integrations in Canada
• Assuming existence of standardized
App 1 ApplApp
1 App
1 1 AppAppl
1 2 App 1
protocol for interfaces
• 68.172 M $CDN (if Simple – 32K)
App 1 ApplApp
3 App
1 1 AppAppl
1 4 App 1 • 202.316 M $CDN (if Medium – 95K)
12 We need a different approach

Interfaces = N (N-1)
55
EHRS Blueprint Approach
EHR SOLUTION (EHRS) Costs basis

• Simple = $32K; Medium = $95K;
Complex = $190K
Health
Ancillary EHR Registries
Information
Data & Data & Data &
Services
Data
Warehouse
Services Services Hypothesis
• All hospitals/long term care
organizations use an integration
engine and count as 1 integration point
• Simple = 4,575; Medium = 8,134;
Complex = 6,597
• 19,306 integration points
• Assuming existence of standardized
interface and protocols
Point of Service Point of Service EHR Viewer
• 2.170 M $CDN
Application Application
56
Rational for Recommended Approach
• Only cost effective scenario to handle degree of application integration required

• Maximized ability to deliver proper response time and consistent access to data
across thousands of source systems
• Maximized ability to apply privacy and security policies in a harmonized and
consistent fashion
• Enables evolutionary path to semantic harmonization of health information
across service delivery points
• Enables high degree of scalability from local health services integration, to
regional, provincial or territorial and cross-jurisdictional
• Enables high degree of flexibility in reconfiguration of health services
delivery networks
57
Business
Architecture
Clinical
Potential
Work Process
Applications
Architecture
CONTEXT
Integration &
System
Deployment
Architecture
Models
Information
Architecture
58
EHRS Work Process Architecture
• The EHR Clinical Reference Framework: Life of the Lamberts

• Depiction of the use of an EHR Solution in different contexts of health service delivery
• 14 different storyboards created
• Extensible by adding new use cases
• System or security administration use cases not represented
• Life of the Lamberts
• Patient centric framework
• Focused on different members of a family and their health status evolution
• Focused on health related events
• Represented with UML use case notation
• Developed under Magic Draw case tool
• Published as artefacts under the Artefact Repository
• Available in HTML and PDF format
• Available in Magic Draw format and XMI for upload to other case tools
59
EHRS Reference Architecture
Comm Step Put New Patient

HIAL
POS APPLICATION
SIGNIFICANT REUSE
Encounter
HERE
Life Of COPD Encounter Clinical Activity Clinical Events EHR IP

The Lamberts Storyboard
Add New Patient
New New Clinic Visit
Storyboard Family Physician Family Physician Admission EHR IP
Activity Activity
Storyboard
Clinical Activity Clinical Events EHR IP
Clinical Events EHR IP
EHR IP EHR IP EHR IP

Radiology EHR IP EHR IP EHR IP EHR IP
Center EHR Viewer
PACS/RIS

POINT OF SERVICE
EHRS Reference
Architecture 60
Documenting EHRi Services Requirements

HIAL
Client
Laboratory
HIAL
Provider
Registry HIAL HIAL HIAL HIAL HIAL HIAL
HIAL
Location
HIAL
Terminology
Registry Longitudinal Record Services
HIAL
Security Mgmt
HIAL HIAL Data
Common Services
HIAL
IP “Put” IP “List” IP “Get”
Communication Bus IP “List” IP “Get”
EHR IP EHR IP EHR IP EHR IP EHR IP
Data Data Data Data Data
EHR IP EHR IP EHR IP EHR IP EHR IP
Hospital, LTC, Physician Physician

EHR Viewer EHR Viewer
CCC, EPR Office EMR Office EMR
POINT OF SERVICE Radiologist Lab Clinician Physician/ Physician/ Physician/

Provider Provider Provider
EHRS Reference
Architecture 61
People Use Cases: Caregiver Perspective

• First class of deliverables are contextual & informational

• They describe the end-user functional requirements and assumptions for use of an EHR Solution
• Establish when POS applications expected to interact with an EHRi in the context of daily work activities
for caregivers
• Infoway not attempting to document all forms of potential uses of an EHR
• Scope is broad enough to cover large spectrum of healthcare and public health service delivery to
achieve representative set
Security Mgmt
Data
Common Services
HIAL
Communication Bus
EHR INTERFACE REQUIREMENTS DOCUMENTATION

Radiology
Center EHR Viewer
PACS/RIS
Life of the Clinical
Storyboards Encounters
Lamberts Activities

POINT OF SERVICE
62
EHR Interoperability Profile (EHR IP)

• Second class of deliverables normative; specify the interfaces between POS applications
and EHR
• Establishes a language to describe types of service requests made to an EHRi
• Positions which data to be exchanged by referring to data views of the data model
• Assumes SOAP-based web services calls where XML encoded HL7 V3 message requests
and responses are carried between POS applications and the EHRi
HIAL
EHR INTEROPERABILITY PROFILE

Radiology
Center EHR Viewer
Services System (LIS) CCC, EPR
Communication Office EMR
PACS/RIS
EHR IP
Steps

POINT OF SERVICE
63
EHR Infostructure IP (EHR I-IP)

Client
INFOSTRUCTURE INTEROPERABILITY PROFILE
Laboratory
Provider
Registry
Location
Rules Infostructure
Index Structures Infostructure
Rules Generic Interface
IP Services Catalogue Specification
Registry
Security Mgmt
Data
Common Services
HIAL
Communication Bus
• Third class of deliverables normative; specify inner workings within EHR Infostructure to
orchestrate and process transactions
• Express sequencing of activities to process transactions
• Express expected capabilities of services within an EHRi to process transactions
POINT OF SERVICE
64
Business
Architecture
Clinical
Potential
Work Process
Applications
Architecture
CONTEXT
Integration &
System
Deployment
Architecture
Models
Information
Architecture
65
EHR Infostructure: Services Drill-Down

