6/16/24, 5:24 PM CHIM305, Module 8 - Topics

Topics
The electronic health record (EHR)
Relationship between EHR, electronic medical record (EMR), and personal health record (PHR)
The interoperable standards and tools

Learning Objectives
By the end of this module, you will be able to:

Describe the role, solutions, and plans of the Canadian health infostructure, as it supports the
Canadian EHR
Evaluate the standards, tools, and resources for the EHR Infostructure (EHRi)

Required Readings/Resources page

Reading

Canada Health Infoway. (n.d.) Understanding EHRs, EMRs and PHRs. Retrieved from
http://www.himconnect.ca/meet-him/faqs/differences-between-emr-ehr-and-phr
Canadian Institute for Health Information.

Introduction
The Canadian healthcare industry has been slow in adopting a holistic platform for collecting and sharing
health related information. This has inadvertently resulted in silos which contain health data, information
and knowledge. Across the globe, most industrialized countries have agreed to embrace a holistic
electronic medium that would be the only way to solve this silo effect. One of the core components for
such a medium is establishing an Electronic Health Record (EHR).

There has been a lot of confusion between the terms electronic health record (EHR), electronic medical
record (EMR), and personal health record (PHR). An EMR is an electronic record of health-related
information on an individual that can be created, gathered, managed, and consulted by authorized
clinicians and staff within one health care organization. A PHR is an electronic record of health-related
information on an individual that conforms to nationally recognized interoperability standards and that
can be drawn from multiple sources while being managed, shared, and controlled by the individual.

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In the Introduction to Health Informatics module we covered the basic concepts of EHR and EMR.
This module defines EHR and builds on the previous module to further introduce the Canadian EHR
initiative.

Video

Don Newsham, CEO of COACH, Canada’s Health Informatics Association (currently Digital
Health Canada), discusses the progress of the EHR and EMR adoption across Canada [2:27].

Electronic Health Record

EMRs and PHRs

Figure 1 - Relationship between EHR, EMR, and PHR

Created by Terrie Tucker

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Figure 1 illustrates the relationship between EHR, EMR, and PHR. EMR is associated to a patient’s
episode with a hospital. There will be many details (resources consumed, other clinician’s opinion,
doctor’s notes, and recommendations for future reference) pertaining to the episode, but only a few will
be reflected on the PHR, such as the summary of the episode and medication required by the patient.
One patient may have many such EMRs for each episode, with the same or different hospitals. A
scenario like this may exhibit how health information is captured in an electronic format, but the irony is
that the information is fragmented and has minimal or no relationship to each other. This is where an
EHR plays a vital role: EHR integrates the health information in its entirety, thus providing pervasive,
continuous, and in-depth information which will be accessible during care delivery.

EHRs
There is no globally accepted or standardized definition for electronic health record (EHR). EHR is often
used as a synonym for electronic patient record (EPR). EHR can be loosely defined as an electronic
information repository of a patient’s health (Figure 1). This normally captures the patient’s demographics,
health history, health issues, and information generated by health encounters such as progress notes,
prescriptions, immunization, pathology, and radiology reports (Healthcare Information and Management
Systems Society, 2011). A much more generalized definition is that EHR relates to the electronic storage
of past, present, and future of a patient’s health. This electronic storage of patient’s health enables easy
capturing, sharing, storing, accessing, and analyzing health-related data and information, not only in a
textual format but includes several multimedia-based formats. Figure 2 illustrates one of the most basic
EHR connectivity models that not only shows the individual’s demographic but also image archiving and
medication history. It consists of two separate components – the electronic storage of data and the
stakeholders (doctors, patients, administrators) who will use that data. The stakeholders access the data
through the connectivity network.

Figure 2 - Simple EHR architecture

Source: Created by Terrie Tucker

According to Canada Health Infoway (CHI), one of the benefits of EHRs [PDF] is that they “… will tie
together a patient’s health information from numerous systems to provide one coherent record for an

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authorized healthcare provider. Whether the information flows from a doctor’s office, a clinic, hospital or
pharmacy; it will appear in a structured format on the record…”

Video

Why We Need EHRs [2:07].

