P3s and the EHR a case study

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P3s and the EHR a case study
D Ostrow Oct 2002
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Principles for the P3 relationship

• 1. Public sector does not have the large capital
  investments needed to achieve our goals
• 2. We can be expected to pay over time (turning
  our IMIS investments into utilities)
• 3. We need to work together to define the areas
  in which it makes sense for the private sector to
  invest
• 4. The private sector must be successful for the
  public sector to be successful
• 5. The ROI that is achieved is not in the area of
  one HA but across the health sector
• 6. We are driven by ROPS as much as ROI
• 7. Investments must therefore be made
  systemically as well as locally

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Case Study

• The VCHA Regional EHR Strategy

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Role of the VCHA
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VCHA - some key metrics

• Acute Beds
• Rehabilitation Beds
• Extended care beds
• ORs
• Physicians
• Staff
• Budget
• Desktops
• E-mail addresses
• Telephones
• Pagers
• IS Operating Budget
• IS Operations as of total

2,200 200 7,900 58(69) 3,200 22,000 1.9B
9,000 10,000 16,000 4,700 50M 2.6
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Current CIS status
Functional, current release
Upgrade required immediately
Upgrade required
Richmond
Vancouver
North Shore
Coast Garibaldi
RH
VHHSC
PHC
LGH
PRGH etc.
Acute
Hospital IS
IDX LastWord
McKesson STAR
Meditech
CCD
Health Vision
Eclipsys SCM
HealthVision ADT
Pharmacy
BDM
IDX LastWord
BDM
McKesson STAR
Meditech
CCD
Radiology
IDXrad
GE ProgRIS
McKesson STAR
Meditech
CCD
LabVision
Misys Lab/CoPath
Laboratory
McKesson STAR
Lab Vision
Meditech
CCD
PACS
Agfa
Agfa
eFilm
Perioperative
ESI Orbit
GE ORMIS
Per Se ORSOS
GE ORMIS
Med. dispensing
Pyxis
Abstract./encod.
3M
3M
3M
ClinTrac/SoftMed
Med 20/20
3M
Telehealth
For Cranbrook Terrace
Community
Comm. health
In4tek PARIS
Procura
Mental health
Synapse
Env. health
Hedgehog
Various
HealthSpace
Abstract./encod.
Access
Infrastructure
Networks etc.
Network issues
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Proposed CIS implementations
Richmond
Vancouver
North Shore
Coast Garibaldi
RH
VHHSC
PHC
LGH
PRGH etc.
Acute
Hospital IS
IDX CareCast
McKesson STAR
Meditech
CCD
Eclipsys SCM
HealthVision ADT
Pharmacy
BDM
IDX CareCast
McKesson STAR
Meditech
CCD
BDM
Radiology
IDXrad
McKesson STAR
GE ProgRIS
Meditech
CCD
Misys Lab/CoPath
Laboratory
McKesson STAR
Lab Vision
Meditech
CCD
PACS
Agfa
eFilm
Perioperative
GE ORMIS
Med. dispensing
Pyxis (add VH)
Abstract./encod.
3M
Telehealth
Community
Comm. health
In4tek PARIS
Procura
Mental health
Synapse
Env. health
Hedgehog
HealthSpace
Abstract./encod.
3M
Infrastructure
Networks etc.
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Caregiver roles and the EHR
Caregiver-patient/client relationship
Ongoing care relationship (family practitioners)
Planned care
Periodic care relationship (specialists,
surgeons, out-patient clinics, community care)
Periodic care
Emergent care relationship (emergency
departments, walk-in clinics, paramedics)
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Two approaches to the EHR
Family practitioner
1. EPR-to-EPR data exchange

• Information requirements are supported through
  the electronic exchange of information between
  EPRs
• This is a "B2B" (business to business) model as
  practiced in other industries
• A "B2B hub" (as contrasted with point-to-point
  interfaces throughout) is an important component
  of a well-designed EPR-to-EPR architecture

EPR
Specialist
EPR
Pharmacy
EPR
EPR
Lab
EPR
EPR
Hospital
Community care
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Two approaches to the EHR
Hospital
EPR
2. The External EHR
Community care

• The EHR is supported by a (preferably virtual)
  service that is external to the caregiver's EPR
• Provides integrated access to clinical
  information drawn from EPR's across the continuum
  of care
• Various integration architectures are possible
  (more later)
• Does not require the caregiver to have an EPR