Client
Laboratory
Provider
Registry
Location

Registry
Security Mgmt
Data
Common Services
HIAL
Communication Bus
Radiology
Center EHR Viewer
PACS/RIS

POINT OF SERVICE
66
EHR Infostructure: Standards Based Connectivity

HIAL
Client
Laboratory
HIAL
Provider
Registry HIAL HIAL HIAL HIAL HIAL HIAL
HIAL
Location
HIAL
Terminology
Registry Longitudinal Record Services
HIAL
Security Mgmt
HIAL HIAL Data
Common Services
HIAL
Communication Bus
EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP
EHR SCP
Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards
Radiology
Center EHR Viewer
PACS/RIS
POINT OF SERVICE Public Health Pharmacist Radiologist Lab Clinician Physician/ Physician/ Physician/
67
EHR Infostructure: Communication Bus

COMMUNICATION BUS
MESSAGING
Transformation Routing
Services Services
Encrypt/Decrypt En/Decoding
Services Services
Parser Serialization
Services Services
HIAL
PROTOCOL Communication bus
App Protocol Network Protocol

Services Services
POINT OF SERVICE
68
EHR Infostructure: Common Services
Ancillary Data EHR Data Data
Registries Data COMMON
& Services
SERVICES & Services Warehouse
& Services
INTEROP PRIVACY & SECURITY

Interoperability Identity Protection Anonymization Consent Directives
Services Services Services Mgmt Services
Search/Resolution Identity Mgmt User Authentication Encryption

Services Services Services Services
Access Control Secure Auditing Digital Signature

INTEGRATION Services Services Services
Service Catalogue
General Security
Services
Services
Broker Services Security Mgmt

SUBSCRIPTION MANAGEMENT GENERAL Data
Mapping Services
Alert/Notification Management Common Auditing
Services
HIAL Services Services Services
Queuing Services
Pub/Sub Configuration Log Mgmt

CONTEXT Services Services Services
Caching Services
Policy Mgmt Exception/Error
Services Handling Services
Session Mgmt
Services
POINT OF SERVICE
69
EHR Infostructure: Longitudinal Record Services

LONGITUDINAL RECORD SERVICES
DATA
Key Mgmt Data
Business EHR Message Normalization Services Services
ETL Replication
Longitudinal Record Services Services Services
BUSINESS
Data Quality Normalization
Services Services
HIAL
Domain Business Components
(Registries, EHR, Domains, User, Context)
EHR Index Business Rules

Services Services
Orchestration Assembly
Services Services
POINT OF SERVICE
70
EHR Infostructure: Longitudinal Record Services

The EHR Index maintains a sequential list of all events that affect the clinical
picture of a client. It also provides the location where the data relevant to each
event is kept in the EHRi. It can be used to retrieve the history of events for a
client or to trace the information about a specific event. LONGITUDINAL RECORD SERVICES
DATA
Key Mgmt Data
EHR INDEX Business EHR Message Normalization Services Services
Event ID (Instance ID of an event)
Parent Folder ID ETL Replication

Longitudinal Record Services Services Services
Focal Class Type
Focal Act Subject (Client ECID)
Focal Act Author (Provider) BUSINESS
Focal Act Service Delivery Location Data Quality Normalization
Focal Act Timestamp Services Services
FocalHIAL
Act Status
Focal Act Language (Registries, EHR, Domains, User, Context)
Focal Act Type:
• Act Mood (e.g. Order Request) EHR Index Business Rules
Services Services
• Act Class Code (type of class, e.g. Lab order)
• Act Code (Class value, e.g. CBC) Orchestration Assembly
Focal Act Source ID (ID provided by POS) Services Services
Focal Act Template ID

Focal Act Data Location ID (URI)
POINT OF SERVICE
71
EHR Infostructure: EHRS Locator Data
CROSS-JURISDICTIONAL INFOSTRUCTURE
• EHRi Client ID (resolved ECID)
• CR instance ID (OID root)
EHRS • EHRi instance ID (which instance of an EHRi)
Locator • EHRi URI (the URI to access the HIAL)
• Optimized for performance
• Information type (drug, lab, DI) (derived from HL7 act classes)
• First created date
• Last updated date
Health Health
Data Data
Warehouse Warehouse
Point of Point of Point of Point of

Service Service EHR Viewer Service Service EHR Viewer
POINT OF SERVICE
72
Centralized Service Approach
EHRS
Locator
EHR SOLUTION (EHRS) EHR SOLUTION (EHRS) EHR SOLUTION (EHRS)
EHR INFOSTRUCTURE (EHRi) EHR INFOSTRUCTURE (EHRi) EHR INFOSTRUCTURE (EHRi)
Health Health Health

Ancillary EHR Registries Ancillary EHR Registries Ancillary EHR Registries
Information Information Information
Data & Data & Data & Data & Data & Data & Data & Data & Data &
Data Data Data
Services Services Services Services Services Services Services Services Services
Warehouse Warehouse Warehouse
Longitudinal Record Services Longitudinal Record Services Longitudinal Record Services
Health Information Access Layer Health Information Access Layer Health Information Access Layer
Point of Service Point of Service Point of Service Point of Service Point of Service Point of Service
Application EHR Viewer Application EHR Viewer Application EHR Viewer
Application Application Application
POINT OF SERVICE
Jurisdiction Jurisdiction Jurisdiction
A B C
73
Distributed Service Approach
EHRS Locator Synchronization
EHRS EHRS
Locator Locator

Data Data Data
POINT OF SERVICE
A B C
74
EHRS Locator: LRS Integrated Approach
EHRS
Locator

