Ontario’s Province-Wide Paediatric Electronic Health Record
T he electronic Child Health Network (eCHN) is an advanced implementation of an electronic health record (E.H.R.). This is the story about the building of a successful integrated and shared E.H.R. from multiple systems at multiple sites for the benefit of patients and clinicians.
Optimum patient care requires that as much information as possible about a person’s overall health and dealings with the health care system be made available, to the appropriate people when and where it is needed. Up-to-date, accurate, and comprehensive patient health data is vital to the process of medical decision-making.
Optimum patient care requires that as much information as possible about a person’s overall health and dealings with the health care system be made available, to the appropriate people when and where it is needed. eCHN’s key objective is to improve the quality of care delivered to children throughout the province of Ontario’s health care system.
As health care delivery has become increasingly specialized, the task of providing coordinated care to Ontario’s children has grown ever more challenging. Patients, especially those with complex conditions, are often required to move among a variety of care providers in different settings, yet a parallel system for circulating vital patient information has been lacking. Whether it was care for chronic diseases or conditions, rehabilitation of patients, or acute care episodes, there has been a common need for a common record for the continuum of care. Similarly, the need has been there whether the patient was seen at a teaching hospital, at a community hospital, at a chronic care facility, at a rehab facility, at a community clinic, or at an individual doctor’s office.
Information transfer among facilities has been a haphazard process Information transfer among facilities has been a haphazard process. Physicians and other care providers have had to make inquiries via phone calls, faxes, or letters which could take days or even weeks for a response. Alternatively, parents of patients were required to collect and carry paper documents to medical appointments themselves or rely on their memory of past visits elsewhere. Crucial information could end up missing or unavailable. The need for a seamless transfer of patient information among care providers has long been evident. eCHN is a pioneering response to the need for such shared records. It started out 10 years ago as a proof-of-concept project, by the Hospital for Sick Children and the Ontario government. The network went live in the year 2000, with just five hospital sites and a few doctors’ offices. It has since grown to over 100 hospital sites, including all six tertiary centres, plus hundreds of doctors’ offices, home care providers, and chronic and rehabilitation facilities eCHN has experienced explosive growth in the past eight years, both in terms of patient numbers and the amount of health care information shared.
eCHN enables health care providers to access the latest medical data about a child instantly, from many different sources, in the consolidated form of a single medical chart. The network pulls together all the data resulting from patients’ interactions with the health care system to provide an accurate and comprehensive patient health record. It supplies such key domains of patient health information as: admission, discharge, and transfer data; lab reports; clinic notes, discharge summaries, consultants’ letters, and surgical notes; radiology images and reports. These are integrated in an easy-to-use web format that duplicates an actual medical chart.
eCHN serves as a data integrator for multiple existing information systems, pulling together multiple data sources and making patient data available to health care providers at the point of care.
Within a hospital, specialized electronic information systems require users to find discrete bits of data for a patient in each system for a complete clinical picture. eCHN uses data from existing clinical record systems and, through interfaces and web services, integrates them into a single electronic record. The data is integrated from any system that is in use at any hospital in Ontario, regardless of the vendor that sold it. A key to its success is that it is a flexible, scalable, open, multi-vendor solution, designed to work with existing hospital systems and other networks. No hospital needs to replace any of its existing information systems in order to become inter-operable with eCHN. Participation by both organizations and individual users is voluntary.
eCHN is Ontario’s fully functioning paediatric E.H.R., serving 3-million people who are under 19. As a remarkably flexible solution that works with any hospital system or network, eCHN was always intended to be the start of a pan-provincial, population-wide shared electronic health record system. It has been growing, evolving, adapting since the year 2000, while meeting standard requirements of Canada Health Infoway, and the Ontario government’s eHealth Program. The results so far, as documented by interviews with health care providers, patients and their families, show a high satisfaction level. eCHN is replacing a paper-based system that was time-consuming and unreliable with an information transfer system that makes the latest patient data readily and immediately available to all the different health care providers who form a patient’s circle of care. The data is up-to-date and accurate.
The process of integrating hospital information system data is constantly becoming more efficient as additional tools are built and utilized and greater integration experience is leveraged. Hospital business processes and workflows are surveyed in great detail to evaluate the hospital site’s readiness to participate in E.H.R. integration. eCHN has worked with all hospital application vendors in Ontario to deploy needed interfaces. A key to eCHN’s success has been to minimize the cycles required from hospital staff who are already overwhelmed with work. Use case scenarios are performed directly in the hospital test environments. Tools are then used to analyze the quality and integrity of the hospital HL7 data. Exact data specifications are produced, as are transformation blueprints and gap analysis documents. Hospital staff receives substantial assistance from eCHN staff to facilitate the initial data analysis all the way through to the integration to paper to glass and glass to glass processes. Transformation blueprints are deployed in the interface engine layers and regression testing is performed on the final HL7 data produced. Once a site is integrated, the process of integration never stops, because hospital sites constantly change their solutions and their data; eCHN staff provides ongoing maintenance of interfaces and repositories through daily error correction and recovery analysis. Physicians will use a clinical solution only when that solution provides accurate and up-to-date information. eCHN has a dedicated medical entities dictionary team that obtains and analyses sites’ tests, procedures and reports. The correctness of test codes is constantly reviewed to ensure SI compliance. eCHN maintains the most sophisticated, complete test nomenclature synonyms system in Canada today supporting both the LOINC and SNOMED code standards.
