Monday, August 30, 2010

Wednesday, August 18, 2010

Health IT Standards in Canada

In Canada, health IT standards are established by Canada Health Infoway's Standard Collaborative. Canada Health Infoway is a not-for-profit organization funded by the federal government to develop pan-Canadian health IT standards and provide incentives for the adoption of health information technologies.

HIT Standards

The following are key standards approved by the Standard Collaborative:

  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) for problem lists, procedures, and other clinical observations. 35,000 SNOMED CT concepts have been translated to Canadian French

  • HL7 Version 3 (HL7 V3) for clinical, ļ¬nancial, and administrative messaging and document exchange. Canada played a key role in the development of the HL7 v3 modeling methodology and tooling. The pan-Canadian HL7 v3 is used for the following core areas:

    • Laboratory
    • Immunization
    • Pharmacy (Drugs)
    • Client Registry (patient demographics)
    • Provider Registry
    • Shared Health Records
    • Electronic Claims
    • Public health surveillance

  • HL7 Clinical Document Architecture (CDA) standards enables pan-Canadian EHR interoperability

  • The pan-Canadian LOINC Observation Code Database (pCLOCD) for lab test results is used by the Lab Messaging and Nomenclature and Public Health Surveillance standards. PCLOCD adds and excludes certain records from the original LOINC standard to support Canadian requirements. Unified Code for Units of Measure (UCUM) is used for units of measures

  • Diagnostic Imaging (DI) Standards are based on DICOM and IHE XDS-I

  • The Health Canada Drug Product Database (HCDPD) provides coding for medications.


Infoway offers certification for the following classes of HIT software:

  • Client registry
  • Consumer health application
  • Consumer health platform
  • Diagnostic Imaging (DI)
  • Drug Information System (DIS)
  • Immunization registry
  • Provider registry

The assessment criteria cover functionality, privacy, security, interoperability and management and are based on the following standards:

  • Functionality – Canada Health Infoway Electronic Health Record Privacy and Security Requirements.

  • Privacy – Canada Health Infoway Electronic Health Record Infostructure (EHRi) Privacy & Security Conceptual Architecture; Government of Canada’s Personal Information Protection and Electronic Documents Act (PIPEDA); The Canadian Standards Association’s Model Code for the Protection of Personal Information – CAN-CSA-Q830-03.

  • Security – Canada Health Infoway Electronic Health Record Infostructure (EHRi) Privacy & Security Conceptual Architecture; The International Organization for Standardization’s Code of Practice for Information Security Management – ISO/IEC 17799:2005; The National Institute of Standards and Technology’s Recommended Security Controls for Federal Information Systems – NIST SP800-53;The USA Health Insurance Portability and Accountability Act (HIPAA) Security Rule.

  • Interoperability – Canada Health Infoway pan-Canadian Standards and Conformance Profile Definitions for diagnostic imaging, laboratory, drug, shared health record, and demographic information.

  • Management – The IT Governance Institute Control Objectives for Information and Related Technology (COBIT); The Office of Government Commerce’s Information Technology Infrastructure Library (ITIL).


The following diagram from Infoway's web site depicts the high level architectural vision from an end user perspective (click to enlarge).

My Assessment

Overall, I am pleased with the choices that have been made by Infoway's Standard Collaborative. I believe that HL7 V3 is a step forward compared to HL7 v2.x because it is based on XML, it is more amenable to a Service-Oriented Architecture (SOA), and it defines a healthcare Reference Information Model (RIM) with associated modeling methodology and tooling. Beyond ICD-9 and CPT, SNOMED CT is definitively the medical terminology language of the future. Consistency is needed for units of measure for lab test results and UCUM is a good choice.

Some flexibility will be needed in standardizing transport protocols to allow lightweight solutions such as SMTP for point-to-point connections (what our friends in the US call NHIN Direct). The e-Health certification process should include some HIT usability testing (see my previous post on the experience of the British NHS in this area).

I am not aware of any pan-Canadian standard in the area of quality reporting. I would like to see Canada Health Infoway put more efforts into creating specifications (messaging, security, privacy) and open source tools for Health Information Exchanges (HIEs) at the provincial and federal levels. More work needs to be done in promoting the use of Computerized Physician Order Entry (CPOE) systems and Clinical Decision Support Systems (CDSS) for the automated execution of clinical guidelines. Finally, more guidance is needed in the area of patient consent in the context of electronic health information exchanges.

