doctor on computerbaby boy

eCHN in the Media

Ontario's eCHN Shows that Integration and Interoperability are Possible

Canadian Healthcare Technology

Andy Shaw

First lesson: integration and interoperability are not the same. The words are not synonymous; though we often use them interchangeably, which adds to the confusion. But like love and marriage, they do go together like a horse and carriage. So, any attempt to “integrate” your systems, meaning by definition combine them into one, unified whole – without your systems being able to “interoperate”, meaning exchange and make use of their information, will inevitably end up in divorce.

Of course, the ones that suffer most in a divorce are usually the children. So maybe it’s only fitting that those who have done the best job so far in healthcare of marrying integration with interoperability are those who care for sick kids. None better, nor longer, than the dedicated folks at Ontario’s eCHN, the electronic Child Health Network.

Since its inception more than 10 years ago, eCHN staff have been integrating with the rest of the province’s healthcare organizations and making their patient information systems interoperable – such that nearly 1.8 million of Ontario’s children now have an eCHN electronic paediatric health record. Those records can now be shared electronically Ontario-wide, thanks to eCHN.

Among eCHN’s other accomplishments and features:

• integrates child care data from disparate systems – including over 100 hospitals and tertiary care providers, such as children’s treatment centres, community health centres, and physicians offices – into one cohesive record;

• enables family physicians to refer and follow up on a child’s visit to a paediatric specialist;

• gives members access to a suite of paediatric care applications on the eCHN portal;

• maintains and staffs its own round-the-clock, high availability data centre;

• operates a technical and user support help desk.

It’s clear that eCHN has more than a child-like grasp on integration and interoperability. That’s very much because, from the top down, they understand the difference in the terms.

“First, we define integration as the creation of links between previously separate computer systems, applications, services or processes,” says eCHN’s chief executive officer, Andrew Szende. “As to interoperability, that’s not about making each separate resource know how the others work but about making sure they have enough common ground to reliably exchange messages without error or misunderstanding.”

Mr. Szende further adds that in defining the word integration: “…the word is normally used in the context of computing, but can apply to business processes as much as to the underlying process automation. In the past, computer integration – for example in enterprise application integration (EAI) – has typically been tightly coupled, or ‘hardwired’, making it difficult to modify in response to changing requirements. But thanks to the advent of web services and the evolution of service-oriented architectures, more agile, loosely coupled forms of integration are now starting to emerge.”

So in this modern “loosely coupled” era, who or what is going to exercise the tight discipline still needed to make sure one’s disparate systems dutifully and reliably establish common ground – so they can indeed exchange messages without fault?

Says Szende: “Standardized specifications go a long way towards creating this common ground where services can interact, but differences in implementation may still lead to breakdowns in communication.”

And in Ontario, they know about breakdowns! Indeed, the scandals surrounding the province’s eHealth initiatives got so heated last year there were meltdowns of entire agencies and programs aimed at both integration and interoperability.

But eCHN cooly withstood the heat. And it wasn’t the first hurdle they’d cleared in building their enviable network.

“As an organization our first obstacle to overcome was integration with Ontario’s hospitals. And as most of your readers will know, Ontario’s hospitals have dozens of different clinical information systems that collect data and store them in unique, site specific ways,” says Szende. “So eCHN built interfaces to the various vendor-provided applications and conducted detailed site specific surveys in order to successfully integrate both the data and its specific business rules into the eCHN solution.”

Still, hospitals are no peas in a pod. Integration with their idiosyncratic, and often proudly held onto systems is both a technical and human challenge. One that’s defied many an integrator, but not eCHN.

“Every hospital site had some degree of customization applied on top of the vendor-provided applications. These customizations had to be understood by the eCHN team, integrated and normalized in order to allow clinicians to view the data in a consistent manner,” says Szende. “And we admit that wasn’t easy. So for our integration efforts we used an experienced data team that had a clinical background that could interact with domain experts at the hospital sites as well as with the clinical application vendors.”

That doesn’t mean eCHN is resting on its laurels, adds Szende quickly. “Our integration effort is really a continuous one. We keep pace with member hospitals who are upgrading and updating their internal systems so we can always communicate with them in real time.”

Well and good, but how do Szende and eCHN know for sure they’re doing a the right things?

“We judge it by the enthusiastic feedback we get from our members, and most of all from clinicians,” says Szende. “They say they can rely on us, and I think that is the key to successful integration. Clinicians will not use systems that contain obsolete or error prone data.”

Another indicator of eCHN’s success is public recognition. Recently, the Hospital for Sick Children in Toronto won a “WOW Award” as Canada’s smartest IT application user in healthcare for its role in helping to develop the eCHN and being an early adopter.

Thus, endeth the first lesson.

Second lesson: Others can do the same. Take, for example, the provincially funded Children’s Treatment Network of Simcoe York, launched in 2004 and now stretching from the north end of Toronto all the way up to Georgian Bay. It has developed an “Electronic Client Record” that reaches beyond healthcare providers and integrates the electronic records of nearly 4,000 children and young people up to age 18 with the systems of over 600 children’s care workers in related fields including educational and social services.

“We sprang from the straits families found themselves in with children who needed complex care,” said Sandy Thurston, a Network founder and now the director of its planning, evaluation, and network development, at a recent show-and-tell LHIN conference in Toronto. “They needed services from such a fragmented and distant array of care providers that the parents, in addition to their own jobs, had another nearly full-time job of being their children’s case managers.”

Moving from that need, through a vision that won the support of over 50 information sharing partners, the Network now has four main features:

1. A single point of access to the care system for families with children suffering from diseases like cancer, and others requiring complex treatment

2. Ten integrated care teams of medical and other specialists available to them

3. A “single plan of care” for each child that integrates not just their healthcare support system but their community, social, school, and even recreation systems

4. An assemblage of a wide range of other child care specialists who could be called on to collaborate with Network care teams.

As a basis for all the collaboration it has engendered, the Children’s Treatment Network is using Microsoft’s SharePoint application. The Network also uses SharePoint for its Family Resource Centre, an internet portal which parents and computer savvy patients can access to share their knowledge and experience with other families and patients.

“We believe, judging from the feedback we get, that we provide as much value for patients out of the Family Resource Centre as we do from our formal care,” said Thurston.

While the Children’s Treatment Network is exemplifying community-wide integration, the electronic Children’s Health Network is sorting out which comes first: the chicken or the egg. Or rather, the fundamental question of how should integration and interoperability relate to each other? Which, in effect, should come first to your attention if you want the marriage of the two to really work?

“Originally, eCHN’s priority was integration. Now interoperability is equally important,” says CEO Szende. “We make eCHN conform to blueprints and strategies, so it can operate with other solutions. To do that we support data exchange conforming to Canada Health Infoway (CHI) preferred information access methods, such as webMethods and the publish/subscribe model that are part of the CHI Blueprint.

“Our team took that approach because we wanted to be compliant with the Blueprint’s electronic health record (EHR) principles,” adds Szende. “We also implemented a service-oriented architecture that makes it easier to interoperate with provincial services and products as they become available.

“As a result, eCHN is currently a flexible, open, scalable and interoperable EHR solution. So if and when the Ontario Laboratory Information System (OLIS) goes live, for example, we’ll be able to interoperate with them and exchange OLIS lab results. We’re also looking forward to hooking up with other provincial services, such as patient and provider registries, when they become available.”

Lesson three: you can do it too. And you don’t have to do it all by yourselves. Not only do you have the shining examples of the eCHN and the Children’s Treatment Network before you, there’s money out there, or at least the promise of it. And not just from provincial coffers.