Transcript D3_Koff_en

DICOM INTERNATIONAL
CONFERENCE & SEMINAR
April 8-10, 2008
Chengdu, China
The Canadian Electronic
Health Records Strategy for
Better Care Delivery
David A. Koff MD
McMaster University, Hamilton
ZHE FENG MD
Sunnybrook Health Science Centre, Toronto
Geographic Specificities
Average distance
that people have to
travel to reach the
nearest specialist
living in the same
province or
territory.
Specialists tend to
be found in urban
areas.
Rural and northern
residents must
travel considerable
distances to see
specialists.
> 100 km
Definitions
• Telehealth is the use of communications and
information technology for clinical care, education
and healthcare services at a distance.
• Telemedicine is the use of communication and
information technologies to provide or support
clinical care at a distance.
• Teleradiology is the electronic transmission of
diagnostic imaging studies from one location to
another for the purposes of interpretation and/or
consultation.
• Teleradiology represents 90% of telemedicine
activity.
• More and more telehealth transactions include
transmission of images.
Numerous projects
• All Provinces and
Territories involved in
Telehealth.
• Over 100 active
telehealth programs.
• Many of those
programs have to
include medical
images.
• Heterogeneous
networks and multivendor programs and
telecommunications
services.
A few examples
• Health Infostructure Atlantic Project
– Interprovincial Integration of Images and
Information (TELE-i4)
– Images shared within the 4 Atlantic Provinces
• North Network
– 80 sites through northern and central Ontario
• Alberta Wellnet
– Integrated system-wide health information
– Provincial PACS project.
Electronic Health Record
• Canada is
focusing its
efforts in
improving
healthcare by
implementing
an interoperable
electronic
health records.
What is an EHR ?
• An electronic health record provides each
individual in Canada with a secure and private
lifetime record of their health history.
• Electronic health record systems provide
authorized healthcare professionals with rapid
access to patient information anywhere anytime.
• Today, only 9% of Canadians have an electronic
health record.
Canada Health Infoway
• Canada Health Infoway
– Launched mid-2001, Infoway is an independent
federally funded agency that works with the 10
provinces and 3 territories to invest in electronic
health records projects.
• Mission
– To foster and accelerate the development and
adoption of electronic health information systems
to have an interoperable EHR in place across 50
percent of Canada by the end of 2009 and all
Canadians covered by 2016.
Canada Health Infoway
• Infoway acts as a strategic investor:
– invests with partners and funds 50% or more of
the cost of a project;
– is involved in project planning;
– monitors progress of projects and quality of
deliverables: gated strategy links reimbursement
to achievement of milestones.
Infoway’s Investment Programs
End-user
Adoption and
Setting the Future
Direction
Innovation & Adoption - $60m
The Electronic
Health Record
Domain
Repositories and
Healthcare
Applications
Interoperable EHR - $175m
Drug
Information
Systems
$185m
Laboratory
Information
Systems
$150m
Diagnostic
Imaging
Systems
$310
Public
Health
Systems
$100m
Telehealth
$150m
Cross Program
Components
Client, Provider and Location Registries - $135m
Architecture and
Standards
Infostructure - $25m
Infostructure
End-user
Adoption and
Setting the Future
Direction
Innovation & Adoption - $60m
The Electronic
Health Record
Domain
Repositories and
Healthcare
Applications
Interoperable EHR - $175m
Drug
Information
Systems
$185m
Laboratory
Information
Systems
$150m
Diagnostic
Imaging
Systems
$310
Public
Health
Systems
$100m
Telehealth
$150m
Cross Program
Components
Client, Provider and Location Registries - $135m
Architecture and
Standards
Infostructure - $25m
Infostructure
• Development of common solution architecture
and standards to ensure interoperability of
EHR.
• Provide to hospitals and vendors the
business and technical guidelines:
– Toolkits: technical and business knowledge (case
studies, templates, plans, reports, etc…)
– EHRS Blueprint, including the Privacy and Security
requirements.
The Use of Standards
•
Teleradiology
– Standards and Guidelines for Teleradiology - CAR
– ACR Technical Standards for Teleradiology - ACR
•
Integration
– IHE (Integrating the Healthcare Enterprise)
•
Diagnostic Imaging Data
–
–
–
–
•
DICOM
JPEG and JPEG 2000
TIFF
BMP
Electronic Health Information
– HL7 v3
– CCR (Continuity of Care Record) - ASTM International
•
Multimedia Conferencing
– ITU-T H.323/H.320 for video and audio
– ITU-T T.120 for data
The Use of Standards
• Launched in 2006, the Standards
Collaborative is a new Canada-wide
coordination structure created to support
and sustain health information standards in
Canada.