EPR
Mental health
Care provider
EPR
External EHR
Lab
EPR
Radiology
EPR
EPR
or
Pharmacy
Paper chart
EPR
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EHR architectures and caregiver roles
Ongoing care relationship (family practitioners)
Periodic care relationship (specialists,
surgeons, out-patient clinics, community care)
Emergent care relationship (emergency
departments, walk-in clinics, paramedics)
For caregivers without EPRs
Extermal EHR
For caregivers with EPRs
EPR-to-EPR data exchange

• External EHR has the potential to support all
  caregivers needs to some extent
• EPR-to-EPR approach supports only some types of
  caregivers
• In the long term, clearly both architectures will
  be needed
• In the shorter term, in the VCHA, the highest
  clinical value can be obtained more quickly from
  an external EHR approach

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What external EHR integration architectures are
possible?
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External EHR integration architecture

• Given the realities of EPR implementations today
  in BC, none of these architectures can by
  themselves solve the problem
• the external EHR solution will use elements of
  all four architectures
• Several of these approaches already being used in
  VCHA and BC
• IDX LastWord at VHHSC
• active data integration - provides an integrated
  data repository which supports core hospital
  system functionality across four sites
• replicated data integration - receives and
  integrates data from laboratory, radiology and
  transcription systems
• The in4tek PARIS community health system
• active data integration supporting community care
  workers across Vancouver and Richmond, and
  eventually all of the VCHA
• PathNET private laboratory results service
• replicated data integration - pulls together data
  from MDS Metro and BC Bio
• PharmaNet
• active data integration - stores data on
  medications dispensed in all community and
  out-patient pharmacies in a single provincial
  database

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External EHR integration architecture
Authorization Service
Authentication Service
Audit Service
Hospital systems
Provider Service
Facility/ Location Service
Client Service
Consent Service
Org. Service
Clinical Event Service
Community systems
Care provider
Mental health systems
EHR Integration Service
Private lab systems
Active data integration
Replicated data integration
Private radiology systems
Standards-based visual integration
Clinical portal
Pharmacy systems
Physician systems
Secure network infrastructure
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CareConnect - stages of evolutionStage 1
Synapse
Care provider
Community mental health
in4tek PARIS
eFilm
Hospital diagnostic images
Agfa PACS
Within VCHA
Authentication Service(tbd)
Client Registry
Meditech
Hospital information systems (VCHA)
McKesson
Eclipsys
Provider Registry
Audit Service (Sentillion)
IDX
CCOW - standards-based visual integration
BCCA document management and simple hospital
encounter index
Consent Service
etc.

• Key infrastructure pieces
• CCOW middleware
• BCCA document management and simple hospital
  encounter index
• Client Registry (as-is)
• secure remote access - two-factor authentication
  and encryption

Hospital information systems (other HAs)
Meditech
Cerner
External to VCHA
PathNET (lab reform?)
Labs
PharmaNet
Pharmacy
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CareConnect Phase 1 Desktop
User P12345
IDX LastWord
Hospital EPR
EHR - lab results
PathNET
EHR - medications
Blaise Pascal - pascalblaise30071958
MediNet PharmaNet
CareDocs
i407js Dr. John Smith
Blaise J. Pascal - PHN 984503931
Client Registry
Patient name Blaise Pascal PHN 984503931 Date
of birth 1 February 1958 Age 43 Sex M
User jsmith1
CareDocs Core hospital documents
Recent hospital visits
Discharge summaries
Operative reports
01 Mar 2002 17 Dec 2001 21 Jun 2001 15 Jun
2001 06 Mar 2001
St. Pauls Hospital Royal Columbian Hospital UBC
Hospital Vancouver General Hospital UBC Hospital
EHR - hospital encounter index and core hospital
documents
Consult reports
Radiology reports
CareDocs
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CareConnect - stages of evolutionStage 1
Synapse
Care provider
Community mental health
in4tek PARIS
eFilm
Hospital diagnostic images
Agfa PACS
Within VCHA
Authentication Service(tbd)
Client Registry
Meditech
Hospital information systems (VCHA)
McKesson
Eclipsys
Provider Registry
Audit Service (Sentillion)
IDX
CCOW - standards-based visual integration
BCCA document management and simple hospital
encounter index
Consent Service
etc.