VistA Imaging is an example of an electronic health record system. The system is used by the Veteran
Affairs (VA) hospitals in the U.S. Its main function is to obtain and store digital images for patient study
and diagnosis purposes. Learn more at VistA Imaging System and VistA Imaging Overview.

Canadian EHR Infostructure

Canada Health Infoway (CHI) is an independent, not-for-profit, and federally funded organization which
has been mandated to implement a countrywide interoperable electronic health information system and
electronic health record for the whole population. CHI was initiated in 2000 with an initial investment of
$500 million and the total investments have already crossed $1.2 billion. A conservative estimate to
implement the Canadian infostructure is $10 billion. CHI has identified a centralized repository, EHR
infostructure (EHRi), as the framework for the new interoperable electronic health record solution
(EHRS) (Canada Health Infoway, 2006; Baskaran et al, 2008). The EHRi will be accessed by multiple
points of service (PoS) across the country. Each of these PoS may represent many healthcare systems,
such as a hospital information access system (a monitor by the bedside), a physician’s information
access system (a diagnosis monitor), pharmacy system, and lab system.

Each of these PoS would have a local database to enable local administration. An EHR viewer is also
available at this level to provide a web-based interface for different healthcare stakeholders, including
patients.

Reading

For more information on how such a health infostructure might work at a pan-Canadian level,
read the Canada Health Infoway Summary Corporate Plan 2019-2010 [PDF] document. After
your reading, reflect on how much of this plan will benefit the general population.

These PoS will access the Health Information Access Layer (HIAL), which provides a communication
layer to connect all the individual components of the EHRS. HIAL is connected to the Longitudinal
Record Services (LRS). LRS provides a metadata repository for services offered by the EHRi. The two
components (HIAL and LRS) provide extensibility (for a pan-Canadian EHRS connecting all the
provinces and union territories) to the EHRS and add other critical features such as privacy, access
control, and enforcement of clinical rules and policies. This can also be construed as the communication

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network that connects the repositories to the user. A separate index is maintained within the LRS to
enable easy and accurate retrieval of data and information. The LRS maps the information source and
the requestor (PoS) for speedy access; the information required may be available locally in the same
EHRi (same provincial setup) or across the country in another EHRS (Infoway Architecture Update,
2006). The services offered by the EHRS could be categorized as registries data and services, ancillary
data and services, EHR data and services, and health information data warehouse. The registry data
and services offered by the EHRS would be related to the information about the patient or health
provider (physician or hospital) such as unique number, location of care, terminologies used, disease
description, and consent information.

Ancillary data will pertain to any outbreak management and public health services provided by the
Ministry of Health to the general population. The majority of the information accessed through the EHRS
is EHR data. This relates to the shared health record (patient’s healthcare events, interventions, and
encounters for future retrieval), drug information (prescription management), imaging diagnostics (X-ray,
mammogram, etc.), and laboratory system (haematology, oncology, histopathology, cytopathology, etc.).
Other health-related data is stored in the health information data warehouse. An EHR Viewer is an
added feature that provides access for those healthcare stakeholders who do not have a PoS at their
disposal. EHR Viewers do not have local databases but provide complete access to the EHRi via HIAL.

Note

For a detailed overview of Ontario’s eHealth Architecture, including the eHealth blueprint,
connectivity strategy, standards, and innovation lab, visit Ontario's eHealth Architecture.

Knowledge Check
We have covered a number of terms and concepts so far, so let’s check that you are developing a good
understanding of the content. In the activity below, you will match different terms with their corresponding
definition.

Canadian Health Infostructure

Term Definition

Health Information Access Layer (HIAL) Solution to enable EHR interoperability

or integrated EHR systems across
multiple health service facilities.
Electronic Health Record Solution
(EHRS)
A system (or interface) used by frontline
Point of Service (PoS) clinicians to access the electronic
health record (EHR) infostructure.