• Housed at Infoway, the Standards
Collaborative will be responsible for the
implementation, support, education,
conformance, and maintenance for EHR
standards currently being developed by
Infoway.
The Use of Standards
• The Standards Collaborative also
encompasses several standards initiatives
formerly managed by the Canadian Institute
for Health Information (CIHI):
– Partnership for Health Information Standards,
– HL7 Canada,
– Canada's participation in DICOM (Digital Imaging and
Communications in Medicine) and,
– in conjunction with the Canadian Standards
Association (CSA), the secretariat to the Canadian
Advisory Committee to ISO/TC 215.
Client, Provider and Location
Registries
End-user
Adoption and
Setting the Future
Direction
Innovation & Adoption - $60m
The Electronic
Health Record
Domain
Repositories and
Healthcare
Applications
Interoperable EHR - $175m
Drug
Information
Systems
$185m
Laboratory
Information
Systems
$150m
Diagnostic
Imaging
Systems
$310
Public
Health
Systems
$100m
Telehealth
$150m
Cross Program
Components
Client, Provider and Location Registries - $135m
Architecture and
Standards
Infostructure - $25m
Client, Provider and Location
Registries
• Answers to the need to accurately
identify patients, health professionals
and healthcare facilities:
– Client Registries: contain patient health
identification number and demographic
information.
– Provider Registry: identification of doctors,
pharmacists, dentists, nurses, etc…
– Service Delivery Location Registry: hospital,
clinics, physician offices.
Drug Information Systems
End-user
Adoption and
Setting the Future
Direction
Innovation & Adoption - $60m
The Electronic
Health Record
Domain
Repositories and
Healthcare
Applications
Interoperable EHR - $175m
Drug
Information
Systems
$185m
Laboratory
Information
Systems
$150m
Diagnostic
Imaging
Systems
$310
Public
Health
Systems
$100m
Telehealth
$150m
Cross Program
Components
Client, Provider and Location Registries - $135m
Architecture and
Standards
Infostructure - $25m
Drug Information Systems
• All data concerning a patient’s medication
history: prescribed and dispensed drugs,
allergies, ongoing drug treatment.
• Drug and drug-interaction checks performed
automatically and added to the patients' drug
profiles in their Electronic Health Record
(EHR).
• Provide physicians and pharmacists with
data to support appropriate and accurate
prescribing and dispensing.
Laboratory Information Systems
End-user
Adoption and
Setting the Future
Direction
Innovation & Adoption - $60m
The Electronic
Health Record
Domain
Repositories and
Healthcare
Applications
Interoperable EHR - $175m
Drug
Information
Systems
$185m
Laboratory
Information
Systems
$150m
Diagnostic
Imaging
Systems
$310
Public
Health
Systems
$100m
Telehealth
$150m
Cross Program
Components
Client, Provider and Location Registries - $135m
Architecture and
Standards
Infostructure - $25m
Laboratory Information Systems
• To allow clinicians to view laboratory
results and reports from all hospital,
community and public health
laboratories.
• The results will be linked to patients'
Electronic Health Records (EHR).
Diagnostic Imaging Systems
End-user
Adoption and
Setting the Future
Direction
Innovation & Adoption - $60m
The Electronic
Health Record
Domain
Repositories and
Healthcare
Applications
Interoperable EHR - $175m
Drug
Information
Systems
$185m
Laboratory
Information
Systems
$150m
Diagnostic
Imaging
Systems
$310
Public
Health
Systems
$100m
Telehealth
$150m
Cross Program
Components
Client, Provider and Location Registries - $135m
Architecture and
Standards
Infostructure - $25m
Diagnostic Imaging Systems
Digital Image Repositories
• Electronic distribution of DI results to all
facilities, referring community physicians
and specialists over reliable networks
(all studies, any time, any where).
• Shared DI Repository scaleable to 1.5
million studies/year (single/multi
jurisdiction or large regions) integrated
with IHE-compliant RIS solution(s).
Repository Current Status
22 shared PACS/Archive Solutions (DI-r)
Target
Planning
Implementation
Completed
Benefits of DI-r
• Patient impact
– Improve report turnaround time
– Reduction in duplicate exams ($132M/year in Ontario)
– Reduction in patient transfers
• Resources impact
– Improve radiologist productivity by 25-28%
– Improve technologist productivity by 10-12%
– Improve clinician productivity
Benefits of DI-r
• Cost impact
– Reduction in film related costs (3.2-4 B$)
– Reduction in stand alone versus shared PACS
system: savings estimated at 40%.
