Health Infostructure Atlantic Better Information Through Atlantic Collaboration

Health and the Information Highway Division, Health Canada
September 2003

Table of Contents

• 1.0 Introduction
• 2.0 Project Description
• 3.0 Achievements
  • 3.1 Goals Reached
  • 3.2 Additional Successes
  • 3.3 Unreached Goals
  • 3.4 Documents or Product Generated
• 4.0 Main Impact
  • 4.1 Human Resources Impact
  • 4.2 Privacy and Protection of Information
  • 4.3 Policy and Research Implications
• 5.0 The Future
• 6.0 Communications
• 7.0 Other

1.0 Introduction

In the fall of 1999, by agreement of the Council of Atlantic Premiers, a collaborative venture known as Health Infostructure Atlantic (HIA) was created to develop greater levels of cooperation in health information technology and information management activities across Atlantic Canada. After an initial visioning and common opportunities assessment in March 2000, HIA pursued and was successful in receiving funding under the Canada Health Infostructure Partnership Program (CHIPP) for the HIA Project Portfolio consisting of three specific initiatives: Case Management, Common Client Registry and Tele-i4.

The HIA Vision
HIA has established the following vision:

"HIA will be a leader in promoting and adopting information and communication technologies, information products, and knowledge that improves the planning, delivery, management and monitoring of health and community-based services available to Atlantic Canadians.

Through collaboration, HIA will support the priorities of the Council of Atlantic Premiers, while respecting individual provincial priorities, and remaining aligned with federal, provincial, and territorial health infostructure initiatives."

HIA believes that a pan-Atlantic Electronic Health Record (E H R), and hence a pan-Canadian E H R, is built incrementally. HIA, representing a collaboration of four provinces, is a microcosm of the challenges the country will face in designing effective inter-provincial E H R s that bring information from a variety of systems, across many provinces, together. HIA is building pieces of the necessary infrastructure so that, over time, our systems on a regional basis can interoperate. Key to this process is the development and implementation of common policies, information and technology standards. Integration at a provincial level is not a simple task. Integration across provinces can be even more challenging. However, HIA is committed to working together to create both information and technology standards so that the systems that we build and enhance at the provincial level will be able to interoperate across provinces while being aligned with the national vision.

Each province has plans for health information management and health information technology and its own approach to integrate patient data from disparate sources. HIA's challenge is to build on what currently exists and what is planned in each province to ensure that systems within each province and systems across Atlantic Canada become interoperable over time.

HIA's master plan is to link our provincial systems through our common client registries. The Common Client Registry (CCR) is not only seen as a building block for the Electronic Health Record, it is an essential integration component. Provincial common client registries must have the ability to link with all health databases resident in each province in order to provide a level of integration between all components of the health system. Accurate and secure linkages to all of these databases create a virtual database that supports the client through the continuum of care. At the Atlantic level, our vision is to support access to provincial CCRs through secure provincial gateways with appropriate query tools.

A key focus for HIA is cooperation and collaboration. HIA has conducted numerous workshops with information technology staff and program staff across Atlantic Canada to create common vision statements and detailed project plans for the initiatives identified as key opportunities for Atlantic Canada. Information, knowledge and lessons learned are shared openly among HIA Steering Committee members and staff. In addition, HIA created several standards committees that consist of representatives from each of the four provinces. Our standards committees were charged with the responsibility for creating information and technology standards, in collaboration with the Canadian Institute for Health Information (CIHI), to ensure that the systems that we deployed in Atlantic Canada, cost shared with the Canada Health Infostructure Partnerships Program (CHIPP), are interoperable. HIA has also been working very diligently to ensure that security and privacy issues are addressed within the context of provincial legislation.

This document will describe the HIA Project Portfolio, the goals reached and achievements realized, and the impact that it is having on the health care system of Atlantic Canada and the benefits accruing to Atlantic Canadians.

2.0 Project Description

The Hia Project Portfolio
HIA was awarded $12 million by the Canada Health Infostructure Partnerships Program to implement the HIA Project Portfolio. The $12 million award was matched with $12 million from Atlantic Canada for a total project budget of $24 million dollars. The HIA Project Portfolio consists of three initiatives comprising eight project components. The three initiatives are: Common Client Registry (PEI), Case Management (NF, NS and PEI) and Tele-i4 (all four provinces). Each of the initiatives and project components is described below.