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EHR Infostructure (EHRi) A platform that provides a metadata

repository for services offered by the
Longitudinal Record Services (LRS) EHRi.

Provides a communication layer to

connect all the individual components
of the EHRS. HIAL is connected to the
Longitudinal Record Services (LRS).

Framework for an interoperable

electronic health record solution
(EHRS).

Reset Exercise Show All Matches

Interoperable EHR
Canada Health Infoway (CHI) and the Canadian Institute for Health Informatics (CIHI) are the custodians
for coordinating, supporting, and sustaining health information standards (Canadian Standards). This will
enable EHR to reach all the healthcare stakeholders. Health information standards are critical for
ensuring disparate health systems to connect, communicate, and synchronize health data. CHI and CIHI
created the Standards Collaborative Committee, which identified a number of areas for standards
development. This was initiated through Standards Collaborative Working Groups (SCWG), such as
client registry standards, diagnostic imaging standards, laboratory standards, clinical messaging
standards, and privacy and security standards. The Standards Collaborative Committee is the liaison
with other healthcare international standards such as Health Level Seven International (HL7), Digital
Imaging and Communications in Medicine (DICOM), International Health Terminology Standards
Development Organizations (IHTSDO), International Organization for Standardization’s Health
Informatics Technical Committee (ISO/TC 215), and Systematized Nomenclature of Medicine-Clinical
Terms (SNOMED-CT) (Healthcare Information and Management Systems Society, 2019). A few of these
standards, especially HL7, ISO/TC 215 and SNOMED-CT will be covered in more detail in other
courses. In a general sense, when integrating across multiple platforms, an organization needs to be
aware of three basic levels of interoperability (see Figure 3), depending on whether it is integrating
across internal systems or with external systems, as well as the direction in which data will be flowing, as
follows:

Foundational (Basic) Level:

Data transmission from one system to another, not requiring the receiving system to interpret
the data, only to display it.

Structural (Intermediate) Level:

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Uniform movement of healthcare data from one system to another, where purpose and
meaning of the data is preserved and unaltered. Structural interoperability ensures format
standardization (e.g. HL7) and that data exchanges between systems can be interpreted
and recognized.

Semantic (Advanced) Level:

Two or more systems exchanging, interpreting, and mapping this information for use.
Intelligent logic is applied in complex “if, then” scenarios.

Figure 3 - Interoperability levels

Source: Created by Andrew Pigou

Technical experts who are assigned the task of designing interoperable systems will need to know the
answers to the questions below. This will enable them to determine what level of interoperable solution is
required:
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Why is interoperability required?

What will the information be used for?
Which information needs to be shared?
Where will the information be shared?
Who will consume the information?
Will the data need to be interpreted, altered, or processed?
How often will the data be transmitted?
Does the data need to be real-time?

Summary
An electronic health record is an indispensable tool to provide an efficient and economical way of making
patients’ health-related information available to healthcare stakeholders. Canada has embarked on
implementing a nationwide EHR infrastructure to enable seamless sharing of health information among
the clinicians, health administrators, and government departments. Many previously identified challenges
have been or are being remedied to make such a system a reality in Canada. A few examples include:

ConnectingOntario: According to the eHealth Ontario website, “The ConnectingOntario ClinicalViewer

is a secure, web-based portal that provides real-time access to digital health records including dispensed
medications, laboratory results, hospital visits, local health integration networks (LHINs), home and
community care services, mental health care information, and diagnostic imaging reports. The
Connecting Ontario ClinicalViewer, available to authorized health care providers in the Greater Toronto
Area and the Northern and Eastern Region, provides a comprehensive view of a patient’s journey
through the health care system, enabling providers to make faster, more informed care decisions.”