Client
Registry
Provider
Registry
Location

Registry
HIAL
POINT OF SERVICE
75
LRS Integrated Services Approach
Client Registry Synchronization

Data Data Data
POINT OF SERVICE
A B C
76
EHR Infostructure: EHR Data Domain Services

Shared Drug Diagnostic

Laboratory
Health Record Information Imaging
SHARED HEALTH RECORD
DATA
Key Mgmt Data

Services Services
HIAL BUSINESS
(Registries, EHR, Domains, User, Context)
Normalization Business Rules

Services Services
EHRi Interoperability Assembly

Services Services
POINT OF SERVICE
77
EHR Infostructure: EHR Viewer

EHR VIEWER
EHRi Interoperability Data

Services Services
EHR Viewer
Business Objects Components
Normalization Business Rules

Services Services
HIAL
End-user End-user
Navigation Services Display Services
EHR Viewer
Physician/
Provider
POINT OF SERVICE
78
EHR Infostructure: Client Registry

Client
Registry
Provider
Registry
Location
Registry
Terminology
Registry
HIAL
POINT OF SERVICE
79
EHR Infostructure: Why A Client Registry?

Client
Registry
Provider
Registry
Location
Registry
Has Mr. Lambert had any ER
Terminology
Registry
visits since I’ve last seen him
one year ago?
HIAL
Patient End-user
Info Info EHR Viewer
Visit Drug
History Profile
Diagnostic
Laboratory
Imaging Physician/
Provider
POINT OF SERVICE
EHR VIEWER
80
EHRi Client Registry: The Challenge
EMPI
1: A 123 Robert Lambert 1 Main St

1: B 456 Bob Lambert 1 Main St
1: C 789 Robert Lambert 1 Main St
1: C 987 Robert Lambert 1 Main St
2: B 444 Robert Lambert 2 Elm St
Pharmacy Lab ???
A B C
123 Robert Lambert 1 Main St 456 Bob Lambert 1 Main St 789 Robert Lambert 1 Main St
444 Robert Lambert 2 Elm St 987 Robert Lambert 1 Main St
81
EHRi Client Registry: What Data?
The generation (or sourcing) Name

Birthdate
of the EHRI Client Identifier Gender Address
(ECID) is a service offered Phone
SIN
ULI
by the Client Registry. MDR ID
ECID
Lab ID
The ECID is the foundation Eligibility status
for interoperability both Coverage details
locally and across EHR
Infostructures.
Static, natural Dynamic, natural Static, artificial Dynamic, artificial Core system data
person identity person identity person-identifying person-identifying about the person
information information information information
82
EHRi Client Registry: Interoperability Pattern
JURISDICTIONAL
ECID: J1 Root ID. Client ID ECID: J2 Root ID. Client ID
Client Client
Registry Registry
J1 Active synchronization J2
of travelling clients only
Client Client
Registry Registry
J1.1 J1/2
Applications Applications
REGIONAL
83
EHR Infostructure: Provider Registry

Client
Registry
Provider
Registry
Location
Registry
Terminology
Registry
HIAL
POINT OF SERVICE
84
EHR Infostructure: Why A Provider Registry?

Client
Registry
Provider
Registry
Location
Registry
Terminology
Have any new test results been
Registry published for me?
HIAL
Patient End-user
Visit Drug
History Profile
Diagnostic
Laboratory
Imaging Physician/
Provider
POINT OF SERVICE
EHR VIEWER
85
Provider Registry: Data Sources
JURISDICTIONAL
Unlicensed
Doctors Dentists
Providers
EHR SCP Standards

Provider Registry
Provider
Registry
EHR SCP Standards

Provider Registry
Applications Applications Applications
REGIONAL
86
Standards-based
Solutions: What Does
It Mean?
87
Interoperable EHR Solutions: Key Architectural Requirements
Standardized Standardized
Architecture Interfaces
Standards-based
Solutions
Standardized
Standardized
Data Vocabularies
Data Structures
(encoding rules)
Standardized
Functional Behaviour
88
Standards-based Solutions
Why Standards?
• They facilitate information exchange; are a critical foundation
for EHR
• They create opportunity for future cost reduction as vendors
and systems converge on pan-Canadian and international
standards
• They ease effort required for replication Infoway’s role
Mandatory Investment Eligibility Requirements
is to set
• Compliance to standards (infostructure, architecture) standards and
• Initiatives must comply with existing guidelines or standards requirements
adopted by Infoway for robust,
• Where standards or guidelines do not exist, projects must
support longer-term interoperability and congruence of
interoperable
solutions products and
outcomes
89
Principles for Establishing Pan-Canadian EHRS Standards
• Infoway has created Principles for Establishing pan-Canadian EHRS

• Standards to provide guidance in the adoption of standards-based solutions
• 11 Principles – accessible via Infoway Knowledge Way
• Business-driven
• Adoption of existing standards where ever possible
• http://knowledge.infoway-inforoute.ca
90
Principles for Establishing Pan-Canadian EHR Standards
• Standards initiatives to be driven by the business of healthcare with a

clearly defined business need
• Existing standards work must be leveraged wherever possible and
practical with an approach that includes adoption, or adaptation of
existing standards, before development
• Health Level 7 V3 messaging standard required for all new message
development related to EHR
• Infoway investments predicated on a commitment to implement
pan-Canadian EHR standards
• Standards to be established, tested, refined and evaluated within the
context of early adopter implementations
• Infoway will support early adopter investment projects that have the
establishment of pan-Canadian standards as their goal
91
Principles for Establishing Pan-Canadian EHR Standards
• Establishing standards is an evolutionary process and will not be

perfect the first time; implementation of standards that are not fully
balloted may be needed
• Infoway is committed to supporting Canada’s leadership role in
influencing EHR international standards
• Infoway will work with other countries undertaking similar EHR
initiatives to leverage their work and bring synergies to the projects as
they move toward internationally balloted standards
• Infoway will partner with CIHI, HL7 Canada, IHE Canada and other
standards organizations in the establishment of pan-Canadian EHR
standards
• Establishment of pan-Canadian EHR standards is coordinated via an
open, transparent and inclusive Stakeholder Collaboration Process as
defined by our stakeholders
92
Standards Collaboration Process (SCP)
• An integral element of and key