Common Client Registry Initiative
A Common Client Registry (CCR) was implemented in Prince Edward Island during the CHIPP time frame and went live in April 2002. HIA worked together to create a common vision, five-year plan, definitions and attributes for the CCR initiative. The HIA vision for the Atlantic Provinces is one logical registry that spans the continuum of health care, and is able to provide accurate information by linking to all health encounters that an Atlantic resident has received.

HIA also created information standards for the CCR to ensure interoperability. The standards created were based on the work of the Canadian Institute for Health Information (CIHI) and the HL7 standard. The CCR standards were implemented in both Prince Edward Island and in Newfoundland and Labrador, who also implemented a CCR during this time frame. The definition of a CCR is one main database per province that is created, maintained and administered at the provincial level. This is the database that maintains the "master" client index for all residents in the province plus it includes out-of-province clients and out-of-country clients when health services have been provided to them.

A provincial CCR must have the ability to link with regional health databases, in order to provide a level of integration between all components of the health care system. It must also have the ability to link with health systems provided directly by the province, such as community health and social services programs. Correct and secure linkages to all these databases create a virtual database and supports the client through the entire continuum of care.

HIA's vision includes the development of a CCR for each province with a future opportunity to electronically link these databases together. The CCR is not only seen as a building block for the electronic health record, it is the essential integration component of the electronic health record. An electronic health record must be able to positively identify a client and provide all the correct and appropriate links to health encounter information on a client that will be available in a multitude of databases and computer systems. If a CCR does not exist, information is fragmented and incomplete and clinical care may be compromised.

Like the vision for the Canada Health Infoway, it is recognized that a complete structure of an electronic health record is built upon several integrated databases, and that the CCR is the link that binds them together.

Case Management Initiative
Case Management applications were implemented in three of the four Atlantic Provinces as part of the HIA Project Portfolio. HIA created a vision, definition and attributes for Case Management applications across Atlantic Canada. In addition, HIA developed a number of information standards for Case Management applications in home care. All standards development work was in collaboration with CIHI. For example, HIA developed a Management Information Standard (MIS) and an Interventions Standard for home care programs. According to HIA, case management "is a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates services to meet an individual's needs through communication and available resources to promote quality, cost-effective outcomes".

Case Management is usually the term applied to the management of health service delivery in the community health sector. The scope of case management can be very broad, as it encompasses community-based programs such as home care, child health services, and mental health clinics, to name just a few. As some provincial ministries of health also include the social services portfolio, case management applications may also include financial assistance, child welfare, and similar programs. Also, in some instances, case management may involve working with other social sector partners such as justice and education. Such multi-disciplinary approaches may be required at times to meet the client's overall needs.

A case management application was deployed in Newfoundland and Labrador in a multi-jurisdictional government program that targets children and youth at risk. The program is a joint effort by several government departments to improve communication and collaboration across staff and includes the following government departments: Health and Community Services, Education, Justice, Human Resources and Employment.

Prince Edward Island and Nova Scotia also implemented case management applications. In Nova Scotia, a case management application was implemented to support a new government program that streamlines access to the continuing care sector called Single Entry Access. The application supports the following functions: intake, assessment, care planning and waitlist management. In Prince Edward Island, the case management software application was deployed to the provincial diabetes program and includes the full range of functionality from intake, assessment, and care planning to discharge planning and financial management.

Tele-i4 Initiative
Tele-i4 stands for the inter-provincial integration of images and information. It refers to the deployment of tele-radiology or Picture Archiving Communication Systems (PACS) equipment across Atlantic Canada. With cost sharing from CHIPP, all four Atlantic Provinces implemented selected deployments of Tele-i4.

HIA brought together experts from across Atlantic Canada to create technical and information standards to ensure that information could be transmitted from rural to urban facilities and to tertiary care facilities for consultation and referral. This work built on the CCR standard that had been previously developed. A key piece of this work was the creation of a patient identification standard to ensure that patient information and images that are transferred from one province to another province electronically, to support good clinical care, could be correctly and accurately assembled in the receiving province.