ClinicalConnect: As described on the Clinical Connect website, “ClinicalConnect is a secure, web-

based portal which provides physicians and clinicians with real-time access to their patients’ electronic
medical information from all acute care hospitals, Local Health Integration Networks’ Home &
Community Care Services and Regional Cancer Programs in South West Ontario, plus various
provincial data repositories. ClinicalConnect is a fundamental tool in bridging the gap between disparate
information systems spanning a wide geographical area and multiple regional health care facilities.”

Health Report Manager (HRM): The OntarioMD website defines HRM as “an eHealth solution that
enables clinicians using an OntarioMD-certified EMR to securely receive patient reports electronically
from participating hospitals and specialty clinics. HRM electronically delivers text-based Medical Record
reports, (e.g. Discharge Summary), and transcribed Diagnostic Imaging (excluding image) reports from
sending facilities directly into patients’ chart, within the clinician’s EMR. Community-based Independent
Health Facilities (IHF) and Specialty Clinics that provide diagnostic and assessment services such as X-
Ray, Ultrasound, Nuclear Medicine, Cardiology, etc. can choose to establish a connection to HRM to
send patient reports to referring clinicians’ electronic medical records.”

Assignments and Activities

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Discussion Board

This week read the article by Viner et al. (2020). Extending large-scale electronic
health records to Canadian family physicians. Can Fam Physician, 66(11).

Provide a brief summary of the article and some of the strengths and weaknesses associated
with extending EHR software beyond the hospital setting.

Reminder

Assignment 2 is in progress

You should be working on Assignment 2 (the Group Project) with your team. Check the
description provided in Module 1 often to check that you are on track. The assignment is due in
Week 11 and it should be posted within the Group Projects Module in the Discussion Board.

References
Baskaran, V., Bali, R. K., Arochena, H., Naguib, R.N.G., Khanapi, M.A.G., Shah, B., ...
Wickramasinghe N. (2008). Health informatics: A UK and Canadian perspective on current and
future Challenges. AMCIS 2008 Proceedings. Paper 111.
Canada Health Infoway (2006). EHRS Blueprint: An Interoperable EHR Framework [PDF].
Retrieved from https://www.infoway-inforoute.ca/en/component/edocman/390-ehrs-blueprint-v2-
summary/view-document?Itemid=0
Canada Health Infoway (2006). Infoway Architecture Update [PowerPoint]. Retrieved from
https://slideplayer.com/slide/1637766/
Canada Health Infoway (2007). 2015: Advancing Canada's Next Generation of Health Care [PDF].
Retrieved from https://www.infoway-inforoute.ca/en/component/edocman/16-2015-canada-s-next-
generation-of-health-care-full/view-document?Itemid=101
Canada Health Infoway (2011). The Case for Electronic Health Records in Canada [PDF].
Retrieved from http://v1.theglobeandmail.com/partners/free/infoway/pdf/Infoway The case for EHR
in Canada EN.pdf
Canada Health Infoway. (2021). Digital Health in Canada. Retrieved from https://www.infoway-
inforoute.ca/en/
Healthcare Information and Management Systems (2011). Electronic Health Records. Retrieved
from http://www.himss.org/ASP/topics_ehr.asp
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Healthcare Information and Management Systems Society (2019). What Is Interoperability?

Retrieved from https://www.himss.org/library/interoperability-standards/what-is-interoperability

Murphy G., Waters K., Hanken M.A., & Pfeiffer M. eds. (1999). Electronic Health Records:
Changing the Vision, pp.129-142. WB Saunders. Philadelphia, PA
Payne, T., Fellner, J., Dugowson, C., Liebovitz, D., & Fletcher, G. (2012). Use of more than one
electronic medical record system within a single health care organization. Applied Clinical
Informatics. 3(4): 462-474.
The National Alliance for Health Information Technology (2008). Defining Key Health Information
Technology Terms [PDF]. Retrieved from https://s3.amazonaws.com/rdcms-
himss/files/production/public/HIMSSorg/Content/files/Code3 _Defining Key HIT Terms - ONC - 4 28
08.pdf

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