GOVERNANCE
requirement for the establishment
EHR Standards Steering Committee
of a pan-Canadian interoperable
Electronic Health Record (EHR)
Pan-Canadian EHR Standards Advisory Committee
•
STRATEGIC COLLABORATION/COORDINATION
The EHR Standards
Collaboration Process includes
those jurisdictions, standards-
related organizations, healthcare PAN-CANADIAN Telehealth
DEVELOPMENT
professionals and vendors that
will build, operate and use an
interoperable EHR Lab
Infostructure/EHR
The EHR Standards Collaboration Interoperable
Expert Working Groups

EHR
Process will establish pan- Diagnostic Imaging
Canadian standards for Infoway
investments through collaboration
Drugs
and consensus
Registries
Infostructure
Pan-Canadian Standards working groups
93
Pan-Canadian EHR Standards: Status
Pan-Canadian Standards Program Projects

Groups
• Drugs • EHRS Blueprint V1
Health Surveillance
• Client Registry • EHR Data Definition & Standards
• Provider Registry • Standards Collaboration Process
• DI/Tele-radiology Telehealth • Standards Tactical Plan
• Laboratory • Artefacts Repository
• Clinical Terminology Lab • Telehealth ISO Interoperability
• iEHR Technical Standards • Telehealth CCHSA Accreditation
(coming soon) Diagnostic Imaging • CeRx (formerly Rx5) HL7 V3 Messaging
• iEHR Clinical Standards • Client Registry
(coming soon) • Provider Registry
Drugs
• Public Health (coming soon) • IRIS (Infoway Reference
Implementation Suite)
Registries • Laboratory Nomenclature & Messaging
• NeCST: electronic claims messaging
Interoperable EHR • EHR Clinical Terminology Integration
• EHR Profiles for Interoperability
between DI, Registries & Consumers
• EHR Blueprint Evolution Project
• Privacy & Security Architecture Project
94
EHR Infostructure: Standards-based Connectivity

HIAL
Architecture Standards Data Messaging Standards

HIAL
HIAL HIAL HIAL HIAL HIAL HIAL

• EHRS Blueprint • Client Registry (in ballot)
HIAL
• EHR Use Cases • Provider Registry iIn ballot)

• EHR Data Model • Pharmacy CeRx (in ballot)
HIAL
• EHR Services Model • Laboratory (in Planning)

HIAL
• EHR Interoperability Profiles • Diagnostic Imaging/Teleradiology (in planning)
• Terminology
HIAL
Standards • iEHR
HIAL
Clinical Messaging (in planning)
• CTI project (underway)
HIAL • iEHR Technical Standards(in planning)
EHR SCP
• Terminology
EHR IP implemented
EHR IP in data
EHR IP • PublicEHR IPHealth ServicesEHR IP Standards EHR IP EHR IP
Standards messaging standards
EHR IP Standards EHR IP Standards EHR IP Standards
• Public EHR IP Standards EHR IP Standards
Health Surveillance Standards
EHR IP Standards EHR IP Standards
POINT OF SERVICE Public Health Pharmacist Radiologist Lab Clinician Physician/ Physician/ Physician/
95
Service-oriented
Architecture (SOA):
What Does It Mean?
96
Level of Encapsulation Can Vary:
Five Normal Forms of Encapsulated Software
External access
1 2 3 4 5
Other data
Own data
Encapsulated software
Programmatic interface
Overloaded, One complete Own data only Exclusive data Opaque data
incomplete; any data function; any data
Source: Gartner
97
SOA as an Enabler
Applications of SOA in EHRi Solutions

• Repurposed legacy applications to offer services as part of
SOA-based EHR Infostructure
• New breed of services to enable coordinated transactions in an EHR
Infostructure (e.g. Longitudinal Record Services)
• Use of commercially available solutions to enable components of
EHR Infostructure
Two Degrees of Separation

• Services exposed outside of an EHRi in the form of supported EHR
Interoperability Profiles for an entire Infostructure perceived as a
single system with transactional services
• Services within an EHR Infostructure to optimize scalability,
maintainability and functional flexibility
98
First Degree: The EHR Service
Registries Data Ancillary Data EHR SERVICE EHR Data Data

Get Outbreak List CD Report
ClientGet Client ID List DI Results Get DI Report
Case Data Events
RegistryResolution Outbreak PHS Shared Drug Diagnostic Health
Laboratory
Provider
Registry List Encounter List Laboratory
Get Provider Results Stream DI Image
Events
Information
Location
List Service
Terminology List Laboratory Orders
Get Laboratory Result
Registry Delivery List Medications
Locations
Get Encounter
Summary
Security Mgmt
Data
Get Clinical Get Client
Get Prescription
Dashboard Demographic Common Services
HIAL
Communication Bus
Radiology
Center EHR Viewer
PACS/RIS

POINT OF SERVICE
99
Second Degree: Inside The EHR Infostructure
Registries Data Ancillary Data