In addition, experts from Atlantic Canada were charged with the responsibility of creating and implementing an Atlantic Request for Proposals (RFP) for PACS equipment. This was the most complex RFP that Atlantic Canada had issued under the Atlantic Canada Procurement Agreement and was considered a huge success.

An HIA vision, five-year plan, definitions and attributes document was created for each initiative. The Tele-i4 vision for the Atlantic Provinces is to deliver clinical information (diagnostic images and reports) in the most expeditious and cost-effective manner to all segments of the health enterprise. To achieve this vision, advanced information and communication technologies that collectively comprise PACS were deployed in selected sites in all four Atlantic Provinces. Based on a thorough assessment of specific provincial requirements, experiences and priority needs, Tele-i4 was implemented in selected rural and small urban hospitals, provincial and Atlantic tertiary referral centers, regional hospitals, and health centers. All four provinces implemented key components of a PACS infrastructure. A chief feature of the Tele-i4 initiative is transferring images across provincial boundaries for specialist referral and consultation.

Tele-i4 is maximizing the use of many advanced communications and information technologies. Through the deployment of Computed Radiography Readers (CR Readers) and Film Digitizers, diagnostic images are captured in digital format, or converted from film to digital format. Once digitized, this information is transmitted over communications networks from one location to another, such as a rural facility in one province to a tertiary referral center in another province.

The Tele-i4 initiative facilitates remote consultations, better utilization of scarce radiology and other specialty resources, and significantly reduces patient and provider travel. Instead of physically moving patients and providers, Tele-i4 moves the information.

Through the deployment of Advanced Software and Diagnostic Workstations, radiologists can magnify and manipulate radiology images, thereby improving diagnostic quality. Clinical Review Stations and Web-based Technologies make it possible for other specialists, primary care physicians, and other members of the multi-disciplinary team, to access and use radiology images and reports when and where needed. To better manage, store, retrieve, share and integrate radiology information and reports into other components of the patient record, Archiving Technologies was deployed at the regional and provincial levels. Collectively, the technologies and enterprise-wide processes deployed in Tele-i4 are "break-through" components for building the Electronic Health Record.

During the CHIPP time line, provincial networks were connected to ensure that patient information and images could be electronically transferred from the Tele-i4 sites and across provincial networks to support current referral patterns for referral, diagnosis, and consultation. It is important to note that the Tele-i4 project is currently the largest inter-provincial implementation of PACS equipment in Canada.

3.0 Achievements

3.1 Goals Reached

The goals achieved by each of the 3 initiatives and their individual project components are described below.

Common Client Registry Initiative
A Common Client Registry (CCR) was implemented in Prince Edward Island (PEI) based on the common Atlantic vision, definition and attributes developed by HIA. All elements originally defined in the project plan were completed including the connections to the Vital Statistics System and the Physician Claims System. In addition, this project also linked the CCR to the Radiology Information System during the CHIPP time frame.

In addition, common standards were developed by a committee of Atlantic Canada subject matter experts in collaboration with the Canadian Institute for Health Information, to support the interoperability of Atlantic Canada common client registries as they are developed and implemented.

Case Management Initiative
This initiative consisted of 3 project components based on the common Atlantic vision, definition and attributes developed by HIA. Case management is the term HIA has adopted to refer to systems that support the coordination of services external to the acute care or hospital sector. This area is very broad and includes home care; long term care, mental health clinics, and child welfare, etc. Case management applications were implemented in Nova Scotia (NS), Prince Edward Island (PEI) and Newfoundland and Labrador (NL). In NS, the case management application was implemented in the continuing care sector to support single entry access to home care and long term care. In PEI, a case management application was implemented in the provincial diabetes program. In NL, a case management application was implemented in a multi-jurisdictional government program targeting children and youth at risk.

In addition, information standards were developed for home care programs in Atlantic Canada in collaboration with the Canadian Institute for Health Information. These standards included a socio-economic standard, an interventions standard and a management information system standard. In addition, Atlantic Canada adopted the patient identification standard developed by the CCR standards working group and created a document describing home care programs in Atlantic Canada.