• For the healthcare system
– Overall cost $7.4 Billion but delivers $9.1
Billion in benefits over 10 years.
Diagnostic Imaging Systems
• Filmless working environment for all
procedure types
(CT, MR, X-Ray, ultra-sound, etc.)
• Implementation of IHE profiles and EHR
interoperability specifications (HL7/DICOM
standards for image acquisition and report
creation)
• Use of optimal compression strategies for
digital images.
IHE Profiles
Use of a shared XDS infrastructure to access Radiology
Reports and Images: development of XDS-I and related
tools by IHE-Canada.
Between Radiology and :
• Imaging specialists
• Non-imaging clinicians
Hospital
PACS Y
Radiology -toRadiology
Radiology -toPhysicians
Physician Practice
PACS Z
Imaging Center
Image Compression
Storage volume …
• Even if the cost of storage is dropping, the
savings are largely surpassed by the
increasing amount of data.
• The cost of operation remains high.
• 40 million diagnostic imaging exams are
performed annually in Canada.
• With an average legal retention period of 7
years upon provincial regulations.
• Use of irreversible compression at 10:1
could save M$100 million per year.
Image Compression
… and transmission times
• and if access to high bandwidth gets more
available in local hospital networks, it is
still premature to expect any health
professional to use 100 mbps connections
on their computers.
• EHR networks cannot support large
medical images and timely access to
diagnostic images requires adequate level
of compression.
Image Compression
• The Canadian Association of Radiologists
PACS/Teleradiology committee has
accepted the principle of irreversible
(“lossy”) compression for use in primary
diagnosis and clinical review, using DICOM
JPEG or JPEG-2000 compression
algorithms, at specific compression ratios
set by image type.
• Adoption conditional to the results of a
large scale evaluation study.
Image Compression
• This study has been performed at
Sunnybrook, supported by a grant from
Canada Health Infoway.
• Prior to that, CHI had commissioned 2
literature reviews and 2 legal assessments.
• Radiologists have been enrolled from 9 out
of 10 Canadian Provinces.
Methodology
Based on previous studies, our
evaluation resulted from the
association of 2 accepted methods:
– Objective measurement of diagnostic
accuracy with ROC analysis
– Subjective image comparison with
original-revealed forced choice (JND)
Methodology
• 3 readers per session, 23 sessions,
more than 100 readers in total from all
across Canada.
• Had to read the images on the DICOM
compliant, calibrated workstation they
use in their daily activity.
• The workstation had to be connected to
the Internet ideally.
• The answers were filled on-line and
directly transferred to our server.
Diagnostic Accuracy
GROUND GLASS OPACITY
Comparison side-by-side
JPEG 2000 15:1
ORIGINAL
Examples
JPEG 2000 20:1
ORIGINAL
PNEUMOTHORAX
Examples
JPEG 2000 25:1
ORIGINAL
CALCIFICATIONS
Results
For 18 anatomical regions/modalities, there was no
difference noted, but discrepancies were noted in 3
occurrences.
CR/DR
Angio
Body
Breast
Chest
MSK
Neuro
Pediatrics
x
x
x
x
x
CT
x
x
x
x
x
x
US
x
x
x
x
MR
x
x
x
x
x
x
NM
x
x
Results
% of Pathologies Correctly
Identified
The Effect of Compression on Sensitivity of CR
MSK Images
100
90
80
70
60
50
40
30
20
10
0
J200020
J200025
J200030
JPEG20
JPEG25
JPEG30
RAW
Results
The Effect of Compression on Subjective Assessment of CT
Body Images
No difference
Just noticeable
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Conspicious
Intermediate
Significant
U
nc
o
m
p
-1
5
JP
EG
-1
2
JP
EG
-1
0
JP
EG
5
J2
K
-1
2
-1
K
J2
J2
K
-1
0
Unacceptable
Results
The Effect of Compression on Subjective Assessment of
CT Neurological Images
No difference
Just noticeable
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Conspicious
Intermediate
Significant
Unacceptable
J2K
-8
J2K
-10
J2K
-12
JPEG
-8
JPEG
-10
JPEG
-12
Uncomp
J2K vs. JPG
J2K 15:1
Noticeable degradation
JPEG 15:1
No noticeable degradation
Difference in performance is due to the fact that JPEG 2000 has good spatial resolution
and discards the low energy high-frequency coefficients during quantization.