EHRi SERVICES EHR Data Data
& Services
CR & Services & Services Warehouse
Services Detection
Outbreak Shared Health Drug DI Lab
Client & Reporting
Services Record Services Services Services Services
Registry Outbreak Services
PHS Shared Drug Diagnostic Health
Laboratory
PR
Provider
Services
Registry
LR Assembly
Location
Services Business EHR Message Normalization Services
Registry EHR Index
Orchestration Services
Terminology Services
Terminology Rules Longitudinal Record Services Normalization
Registry
Services Services
Services
Security Mgmt
A&A Brokering Consent Session Privacy Data
Logging Configuration
Data
Services Services Services Services Services
Common Services
HIAL
Communication Bus
EHR IP
Any
Point-of-Service
Application
POINT OF SERVICE
100
Functioning Principles
101
Functioning Principles/Rules
• Home/no-home EHR • Level of parameterization

• EHRi Identifier Management • Primary Purpose for EHRi repositories
• EHR Index • Other uses of the HIAL (POS to POS)
• EHRS Locator • Multilingual capabilities
• POS to EHRi interface • Runtime environment
• Level of transparency of EHR to • Performance principles – targets
POS applications • POS Integration environment
• Transaction scope • Error Handling
• Trust Models valid for an EHRi • Consent
• Normalization • Authentication & Authorization
• Auditing, logging, use of logs • OIDS as a principle
• HL7 V3 (Messaging and templates) • Prospective Events
102
Business
Architecture
Clinical
Potential
Work Process
Applications
Architecture
CONTEXT
Integration &
System
Deployment
Architecture
Models
Information
Architecture
103
EHRi Conceptual Data Model
Governance
• High-level model representing

generalized concepts
• Event driven model to represent instances of
clinical service impacting a patient record Role Event Linkage
• Broad range of event typing – governance,
people playing roles, delivery, environment,
resource
Event
• Derived from the Canadian conceptual health
data model (CCHDM)
• Aligned and mapped to HL7 V3 RIM
• Mapped against several local and People Place
international EHR data models – Quebec,
Alberta, Ontario, Australia, etc.
• More detailed views available – transactional Capability
views, domain views
Resource Environment
104
Business
Architecture
Clinical
Potential
Work Process
Applications
Architecture
CONTEXT
Integration &
System
Deployment
Architecture
Models
Information
Architecture
105
HIAL Integration Layer:
Evolutionary Path
106
Interim State: No EHR Services (Undesirable) Each Jurisdiction Infostructure level
system uses patient and other
JURISDICTIONAL INFOSTRUCTURE required strong identifiers (e.g.
provider, encounter) based on
Registries Data EHR Data point-of-service generated IDs
& Services & Services (e.g. MRNs). The CR-EMPI source
systems make the CR-EMPI aware
Drug of client identifiers. The Point-of-
CR API
Client Information Service applications and

Registry System Infostructure systems query the
CR API
Repository
DR API CR EMPI for these identifiers in
order to access data within any
Infostructure System. The level of
queries and maintenance of MRNs
in the EMPI is not scalable to
hundreds or thousands of Point-of-
Service systems. There are
Search/Resolve
HL7 (CR) HL7 v3 (CeRx) performance issues accessing

CR/EMPI for every Drug system
interaction.
Client Registration Pharmacy Profile

1) Search client 4) Request drug profile
2) Create new client 5) Request DUR
3) Update existing client 6) Enter new prescription
PATIENT ENCOUNTER
Client Registration CR API DR API
HL7 v3 (CeRx)
CR API
1) Search client Pharmacy
2) Create new client EHR Viewer
System DR API
3) Update existing client
HL7 (CR)
Pharmacy Profile
4) Request drug profile
5) Request DUR
6) Enter new prescription
Pharmacist Physician
POINT OF SERVICE
107
Interim State: HIAL Without LRS
The Client Registry system
JURISDICTIONAL INFOSTRUCTURE “determines” a global unique ID
(EHR ID) for patients. The Drug
Registries Data Client Registration EHR Data
& Services & Services Informaton System (DIS) will
1) Search client Search/
use the EHR patient ID to store
2) Create new client Resolve
Drug prescribing and dispensing data.
3) Update existing client Get EHR ID
Client Information Point-of-Service applications
HIAL
HIAL
Registry System query the Client Registry and
HL7 v3 (CeRx)
HL7 Repository obtain the EHR patient ID and
(CR) will use this ID as a token
Pharmacy Profile throughout the entire business
4) Request drug profile transaction. This model
5) Request DUR eliminates the need for
Determine 6) Enter new Prescription communication between the
HIAL
EHR Client ID DIS and CR and reduces the

transactions to the CR to one
per business transaction.
Security Mgmt
Data
Common Services
HIAL
Communication Bus
PATIENT ENCOUNTER
Client Registration
1) Search client
2) Create new client HL7 HL7
EHR IP
EHR IP
Pharmacy
3) Update existing client EHR Viewer
System
Pharmacy Profile
5) Request DUR
POINT OF SERVICE
108
Interim State: HIAL Without LRS
The Client Registry determines
Registries Data EHR Data & Services a global unique ID (EHR ID) for
Client Registration
& Services patients. The DIS will use the
1) Search client
2) Create new client EHR patient ID to store
Search/Resolve
3) Update existing client prescribing and dispensing
Get EHR ID
Client data. EHR services will use the
HIAL
Registry Drug CR to map any local MRN found