In Nova Scotia, a software application was purchased and customized to support single entry access to the continuing care sector. The application currently supports single entry access to the continuing care sector across the province along with a standardized approach to assessment and centralized management of waitlists for this sector. In addition, the province was able to purchase and implement the care planning module within the existing budget and within the CHIPP time lines.

To support the successful implementation of this software, extensive consultations were held with staff from across the province; business processes were examined and modified; comprehensive staff training packages were developed and implemented; change management plans were developed and implemented; software was acquired, customized, tested and implemented; hardware was acquired and deployed; and, a decision support system was developed and implemented. It is noteworthy that Nova Scotia is currently the first province in Canada to adopt and implement, on a provincial basis, the Resident Assessment Instrument for home care programs, which is a standardized tool that assesses the ability of applicants to manage their daily activities.

Prince Edward Island also implemented case management software with CHIPP funding. The PEI application will eventually support all community-based programs funded by the Department of Health and Social Services. During the CHIPP time frame, the application was acquired, customized and implemented in the diabetes program delivered by provincial home care staff. Further, extensive consultations were held with provincial home care staff; business processes were examined and modified; software was customized and tested, hardware was acquired and deployed; a decision support system was developed and implemented; and extensive staff training programs were designed and implemented.

The Department of Health and Community Services in Newfoundland and Labrador (NL) developed a case management system to improve the coordination of community-based services. During the CHIPP time frame, NL deployed a case management application to a government program that targets services to children and youth at risk. The "Children in Need" program is a program that encompasses several government departments including Health and Community services, Education, Justice, Human Resources and Employment.

During the CHIPP time frame extensive consultations were held with the key stakeholders to revamp the child profile form. The child profile form is the common communication and coordination tool used by service providers across various government departments involved with the program and needs to reflect the information requirements of all the areas participating in the program. During the CHIPP time frame, the child profile form was refined and adopted, and the software application was modified to capture the plans developed by staff for children and families being served by the program and to track those plans over time. In addition, consultations were held with management staff to develop reports based on the information captured in the application for planning and evaluation purposes. Further, additional capacity was built into the system to support ad-hoc queries. The technology was web-enabled with a secure safe-guard developed and implemented to protect the privacy and security of the client information.

Tele-i4 Initiative
All 4 Atlantic Provinces implemented aspects of Tele-i4 in selected sites. Tele-i4 stands for the interprovincial integration of images and information and refers to the capture and transmission of digital images and information across broad band networks within provinces and across provincial boundaries to support clinical care.

All provinces worked together to create and release a common Atlantic Request for Proposals (RFP) under the Atlantic Procurement Agreement. This was the most complex RFP ever released under this agreement. The Tele-i4 RFP consisted of sophisticated software and hardware requiring different configurations for each province. Digital imaging (DI) experts, radiologists and information technology experts from across Atlantic Canada worked together to create the RFP that also included the technical specifications and the evaluation criteria. Procurement staff from the Nova Scotia Department of Transportation and Public Works and an external procurement consultant were added to the working group to ensure that the right expertise was brought together to make the RFP a success. Following the completion of the RFP, the team of Atlantic DI experts continued to work together to develop the interoperability standards to ensure that images and identifying information would be able to travel between regions and provinces once the technology was operational.

In Prince Edward Island, the deployment started with a network review and upgrade to ensure that the volume and size of the images that would travel over the network could be accommodated. Once this was completed, equipment installations began at the Prince County Hospital in Summerside and the Queen Elizabeth Hospital in Charlottetown. A provincial archive was implemented at the Queen Elizabeth Hospital and all modalities were included in the Tele-i4 deployment at this hospital with the exception of mammography and chest xrays. Further, the installations at this site and the Prince County Hospital sites were web-enabled so that physicians in various locations in these facilities could access images as required. Radiology Information Systems (RIS) were deployed and connections were made between the RISs and Tele-i4 so that the images and the consultant's report could travel together across the system. The plan for the entire province is to be totally film less after the two phases of the project are completed.

Tele-i4 functionality was implemented in the following rural communities in Prince Edward Island: Souris, O'Leary, Alberton, Montague, and Tyne Valley and full PACS functionality was deployed in Summerside and Charlottetown.