Recommendations
• Lossy compression can be used at
the lowest levels of compression
tested, as there was no significant
loss of diagnostic information at
those levels.
• No difference between Lossy JPEG
and JPEG 2000 at the lowest levels of
compression.
Results: recommended values
CR/DR
Angio
Body
CT
10-15
20-30
JPEG 10-15
J2K 10
Breast
Chest
20-30
10-15
MSK
JPEG 20-30
J2K 20
10-15
Neuro
Ped
US
10-15
NM
MG
16-24
8-12
16-24
8-12
16-24
8-12
16-24
JPEG 8-12
J2K 8
20-30
MR
9-11
15-25
16-24
8-12
16-24
9-11
45
Public Health Systems
End-user
Adoption and
Setting the Future
Direction
Innovation & Adoption - $60m
The Electronic
Health Record
Domain
Repositories and
Healthcare
Applications
Interoperable EHR - $175m
Drug
Information
Systems
$185m
Laboratory
Information
Systems
$150m
Diagnostic
Imaging
Systems
$310
Public
Health
Systems
$100m
Telehealth
$150m
Cross Program
Components
Client, Provider and Location Registries - $135m
Architecture and
Standards
Infostructure - $25m
Public Health Systems
• Solutions that support the identification,
management and control of infectious disease cases
and outbreaks that pose a threat to the public's
health.
• In March 2004, taking into account the lessons
learned from the SARS outbreak and public concern
about the ability of public health authorities to deal
with emerging communicable disease threats, the
federal government assigned Infoway the task of
developing a communicable disease surveillance
system in partnership with the provinces and
territories.
Telehealth
End-user
Adoption and
Setting the Future
Direction
Innovation & Adoption - $60m
The Electronic
Health Record
Domain
Repositories and
Healthcare
Applications
Interoperable EHR - $175m
Drug
Information
Systems
$185m
Laboratory
Information
Systems
$150m
Diagnostic
Imaging
Systems
$310
Public
Health
Systems
$100m
Telehealth
$150m
Cross Program
Components
Client, Provider and Location Registries - $135m
Architecture and
Standards
Infostructure - $25m
Telehealth
• Electronic solutions that facilitate the
delivery of health information and services
between patients and providers regardless of
distance.
• Multiple projects based on:
– Geographic (tele-education, home healthcare,…)
– Cultural (First Nations, language minorities)
– Clinical (post cardiac surgery, wound care assistance,
telepsychiatry…)
– Management Models as well as Technology and
Standards
Interoperable EHR
End-user
Adoption and
Setting the Future
Direction
Innovation & Adoption - $60m
The Electronic
Health Record
Domain
Repositories and
Healthcare
Applications
Interoperable EHR - $175m
Drug
Information
Systems
$185m
Laboratory
Information
Systems
$150m
Diagnostic
Imaging
Systems
$310
Public
Health
Systems
$100m
Telehealth
$150m
Cross Program
Components
Client, Provider and Location Registries - $135m
Architecture and
Standards
Infostructure - $25m
Interoperable EHR
• Implementation of solutions that allow clinicians to
view and update an integrated patient-centric health
record anywhere at any time.
• Supports EHR initiatives that demonstrate value and
benefits in a specific health practice domain
integrating information across multiple points of
service and multiple caregivers.
• Commercially available integrated EHR solutions will
be deployed regionally or supra-regionally to
demonstrate interoperability, scalability and
replicability.
Innovation & Adoption
End-user
Adoption and
Setting the Future
Direction
Innovation & Adoption - $60m
The Electronic
Health Record
Domain
Repositories and
Healthcare
Applications
Interoperable EHR - $175m
Drug
Information
Systems
$185m
Laboratory
Information
Systems
$150m
Diagnostic
Imaging
Systems
$310
Public
Health
Systems
$100m
Telehealth
$150m
Cross Program
Components
Client, Provider and Location Registries - $135m
Architecture and
Standards
Infostructure - $25m
Innovation & Adoption
• Infoway supports initiatives that bring
clinical value and optimize the use of
EHR:
– Knowledge portals
– Evidence-based medicine
– Computerized physician order entry and
clinical decision support systems.
– Disease management solutions.
Conclusion
• Canada started late in the
implementation of a nationwide
Electronic Health Record, but has
developed a tremendous effort to get
50% of the population covered by end
of 2010 through a number of initiatives
supported by Canada Health Infoway.
• We’ll do our best to reach this goal.
Conclusion
Thank you.