HL7 HL7 v3 (CeRx)
Information within transactions to the
HIAL
Longitudinal Record Services (CR) System corresponding EHR client ID.
Repository The POS applications do not
Data Access
Business Components necessarily have to be aware of
EHR Pharmacy Profile the EHR client ID or they can
CR API DR API Index
Determine 4) Request drug profile continue to provide this ID
EHR Client ID 5) Request DUR themselves after querying the
6) Enter new Prescription CR (compatible with prior
model).
Security Mgmt
Data
Common Services
HIAL
Communication Bus
PATIENT ENCOUNTER
Client Registration
1) Search client
2) Create new client HL7 HL7
EHR IP
EHR IP
Pharmacy
3) Update existing client EHR Viewer
System
Pharmacy Profile
5) Request DUR
POINT OF SERVICE
109
Target State: Full Featured EHR Infostructure
JURISDICTIONAL INFOSTRUCTURE The client, provider, location
registries and EHR Services
determine (respond with)
global unique ids for patient,
Client providers, encounters and other
Registry Outbreak PHS Shared Drug Diagnostic required strong identifiers.
Health All
Laboratory
Infostructure systems use these
unique IDs to store clinical data
Provider
about a person. The EHR
Registry
Services will map any local ID
to the corresponding EHR ID.
Location The Domain services (DIS,
DI, Lab) systems rely on the
EHR Services to ensure that
Terminology the necessary EHR IDs are
Registry provided with every transaction.
Security Mgmt
Data
Common Services
HIAL
Communication Bus
Radiology
Center EHR Viewer
PACS/RIS

POINT OF SERVICE
110
EHRS Infostructure:
Deployment Models
111
JURISDICTIONAL
Large & Medium Deployment Models
Client Provider Laboratory Drug
REGIONAL/
Registry Registry Repository Repository Larger size Jurisdictions

• Provincial Client and Provider and
REGION 1 REGION 2 Location Registries
• Provincial Lab, Drug Repositories
DI Shared DI Shared and HIAL
Repository Health Record Repository Health Record
• Supra-regional LRS, Shared Health
Record and DI Repositories and
LOCAL/REGIONAL
EHR Viewer
Common Services • EHRS Locator across regions
HAIL
Communication Bus
• Local EMR, CIS and other
EHR applications
CIS EMR CIS EMR
Viewer EHR
Viewer
Client Provider Laboratory Drug

JURISDICTIONAL Registry Registry Repository Repository
Medium size Jurisdictions
REGIONAL/
• Provincial Client and Provider and Location

Registries Shared DI
Health Record Repository
• Provincial Lab, Drug, DI, Shared Health
Record, LRS, HIAL and EHR Viewer
• EHRS Locator across Provinces
Common Services
• Local EMR, CIS and other applications HAIL
Communication Bus
EHR
LOCAL
CIS EMR
Viewer
112
Small Jurisdictions
PROVINCIAL
Client Provider DI
Registry Registry Repository
Shared
Health Record
Drug/Lab
Common Services
HIAL
Communication Bus
LOCAL
CIS EHR Viewer EMR
• Provincial Client, Provider & Location Registry

• integrated hospital CIS solution fulfilling the roles of the Provincial EHR Services, Laboratory and Drug services
• Provincial DI Service
• Provincial HIAL & EHR Viewer
• Local physician office systems & other CIS connect as POS Systems
113
Model 1: Single EHR Infostructure
PROVINCIAL
Registry & Data Services EHR Data & Services
Client Provider Location Terminology Drug

registry Registry registry Registry Information
EHR Data & Services
Shared Diagnostic
Laboratory
Health Record Imaging
Business EHR Message Normalization

Security Mgmt
Data
Common Services
HIAL
Communication Bus
Radiology
Center EHR Viewer
PACS/RIS

POINT OF SERVICE Provider Provider Provider Provider
114
Model 2: Shared EHR Infostructure
PROVINCIAL

REGIONAL REGION 1 REGION 2 …
Shared Diagnostic Shared Diagnostic Shared

Laboratory Laboratory
Health Record Imaging Health Record Imaging Health Record
Business EHR Message Normalization Business EHR Message Normalization

Rules Index Structures Rules Rules Index Structures Rules
Security Mgmt
Data
Common Services
HIAL
Communication Bus
Radiology
Center EHR Viewer
PACS/RIS

115
Model 3: Distributed EHR Infostructures
PROVINCIAL

REGIONAL REGIONAL REGIONAL

EHR Data & Services EHR Data & Services EHR Data & Services
POINT OF POINT OF POINT OF

SERVICE SERVICE SERVICE
Region 1 Region 2 Region X
Least leverage Most leverage
No
No Different
Different Different
Different Specification
Specification Data
Data Business
Business Business
Business User
User Same
Same Use
Use shared
shared
solution
solution specification
specification standards
standards &
& standards
standards model
model process
process rules
rules Interface
Interface solution
solution service
service
Reuse drives down cost, accelerates timelines, reduces risk and enables interoperability
116
Deployment Decisions
Business choices?
PROVINCIAL • Who, where, when, what
• Clinical value
Client Provider Location Terminology • Adoption Drug
Solution development choices?
• Services/functions
EHR Data & Services
• Data persistence
Shared Diagnostic
Health Record • Communication
Imaging standards
Laboratory
• Data standards
• Integration tooling
Business EHR Message Normalization
Rules Index Structures Rules Evolution plan?
Longitudinal Record Services • What functionality when
• EHR Service evolution path
Deployment
Security Mgmt
Data
configuration
Privacy Data choices?
Configuration
Common Services• Provincial vs regional

HIAL
•
Communication Bus Single Solution/many deployments
• Multiple solutions
Radiology
Center EHR Viewer
PACS/RIS

117
Business
Architecture
Clinical
Potential
Work Process
Applications
Architecture
CONTEXT
Integration &
System
Deployment
Architecture
Models
Information
Architecture
118
EHR Infostructure Deployment

Client
Laboratory
Provider
Registry
Location

Registry
Security Mgmt
Data
Common Services
HIAL
Communication Bus
• Strategic planning • Testing (compliance)

• Change management • System implementation
• System development/integration • Education & training
• EHR SCP message development • Operation & maintenance
119
EHRS Data: Value Enabler For Existing Applications
EHR Infostructure (EHRi)
• Client data • Clinical notes