In Nova Scotia, a provincial archive was established at the Queen Elizabeth II Health Science Center in Halifax to store CT digital images for the entire province. Tele-radiology systems were already in place in the radiology department of the Queen Elizabeth II Health Sciences Center with viewing capabilities in the emergency department. CT Scanners in all 9 regional hospitals were then connected to the provincial archive so that images could be sent to the QEII for interpretation and storage. Full PACS capability was deployed at the Dartmouth General Hospital and the IWK/Grace Hospital in the radiology departments and these sites were connected to the provincial archive as well. In regional sites, along with connecting the CT scans to the provincial network other modalities were connected as well, as time and budget allowed.

The regional sites included:

• Halifax
• Dartmouth
• Sydney
• Antigonish
• New Glasgow
• Yarmouth
• Bridgewater
• Truro
• Amherst, and
• Kentville

Work was undertaken with the telecommunications provider to determine the total bandwidth requirements for Nova Scotia to support the Nova Scotia Telehealth Network, Tele-i4, and the Nova Scotia Hospital Information System, which is currently being implemented across the province. In addition, due to the demand in the physician community for this technology, NS revisited and updated the Provincial PACS strategy that had been developed in 1998.

In Newfoundland and Labrador, Tele-i4 was implemented in a variety of locations throughout the province. This included deploying tele-radiology and PACS in a number of selected sites across the province including:

• Janeway Child Health Center, Health Care Corporation of St. John's,
• the Peninsulas Health Care Corporation,
• the Central West Health Board, and
• the Avalon Health Care Institutions Board

In addition, scanners and digitizers were installed in a number of rural community hospitals throughout the province and connected to the provincial network so that images could be sent to the regional hospital for diagnosis by a radiologist.

With cost-sharing from CHIPP, Tele-i4 was deployed in the following communities:

• Clarenville
• Bonavista
• Burin
• Grand Falls
• BaieVerte
• Springvale
• Harbour Breton
• St. Albans
• Carbonear
• Placentia and
• St. John's

The last task completed was connecting the provincial network to the Queen Elizabeth II Health Science Center in Halifax so that images could be transferred to the QEII and the IWK/Grace Hospital for Children for specialty consultation and referral.

In New Brunswick, Tele-i4 was implemented in emergency departments and radiology departments in selected sites in the province. Following is a list of the sites where Tele-i4 was deployed:

• Moncton
• Sackville
• Lameque
• Bathurst
• Woodstock
• Fredericton, and
• Ste Anne de Kent

All hospitals in New Brunswick are linked with a high-speed telecommunications network, known as the Wellness Network. For Tele-i4 this means that an image can be captured where the patient is located and transferred to any other facility in the province for appropriate diagnosis and consultation.

The CHIPP implementation of Tele-i4 focuses on the capture of x-rays only with a longer term plan for the province to be completely filmless once all modalities are included and the technology is deployed throughout the province.

Tele-i4 Interprovincial Connections
Each province has connected their Tele-i4 site installations to their regional and provincial networks. HIA put a team in place to coordinate the connections between provinces to ensure that transferred images and reports could be accurately and correctly assembled in the receiving facility. All provinces are now connected to the Queen Elizabeth II Health Sciences Center in Halifax, which has assumed the responsibility for moving the images to other locations in Atlantic Canada as required. HIA also established a standards committee to build on the patient identification standard developed for the Common Client Registry and extended for the Tele-i4 implementation. The patient identification standard was needed to ensure that sufficient information travels with the patient to ensure that the patient is correctly identified once the information is stored in the database.

Further Enhancements A number of provinces and regional health/hospital authorities provided additional funding to enhance the planned Tele-i4 deployment. The NB Department of Health and Wellness contributed an additional $1.0 million in funding and the NL Department of Health and Community Services contributed an additional $1.5 million. In addition, one of the NB Hospital Corporations contributed $1.9 million to move the region closer to its goal of being totally filmless in the next 5 years. Nova Scotia extended their planned deployment of the case management application to include the care planning module with the result that the continuing care sector is better supported with automation and they are now much better positioned to add additional modules to support care management. The deployment that was cost shared with CHIPP included intake, assessment, wait list management and care planning.