• Stage 1 weaknesses
• existing Client Registry/ PHN for patient linking
• no comprehensive clinical event/encounter index
• no hospital data integration (only documents)
• application navigation

Hospital information systems (other HAs)
Meditech
Cerner
External to VCHA
PathNET (lab reform?)
Labs
PharmaNet
Pharmacy
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EPRs
CareConnect EHR Integration Services
Active data integration
Replicated data integration
Standards-based visual integration
HL7
CCOW
Hospital systems
Active data integration
CCOW
Community systems
Active data integration
Care provider
CCOW
Mental health systems
EPR-to-EPR data exchange (HL7)
Replicated data integration
CCOW
HL7
Private lab systems
Replicated data integration
CCOW
HL7
Private radiology systems
In future, will also introduce portal solutions
in this tier when they mature and become more
standards-oriented
Active data integration
CCOW
Pharmacy systems
Authorization Service
Authentication Service
Provider Service
Audit Service
Facility/ Location Service
Client Service
Consent Service
Org. Service
Clinical Event Service
Secure network infrastructure
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CareConnect - stages of evolutionStage 2
Synapse
Care provider
Community mental health
in4tek PARIS
eFilm
Hospital diagnostic images
Agfa PACS
Within VCHA
Authentication Service(tbd)
EMPI/ Client Service
Meditech
Hospital information systems (VCHA)
McKesson
Eclipsys
Provider Registry
Audit Service (Sentillion)
IDX
CCOW - standards-based visual integration
BCCA document management and simple encounter
index
Consent Service
Clinical Event Service
etc.

• Implement robust EMPI
• integrated registration across VCHA
• perhaps part of an improved Client Registry
  (Client Service)?
• Implement clinical event service
• Remaining weaknesses
• no hospital data integration
• application navigation

Hospital information systems (other HAs)
Meditech
Cerner
External to VCHA
PathNET (lab reform?)
Labs
PharmaNet
Pharmacy
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CareConnect - stages of evolutionStage 3
Synapse
Care provider
Community mental health
in4tek PARIS
eFilm
Hospital diagnostic images
Agfa PACS
Within VCHA
Authentication Service(tbd)
EMPI/ Client Service
Meditech
VCHA hospital data integration solution
Hospital information systems (VCHA)
McKesson
Eclipsys
Provider Registry
Audit Service (Sentillion)
IDX
CCOW - standards-based visual integration
BCCA document management and simple encounter
index
Consent Service
Clinical Event Service
Implement VCHA hospital data integration solution
etc.
Hospital information systems (other HAs)
Meditech

• consolidate HISs?
• clinical data repository?
• portal?
• combination of these?
• how to address data from external hospitals?
• Remaining weaknesses
• application navigation

Cerner
External to VCHA
PathNET (lab reform?)
Labs
PharmaNet
Pharmacy
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CareConnect - stages of evolutionStage 4
Synapse
Care provider
Community mental health
in4tek PARIS
eFilm
Hospital diagnostic images
Agfa PACS
Within VCHA
Authentication Service(tbd)
EMPI/ Client Service
Meditech
VCHA hospital data integration solution
Hospital information systems (VCHA)
McKesson
Eclipsys
Provider Registry
Audit Service (Sentillion)
IDX
CCOW - standards-based visual integration
Standards-based clinical portal
BCCA document management and simple encounter
index
Consent Service
Clinical Event Service
Authorization Service
Org. Service
etc.
Hospital information systems (other HAs)
Meditech
Facility/ Location Service
Cerner
External to VCHA
PathNET (lab reform?)
Implement a standards-based clinical portal for
more integrated navigation Also implement further
infrastructure services
Labs
PharmaNet
Pharmacy
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Where do we see the Private sector in this model?
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External EHR integration architecture
Authorization Service
Authentication Service
Audit Service
Hospital systems
Provider Service
Facility/ Location Service
Client Service
Consent Service
Org. Service
Clinical Event Service
Community systems
Care provider
Mental health systems
EHR Integration Service
Private lab systems
Active data integration
Replicated data integration
Private radiology systems
Standards-based visual integration
Clinical portal
Pharmacy systems
Physician systems
Secure network infrastructure
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Who are the likely partners???????

• Consortium from the private sector
• Telephone /cable /wireless companies
• secure remote access to high
  quality information
• Verification companies/banks
• managing the services authorization,
  authentication, provider registries, empis,
  consent registries, event registries,
  organization registry,
• Integration companies
• Building and ? Managing the HW/SW

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Building the consortia

• How to build them
• Who are the public sector partners
• DISCUSSION