• Provider data • Observations/
• Location data problems/conditions
EHR SOLUTION (EHRS) • Privacy data • Orders/Results data
Ancillary Health EHR Registries
• Security data • Referrals data
Data & Information Data & Data & • Encounter data • Lab data
Services Data Services Services
Warehouse • Blood/allergy/ • Pharmacy data
HIAL
immunization data • Diagnostic Imaging
• Encounter summaries data
EHR SCP EHR SCP EHR SCP EHR SCP EHR SCP
Standards Standards Standards Standards Standards
ADT CDR PMS Rx Lab DI
Data loading Enhanced Enhanced Chronic Disease Health Education Custom projects
Data feeds presentation presentation Health Prevention Data Mining
Initial data load/ Hospitals/private clinics/

Laboratories/pharmacy / Self-care Research/surveillance
data feeds/integration emergency/homecare/specialty
diagnostics
of systems centers/LT care
120
End-User Perspective: EHR Viewer

Client
Laboratory
Provider
Registry
Location

Registry
Security Mgmt
Data
Common Services
HIAL
Communication Bus
Patient End-user
Visit Drug
History Profile
Diagnostic
Laboratory
Imaging Physician/
Provider
POINT OF SERVICE
EHR VIEWER
121
End-User Perspective: EMR Application

Client
Laboratory
Provider
Registry
Location

Registry
Security Mgmt
Data
Common Services
HIAL
Communication Bus
Patient End-user Physician

Info Info Office EMR
Patient Drug
EMR History Profile
Database
Diagnostic
Laboratory
Imaging Physician/
Provider
POINT OF SERVICE
EMR APPLICATION
122
EHRS Data: Enables New Classes of Applications
EHR Infostructure (EHRi)
• Client data • Clinical notes

• Provider data • Observations/
• Location data problems/conditions
EHR SOLUTION (EHRS) • Privacy data • Orders/Results data
• Security data • Referrals data
Health
Ancillary EHR Registries • Encounter data • Lab data
Information
Data & Data & Data & • Blood/allergy/ • Pharmacy data
Data
Services Services Services immunization data • Diagnostic Imaging
Warehouse
• Encounter summaries data
EHR SCP EHR SCP EHR SCP EHR SCP

Standards Standards Standards Standards
? ? ? ? ? ? ? ? ?
Decision support Automated workflow

The Helper Drug interactions New applications Custom projects
The Mentor Abnormal results Patient monitoring Data mining
Patients
123
Deployment Configurations:
COTS-based Solutions
124
COTS: CIS with Integrated Viewer
Registries Data Ancillary Data EHR Data

& Services & Services & Services
HIAL
Client
Registry PHS Drug
Outbreak Diagnostic
Reporting Information
Services Imaging
Services System
HIAL
Provider
Registry HIAL HIAL
HIAL
Location CLINICAL INFORMATION SYSTEM

Registry
EAI Shared Laboratory

HIAL
Terminology Health Record

Registry Consent Management
Interoperability General
Laboratory Shared Health Record
Integration Subscription
Authentication/Acess Control
Context Management Longitudinal Record Services
Auditing/Logging Communication Bus
EHR Viewer Server
EHR IP Transactions: Get, Put, List; Pan-Canadian

EHR Standards
Radiology
Public Health Pharmacy Lab System Hospital, LTC, Physician EHR Viewer
Center
Services System (LIS) CCC, EPR Office EMR Client
PACS/RIS
POINT OF SERVICE
125
COTS: CIS with External Viewer

HIAL
Client
Registry PHS Drug
Outbreak Diagnostic
Services Imaging
Services System
HIAL
Provider
Registry HIAL HIAL
HIAL
Location CLINICAL INFORMATION SYSTEM

Registry
EAI
HIAL
Terminology Shared Laboratory

Registry Consent Management Health Record
Integration Subscription Laboratory Shared Health Record
Context Management

EHR Standards
Radiology
Center
PACS/RIS
POINT OF SERVICE
126
COTS Based: EAI Centric

HIAL
Client CIS:
Registry PHS Drug
Outbreak Shared Health Diagnostic
Services Record & Imaging
Services System
Laboratory
HIAL
Provider
Registry HIAL HIAL HIAL
HIAL
Location
Registry
EAI
HIAL
Terminology
Registry Consent Management
Integration Subscription
Context Management

EHR Standards
Radiology
Center
PACS/RIS
POINT OF SERVICE
127
EHRS Blueprint: In Summary
128
EHRS Blueprint As Design Pattern & Standard
Provides specifications for provider

organizations & the vendor community
to design and develop:
• EHR infostructure
• Interfaces to allow existing systems to
interoperate using EHR infostructure
• New applications that take advantage of the
EHR infostructure to provide added value to
service providers, patients; to promote
wellness of Canadians
Provides design pattern & set of
standardized specifications that:
• Provide flexibility to meet the variety found in
existing service delivery settings while
providing an ability for jurisdictions to evolve
their solution set, leveraging their current
investments in systems
• Allowing the managed addition of contributors
to and users of Electronic Health Records
129
From Concept to Implementation
Infoway’s interoperable EHR The second vehicle for This process will be the
investment program provides testing and refining the test-bed for the EHRS
the primary vehicle for Blueprint specifications is Blueprints specifications
transitioning the Blueprint from adoption by the vendor • Elements of the EHRS Blueprint
community and acquisitions specifications will be updated by
architecture to working
of “interoperable ready” these project teams as the concepts
components through: applications are tested and refined
• partnering with jurisdictions ready
• Major vendors have • Implementation guidelines will be
to build interoperability between
incorporated the Infoway produced to assist others in
existing systems
architectural approach into implementing these capabilities
• jurisdictions ready to incorporate their product strategies
their registries and domain • The Blueprint can provide the
repositories
framework for jurisdictions to
evaluate vendor provided
solutions and ensure they will
work with their evolving EHR
infostructures
CONCEPT IMPLEMENTATION
130
Maintaining the Blueprint as a
Pan-Canadian Standard
• Infoway understands the importance of having a