In New Brunswick, two regional health authorities where PACS equipment was already installed connected their equipment to Tele-i4 to broaden the service coverage in the province. Examples of additional sites that were connected to the Tele-i4 network as a result of this strategy include Campbellton and Edmunston. In addition, two other regional health authorities negotiated funding from the New Brunswick Department of Health and Wellness to acquire PACS technology and connected it to the Tele-i4 equipment. Examples of additional sites connected as a result of this strategy include Saint John and Miramichi.

In Newfoundland and Labrador, additional funding was used to expand the implementation at the four regional board's central sites. This investment allowed these sites to acquire the additional equipment necessary to bring additional modalities online and increase access to the system throughout their primary sites. Through these investments, boards are positioned to make a significant reduction in the use of film, which will facilitate further improvements in service and generate savings, which can be applied against the operational cost of the system as well as support further expansion at additional sites.

Nova Scotia was able to connect a number of additional digital modalities in selected regional hospitals to the provincial Tele-i4 infrastructure within the existing budget. Nova Scotia was also able to update their provincial PACS strategy to reflect the current status and to plan better for the future. Critical to this plan is the integration of Tele-i4 with the Nova Scotia Telehealth Network and the Nova Scotia Hospital Information System.

Contributing Factors
The following factors contributed to the successful implementation of this large complex project:

• HIA selected their priorities based on strategic planning processes that were in place in each of the provinces. This ensured that the HIA Project Components would have clear support and would be sustainable over time.
• HIA representatives had the appropriate authority, mandate and experience to implement projects of this size and complexity.
• HIA acquired the appropriate resources to ensure project success including project management, technical expertise and subject matter expertise.
• HIA established a Project Office to be the central coordinating body for a number of functions including quality management, finance, communications, evaluation and reporting.
• HIA used a common project management methodology across all initiatives and project components to report regularly on the progress of all project components.

Obstacles and Challenges
The following lists some of the challenges and how they were addressed:

Resizing and Rescoping the Original Project Plan
One of the first challenges that HIA had to address was the revision of project scope based upon a CHIPP award that was substantially less than requested. A similar strategy to the preparation of the original CHIPP application process had to be launched to revise the project plan and rescope the project with the multitude of stakeholders involved. This exercise had to be executed carefully to ensure that support and cooperation across the health care enterprise could be maintained at the same time as expectations had to be managed to fit a smaller budget. In addition, CHIPP required the completion of an entirely new set of forms and schedules describing the project plan.

Common Atlantic Request for Tele-i4 Equipment
Another significant challenge early on in the project was the common Atlantic Request for Proposals (RFP) that HIA developed to purchase Tele-i4 equipment. Constructing the RFP, meeting Atlantic procurement guidelines, ensuring that provincial requirements were met, and ensuring that the evaluation criteria were clearly and fairly developed for the vendor community was very challenging. In addition, there was an added time constraint imposed by Health Canada for reprofiling the allocated budget, if needed, into the next fiscal year. To ensure that HIA didn't risk losing federal funding but still could release a good quality RFP, allowing sufficient time for vendor responses, evaluation, and follow-up, HIA added a government procurement specialist to the working group and also hired the services of a procurement expert.

Compliance with CHIPP Reporting Requirements
The HIA Project Portfolio was a very large and complex project comprised of 8 project components totaling $24 million dollars. CHIPP required the submission of quarterly claims consisting of a number of schedules including expenditures for consultants, equipment, labor, direct materials and other. Schedules had to be completed for each project component and then amalgamated into a single claim for submission to CHIPP for payment. To address the reporting requirements, HIA created a Project Office to amalgamate the information supplied by each Project Manager into a single claim. Project Managers were asked to use the forms defined by HIA and submit their documentation according to a pre-defined schedule each quarter. When HIA became concerned about fiscal year expenditures, Project Managers were asked to report their expenditures monthly. In this way, HIA could monitor the expenditures and claims for the entire project on a regular basis.

Adopting a Common HIA Project Management Methodology
To ensure that good project management practices were used across all projects and to reduce the risks associated with the implementation of this large and complex project, HIA adopted a common project management methodology and trained all the project managers in the use of this methodology. In addition, to provide support to the project managers and to ensure that project risks were adequately identified and addressed, HIA hired a Quality Manager. The Quality Manager met with each of the Project Managers monthly to review progress and to ensure that all HIA and CHIPP documentation and reporting requirements were met.