Sunday, August 1, 2010

Content Integration in the Aviation Industry Using CMIS

The recently approved Content Management Interoperability Services (CMIS) specification could play a very important role in ensuring that aircraft operators receive up-to-date maintenance and operation documentation from aviation manufacturers.

The safe and efficient maintenance and operation of air vehicles require clear, technically accurate, and up-to-date technical documentation. The technical documentation is supplied by original equipment manufacturers (OEMs), regulatory agencies, and the aircraft operator's own engineering staff. OEMs (e.g. airframe, engine, and component manufacturers) provide regular publications such as Aircraft Maintenance Manuals (AMM) and Flight Crew Operating Manuals (FCOM) as well as time-sensitive supplements such as Service Bulletins (SBs) and Temporary Revisions (TRs). Regulatory agencies like Transport Canada and the US Federal Aviation Administration (FAA) also publish technical information that affects the maintenance and operation of air vehicles and equipments. Examples are Advisory Circulars (ACs), Airworthiness Directives (ADs), and various forms and regulations.

A typical airline faces the following challenges:

  • The elimination of the high costs associated with the shipping, storage, and distribution of physical products (paper, CDs, and DVDs) containing the technical documentation.

  • The safety and regulatory compliance concerns related to the use of out-of-date technical information (currently, some airlines receive revisions to technical manuals only four times a year).

The aerospace industry is in the process of adopting the new S1000D technical publications standard. S1000D is based on the concepts of modularity, reuse, and metadata (see my post on S1000D Content Reuse). The Flight Operation Interests Group (FOIG) of the Air Transport Association (ATA) is developing a data model and XML Schema for flight deck procedures and checklists also based on the S1000D data model. While S1000D is the right payload format, the exchange between content management and publishing systems within the industry must be orchestrated in an efficient manner.

Airlines, repair stations, regulatory agencies, and original equipment manufacturers (OEMs) manage and publish technical content using proprietary content management systems (CMS) each with its own proprietary API. Some companies now provide online portals where customers can login to get the latest documentation. However, pilots and technicians don't really want to login into the support sites of all those content providers to find out what is new and updated. To minimize aircraft downtime, aircraft mechanics want to connect to the aircraft's health and usage monitoring system (HUMS), determine what problem needs to be fixed, and have the appropriate content aggregated (work package) and presented to them.

With CMIS, an airline or aircraft operator can create a portal to aggregate content from the repositories of its OEM suppliers using a single standardized web services interface based on either SOAP or AtomPub (the RESTful alternative). This allows the aircraft operator to keep their maintenance and operation documentation updated at all time without having to wait for a CD or paper manual to be shipped by the OEM.

The second scenario is distributed authoring driven by the shift to distributed aircraft manufacturing. For example, the content of the Aircraft Maintenance Manual (AMM) can be provided by different aviation manufacturers participating in a consortium to design, manufacture, and support a new aircraft. In such as a scenario, a centralized CMIS-compliant content repository (hosted by the airframe manufacturer acting as the content integrator) can provide the following CMIS services to other members of the consortium:

  • Policy and ACL Services to obtain the policies (such as retention) and Access Control List (ACL) currently applied to a document

  • Navigation Services to programmatically navigate the content repository

  • Discovery services to query content. CMIS supports SQL-92 with some extensions and full-text search and can handle federated search across multiple repositories

  • Relationship Services to obtain the relationships (such as links) associated with a document

  • Versioning Services to check-out and check-in a document

  • Object Services to obtain the properties of a document and create folders and documents

  • Filing Services to add a document to a folder.

The third example use case is the ability for a SCORM-compliant Learning Management System to integrate with CMIS-compliant S1000D Common Source DataBases (CSDB) in order to repurpose technical publications content for training purposes. The International S1000D-SCORM Bridge Project is an interesting initiative to create such an integration.

In general, CMIS will enable new capabilities such as the remote access to library services, cross-repository exchange, cross-repository aggregation, and cross-repository observation (or notification).

CMIS is now supported by major CMS vendors including EMC, IBM, Alfresco, and Microsoft. A list of open source and commercial implementations of CMIS is available at this page.