The greatest challenge for E.H.R. implementations worldwide has been runaway costs and the lack of utilization by physicians The greatest challenge for E.H.R. implementations worldwide has been runaway costs and the lack of utilization by physicians. eCHN has turned out to be highly cost effective and utilization continues to grow every day. The key has been the involvement of physicians in the design and implementation of the solution itself. Functional enhancements have been driven by physicians as much as by the need to adhere to the CHI Blueprint principles. The obsessive focus on data quality has built and re-enforced the trust that physicians have in the eCHN solution. eCHN has built its solution following open standards and in adherence to provincial and federal guidelines (CHI Blueprint). Proven technologies and commercial applications are utilized whenever possible. A strong middle tier is used on a highly performant, scalable, reliable and flexible platform. Support is provided for multiple-device viewers and points of service applications. Seamless integration is facilitated into provincial registries. Connectivity with 3rd party systems and other electronic health record infostructures is also facilitated. Industry standards are followed but the pragmatic approach is emphasized. In other words, standards are not implemented for the sake of standards; rather, as hospital information system vendors implement E.H.R. industry standards, eCHN incorporates them. The flexible architecture and design of eCHN has enabled it to deliver and adapt to Ontario’s E.H.R. needs. The current emphasis on disease specific monitoring and management will also be able to leverage eCHN’s accomplishments. With more than 100 hospital sites as members, eCHN is uniquely positioned to support the efforts across Ontario to manage diabetes. The eCHN group already has extensive experience integrating clinical data from hospitals specific to chronic diseases, having interacted closely with cardiac and Asthma groups, as well as Bloorview Kids Rehab, over the last few years. eCHN has been highly successful in translating clinical needs into a working production solution that provides immediate benefits. eCHN’s record of achievement arises out of the methodology employed by the eCHN group of making steady progress, producing real results within months, not years, and therefore facilitating credible outcomes that have the full support of the stakeholders.
Building a strong chronic disease management solution utilizing eCHN is vital for the success in the province of treating these diseases and of reducing their occurrence in the first place. Healthy children produce healthy adults; conversely, if efforts are not taken to manage and prevent these diseases in the early years, the problem only compounds itself as these children become adults.
Key to eCHN’s success and the success of any E.H.R. are privacy and security. eCHN, as the agent of the province’s health information custodians, protects the privacy of patients’ personal health data.
Only authorized health care professionals involved in a specific patient’s circle-of-care are allowed to gain access to the patient’s chart. eCHN adheres to all of the government’s privacy law requirements but the data is not available to the government itself. eCHN does not own data, but guards it carefully for the patients/owners (the Health Information Custodians). Similarly, when it comes to security, eCHN operates with the highest level of security safeguards set by provincial and federal authorities. The data is encrypted and travels through a secure provincial health network, not the Internet. A rigorous audit system keeps track of who signs in, when and why. eCHN’s security policies are continually being subjected to internal and external review, updating and testing.
The eCHN system has proved to have multiple benefits for patient health care The eCHN system has proved to have multiple benefits for patient health care. For instance, health care providers in remote locations have immediate and consistent access to results and notes from their colleagues at tertiary centres in major cities. This makes it easier to provide patient care on a local basis, even with a small paediatric staff, thereby reducing the need for patient travel. eCHN makes it possible to improve the continuity and coordination of patient care, across the entire spectrum of health care delivery. Emergency care workers, faced with the necessity of making rapid, sometimes life-and-death decisions, can be confident that the medical information they rely on is up-to-date, complete and accurate. Family physicians are able to discharge their primary care obligations more effectively when they can stay apprised of the details of patient visits to specialized providers. Furthermore, diagnostic tests of patients need not be repeated when results from another site can be immediately accessed. It turns out, as well, that health care providers can provide more efficient, focused care when they are spending their time on patient care issues rather than on locating the patient data they require. Some particularly appreciate the fact that they can, at their discretion, even share test results and radiology images with patients, directly from the computer screen. Thus, the eCHN E.H.R. enables physicians and other providers to deliver an improved quality of patient care, particularly to patients with chronic conditions that require constant and prolonged care.
While in the first few years, eCHN responded to the need for a general all-purpose integrated electronic health record, in recent years, it has been focusing on leveraging its data repositories to solve the pan-provincial pediatric integration needs of specialized practice groups, such as Paediatric Oncology, Provincial Newborn Screening Program, Paediatric Cardiac Network, Paediatric Diabetes, Paediatric Asthma, and Paediatric Surgery.
Building a strong chronic disease management solution utilizing eCHN is vital for Ontario’s success in treating these diseases and in reducing their occurrence in the first place. Healthy children produce healthy adults; conversely, if efforts are not taken to manage and prevent these diseases in the early years, the problem only compounds itself as these children become adults.
Since the whole system is a voluntary or optional service to health care providers, eCHN relies on champion users who help in the recruitment of additional physicians. eCHN provides individual help to its users. Each hospital or organization has its trainers and coordinators. ECHN provides train-the-trainer sessions. Users with questions, problems get one-to-one assistance. Synergies with specialized groups are identified and eCHN is used to provide operational solutions. New users are added both within hospital walls and within their clinic offices. Champion users provide constant feedback on ways to enhance eCHN solution with additional functionality. eCHN regularly and constantly follows up with users in order to increase utilization and satisfaction with the system. The lessons this E.H.R. teach us include the approaches that benefit health care providers, the patients and the system as a whole. Canada’s largest functioning integrated E.H.R. is serving 3 million people and transforming the quality of health record keeping and clinical decision making in Ontario. eCHN enables health care providers across Ontario to share accurate patient data – in real time. It is helping the province understand the challenges of building a population-wide E.H.R.
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