3.2 Additional Successes

HIA enhanced a number of the project components with additional funding provided by provincial departments of health, regional or hospital authorities and by extending the use of available dollars. Both the governments of New Brunswick and Newfoundland and Labrador provided additional funding for the Tele-i4 project components. The New Brunswick Department of Health and Wellness provided about $1 million in additional funding for the Meditech interfaces so that the Tele-i4 deployment could be seamlessly integrated into existing hospital information systems. This supported the inclusion of two additional sites, Campbellton and Edmundston, and the ability to connect other legacy-based sites to the existing network, such as Saint John and Miramchi. Further, Region 1 South East (Moncton) decided to build on to the infrastructure being deployed with CHIPP funding with an additional $1.9 million in funding to accelerate their plan to become completely filmless in 2003.

The Newfoundland and Labrador Department of Health and Community Services provided additional funding of $1.5 million. This investment allowed the central sites at four regional health boards to bring additional modalities online and increase access to the system throughout their primary sites. Through this expansion, boards will be able to improve services and reduce expenditures on film and film processing. This will also generate savings, which can be applied against the operational cost of the system as well as support further expansion at additional sites.

In Nova Scotia, several other modalities, in addition to the CT scanners, were connected to the provincial archive located at the Queen Elizabeth II Health Sciences Center in Halifax. This was done within the existing Tele-i4 budget, at very little cost but with significant benefits to patient care. Further, the adoption of common standards and provincial planning supports the integration of the Tele-i4 implementation with other provincial information technology deployments either existing or in the process of being implemented, such as the Nova Scotia Telehealth Network and the Nova Scotia Hospital Information System. With good management, careful planning, and strong support from staff in the field, the deployment of the Nova Scotia case management project was extended to include the care planning module with significant benefits to patient care and staff productivity. This brings the Nova Scotia case management application to the point where additional modules can be deployed for the management of home care services which is a significant step for the planning and delivery of a provincial program.

Contributing Factors
In all cases, where the project was extended by either additional funding or through enhanced deployment of existing dollars, there was strong support from service delivery staff. In the case of Tele-i4, the technology is in demand from the radiology community who see the value to patient care and to their ability to deliver a high quality service. There has been considerable push from the field to acquire this technology and once a province starts down this path, organizations see the value and are willing to provide funding. There continues to be considerable pent-up demand for this technology. HIA attempted to meet the existing demand by implementing the technology to address a care need and support an existing care delivery model. This was the right amount of change to introduce at the time and its success is an important change management lessons learned.

3.3 Unreached Goals

In New Brunswick, the planning and design phase examined how best to deliver and support the archive function, determining whether it should be centralized or decentralized. After careful consideration of the options in light of available funding, the province decided to proceed with a decentralized archive function rather than a centralized provincial archive. A similar exercise was conducted in Newfoundland and Labrador to address the best configuration for their archive and they decided to proceed with a decentralized archive configuration as well. The decision to proceed with a decentralized model in both cases was based on a closer examination of the requirements, the costs of acquisition and implementation, and how best to proceed given limited resources and short time lines. The objectives were still achieved for these projects and, in fact, the deployments were enhanced as funding was made available from other sources such as provincial ministries of health, hospitals or regional boards.

3.4 Documents or Product Generated

Document/Product Name	Available in Paper and/or ElectronicForm	License Fee Required for use (Yes/No)	Previously Provided to Health Canada(Yes/No)	Appendix Name/Number
Template(s) for vendor RFP	E	No	No
Template(s) for vendor contract(s)	E	No	No
User Guide(s) and/or Training Manual(s)	E Project Management Manual	No	No
Template(s) for equipment testing	No	NA	NA
Policy and Procedure Manual(s)	E Project Management Manual	No	No
Job Descriptions and/or recruitment material	E For HIA Project Office staff	No	No
Software Application(s), includes: EHR application Security/access alert software Telehealth scheduling software Other	No	Yes	No
Standards, includes: Data (includes minimal data sets) ImageMessaging Other	Yes, E	No	No
Clinical Training Protocols	NA	NA	NA
Clinical Program Protocol(s)	NA	NA	NA
Video Conference Protocols and Etiquette Guide	NA	NA	NA
Quality Assurance Procedures	E, Quality Management part of Project Management Methodology	No	No
Confidentiality and Privacy Documents	E, Security Documents for Tele-i4	No	No
Consent Forms	NA	NA	NA
Sustainability Plan	No	No	No

