The main existing sources of data across Canada include billing systems, EHR databases, physician EMR’s and hospital information systems (HISs). For reference, Alberta, illustrated above, provides a representative example of key digital health assets, including existing provincial repositories of diagnostic imaging, drug, claims and laboratory data.
At the outset, HIS systems are likely to be primary sources of patient data to support real word evidence collection and analysis. These systems are typically used to record the transactions related to patient care. Significant HIS development and modernization is occurring across Canada. Upgrading and consolidation through clustered implementations is occurring in Ontario. Most other provinces have regionalized HIS implementations. Alberta and Nova Scotia are pushing this model further by implementing single HIS instances province-wide.
All provinces and territories have established electronic health records, largely in cooperation and coordination with Canada Health Infoway. Most provinces conform to similar technical architecture and data standards. Some smaller provinces (i.e. PEI) and territories have largely hospital-centric architectures, with HISs performing the core EHR functions. Alberta and Nova Scotia, who are moving to provincial HIS implementations, will replace existing provincial EHR functionality. EHR databases record copies of information generated by local HIS, LIS, RIS/PACS and retail pharmacy systems for specific data types. These repositories are likely to be useful in the medium to longer term to support the requirements of a Pan-Canadian Research Data Network. The key EHR data repositories in each province include:
- Drug Information Systems
- Diagnostic Imaging
- Laboratory Information Systems
- Shared Health Records
Hospital Information Systems
HIS systems are likely to be key sources of patient data to support real word evidence collection and analysis. These systems are typically used to record the transactions related to patient care. Outside of Quebec and Ontario, the four largest US-based Hospital Information System (HIS) vendors, (EPIC, Cerner, Meditech and Allscripts), dominate the Canadian marketplace. There are approximately 10 different HISs in use in Ontario, however. The largest market share in Ontario is held by Meditech, Cerner, Epic, McKesson and Quadramed. Significant upgrading and consolidation through clustered implementations is occurring in Ontario. Most other provinces have regionalized HIS implementations. Alberta and Nova Scotia are pushing this model further by implementing single HIS instances province-wide.
In many implementations, HISs are not monolithic enterprise systems. HISs can be integrated with separate Radiological Information Systems (RISs), Picture Archiving and Communications Systems (PACSs) and Laboratory Information Systems (LISs), for example. In addition, specialists who practice in hospital settings may use their own EMRs (see below), to document patient interactions. As a result, research efforts that are hospital-based may need to draw data from a variety of sources. In all provinces in Canada, HISs are integrated with provincial clinical viewers (see below) to provide in-context access to Electronic Health Record repositories.
Health Data Standards
HIS data is typically based on proprietary vendor standards. However, most vendors incorporate international standards such as ICD diagnostic codes, SNOMED and LOINC terminology, etc. HIS pharmacy data typically utilizes Canadian DIN numbers. HIS data includes both structured and unstructured data, such as clinical notes.
Electronic Medical Records
There is extensive penetration of physician EMRs across Canada. These are largely employed by community-based physicians, particularly GPs. Specialists in hospitals typically use HISs to book appointments and record clinical results, however some hospital-based specialists use EMRs for this purpose. All provinces, except PEI, have had an investment and certification program for physician EMRs. Typically, the programs have been funded by Infoway, together with the provinces, and administered by the medical association in each province. Most of these programs, (with the notable exception of Ontario), have been sunsetted. EMRs contain physician notes and records of immunizations, prescriptions and referrals. Provincial certification programs have resulted in a degree of standardization of EMR functionality. There is a high concentration of ownership of EMRs, with TELUS having acquired a large number of EMR companies across the country. Certified EMRs tend to be integrated with provincial clinical viewers (see below) to provide in-context access to EHR repositories.
Health Data Standards
While provincial certification programs have resulted in some standardization of EMR functionality in each province, there has been little standardization of data. In Ontario, the certification program requires that all EMRs contain the following core data elements:
- Patient Demographics
- Patient Address
- Patient Alternative Contact
- Provider Information
- Family Medical History
- Ongoing Health Conditions
- Past Medical & Surgical History
- Laboratory Test Results
- Allergies & Adverse Reactions
- Risk Factors
- Alerts & Special Needs
- Reports Received
- Care Elements