stable, managed specification for interoperability
• Jurisdictions and provider organizations need to be
confident that their commitment to implementing EHR
infostructure is based on a sound specification that
will be maintained and managed
• Implementations of the infostructure will reveal where
the specification needs to be adjusted to optimize
performance and ensure reliability
• For this reason, the EHRS Blueprint specifications
will be subject to the pan-Canadian Standards
Collaboration Process established by Infoway
• Ensuring pan-Canadian participation in
requirements definition
• Providing foreknowledge of the financial and change
management requirements to all affected groups
and organizations
• Providing a scope and change-management model
for the Blueprint specifications themselves
131
The Architecture In Summary: EHR Repository
Concepts Benefits
• Patient’s data is stored and accessed • Interoperability, performance, scalability
from one logical EHR • Provider adoption, supports use cases
• Patient’s longitudinal clinically relevant across continuum of care, timely and
information, authoritative & reliable accurate for provider
• EHR co-exists with provincial • Preserves investments, does not
domain repositories unnecessarily duplicate data
• EHR may be implemented at any • Flexibility, configurable to local &
jurisdictional level provincial needs
• EHR has a common definition • Cost effective, standards-based,
across Canada Interoperability
132
The Architecture In Summary: HIAL
Concepts Benefits
• HIAL (Health Information Access Layer) • Common and standards based is most cost
provides common way to interoperate with effective, secure & private; applications
EHR, registries, domain repositories focus on clinical logic vs. integration logic
• Provider applications interoperate through • Cost effective environment for broad set of
HIAL to access EHRS provider applications, standards based
• Provides peer-to-peer trusted integration
communication and value-added common • Secure & private, efficient, scalable, cost
services to enable interoperability across effective and standard runtime
the continuum of care and across environment, responsive
jurisdictions
133
The Architecture In Summary: EHRi
Concepts Benefits
• Common standards will enable integration • Reduces design, development, test &
& interoperability operational costs
• Standard message data protocol for • True interoperability, international standard
external communications is HL7 V3 will incent vendors
• Registries have common definition • Interoperability, cost, security & privacy
across Canada
134
The Architecture In Summary: Applications
Concepts Benefits
• Messages initiated by point-of-care • Low cost and common model of integration,
applications populate EHR with clinical secure and private, scalable, extensible,
data preserves current investments
• Provider applications read data out of • Mass customized views of data tailored to
the EHR via the HIAL in addition to provider needs, secure and private,
their operational data stores scalable, authoritative, reliable, responsive
• Use cases, business rules and • Vendors compete and innovate, extensible,
visualization of data is a function of the value added services for providers
point-of-care application
135
Thank you!
Website: infoway-inforoute.ca
E-mail: rparker@infoway-inforoute.ca
136

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EHRS Blueprint Presentation

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Infoway Architecture Update

EHRS Blueprint Scope

Clinical/Work Process Architecture

Integration & Deployment Options

Summary & Conclusion

End User Adoption & Innovation & Adoption

The Electronic Health Interoperable EHR

Drug Laboratory Diagnostic

Cross Program Client, Provider & Location Registries

EHRS BLUEPRINT V1.0 ADDRESSED BUSINESS CONTEXT

WORK PROCESS INFORMATION SYSTEM TECHNOLOGY

Logical Blueprint V2 Blueprint V2 Blueprint V2

EHR Implementations across Canada

Planning & Provides $

Planning & Tax

IT spending as a % of total expenditures

Worldwide Health Providers 4.2

Pulp & Paper 1.6

Canadian Healthcare 1.4

Food & Bev 1.2

Canadian IT budgets as a % of total

The Old World The New World

The changes in healthcare require

WILL CONVERGENCE CAPACITY

EHR SOLUTION (EHRS)

EHR INFOSTRUCTURE (EHRi)

Ancillary Health EHR Registries

Longitudinal Record Services

Health Information Access Layer

Point of Service Point of Service

EHR INFOSTRUCTURE (EHRi) EHR INFOSTRUCTURE (EHRi)

Longitudinal Record Services Longitudinal Record Services

Health Information Access Layer Health Information Access Layer

Point of Point of Point of Point of

EHRS EHRS EHRS EHRS EHRS EHRS EHRS

Registries Data Ancillary Data EHR Data Data

Terminology Longitudinal Record Services

Public Health Pharmacist Radiologist Lab Clinician Physician/ Physician/ Physician/

• Patient-centric • Leverage legacy systems & solutions

• Timely, accurate information • Scalable

• Enable sharing at local, regional, • Extensible to support future growth

EHR INFOSTRUCTURE (EHRi) EHR INFOSTRUCTURE (EHRi)

Longitudinal Record Services Longitudinal Record Services

Health Information Access Layer Health Information Access Layer

Point of Service Poin of Service Point of Service Point of Service

Community Care Emergency Community Care Emergency

Specialist Pharmacy Specialist Pharmacy

Hospital Laboratory Hospital Laboratory

• Focuses on managing health status of populations

New services required to support:

• Public Health Alert Management

• Communicable Disease Case Management

Some Public Health business requirements can be sustained by the

Public Health Surveillance Portal

Pharmacist Radiologist Lab Clinician Physician/ Physician/ Physician/

• Telehealth: the use of information & communication technologies to deliver health

Tele-consultations Tele-education Tele-homecare Tele-triage

Videoconferencing Videoconferencing Active or passive Centralized call centers

Registries Data Ancillary Data EHR Data Data

Terminology Longitudinal Record Services

Patient End-user Referring Attending

Longitudinal Record Services Longitudinal Record Services

Health Information Access Layer Health Information Access Layer

Longitudinal Record Services Longitudinal Record Services