4.0 Main Impact

The Impact the HIA Project is making in the Community/Region
Service to rural areas of Atlantic Canada has improved as a result of the Tele-i4 project. Diagnostic images are now moving at a faster rate than before saving patients the time, expense and inconvenience of traveling to other locations for service. The fact that the information is moving rather than the patient reduces the risk to the patient as well, particularly in the winter months where many roads are not passable when winter storms move in. Specialty services and sub-specialty services in regional and tertiary centers are now more easily accessed than before with faster turnaround times for consultation and referral.

The Impact on Patients, Health Care Professionals, and the Organization's Management and Structure
The Tele-i4 Initiative is making a difference to the patient population in Atlantic Canada who are recipients of diagnostic services. As a result of the Tele-i4 implementation, specialty and sub-specialty consultation and referral are now available to many residents of rural communities at the click of a mouse. Patients in rural communities only need to travel if it is necessary as the technology moves the information, rather than the patient having to move to the service location. Further, radiologists in certain areas of the Atlantic region are now able to arrange improvements to their on-call schedules as a result of this technology. HIA anticipates that the health care system's ability to recruit and retain physician specialists, including radiologists, in rural communities, will be positively affected by this technology. In fact, this is already happening. PEI was able to recruit 2 new radiologists as a result of this technology. The demand for this technology will escalate as more and more radiologists discover its benefits and its ease of use. In addition, there is already considerable demand from the radiology community to make the images web-enabled so that radiologists and consulting physicians can view the images from home or office over secure networks. Other project components such as the case management projects in NL, NS, and PEI and the Common Client Registry in PEI have increased program efficiencies and staff productivity. Patient care benefits are also being realized in the NL case management application through improved coordination of services to children and youth targeted by this program. Similarly, in NS and in PEI, efficiencies were created in the service delivery system with the result that more provider time could be devoted to service delivery as efficiencies were captured through the technology for inputting and accessing the forms.

Also of critical importance is the increase in information that will be available to policy, planners and researchers as a result of these projects. Information from operational databases is now available to planners and policy makers through the development and implementation of decision support systems thus moving many of these programs to a better basis for evidenced-based decision making.

Changes Noted in the Provision of Services
While it is a little too early to expect or detect changes in service provision, the deployment of Tele-i4 across each province and across Atlantic Canada has started discussions between radiologists, at least in Nova Scotia, on their on-call schedule. Currently, radiologists are in short supply in certain parts of the province and in some of those areas they have started to take advantage of the technology that allows them to push images to another location for interpretation. This results in fewer on-call shifts than before as physicians can push the image to another site for diagnosis and consultation.

Potential Impact on the Development of Responsive Health Delivery Policy and the Applied Research Agenda
While it is somewhat premature to be reporting implementation findings, it is worth noting that all project components will, over time, support improved service delivery and system planning. For example, the Common Client Registry in Prince Edward Island with its associated decision support system will begin to reveal important information about the provincial population that can be used for improved planning and service delivery. Each of the case management applications as a result of the capture, storage, retrieval and analysis of information will begin to assemble information that can be used to improve the service delivery system. As these databases capture more information over time they will be used for policy analysis, improvements in service delivery, and improvements in the overall management of the health care system. Similarly with Tele-i4, the availability of provincial archives provides a very rich source of data for medical training, continuing education and research. Mining these data will result in improvements in the health delivery system and also support tracking specific diagnoses and patient outcomes over time thereby improving both the clinical system and the management and organization of health care.

4.1 Human Resources Impact

There have been human resources impacts even though this technology is still just newly deployed. A more complete understanding of the impact of this technology on human resources will likely take close to a year to realize. Certainly, some of the Project Managers hired to implement the Project Components have acquired new skills, specifically in the area of project management methodology. Many staff across Atlantic Canada were trained on the use of the applications deployed. In addition, some staff had to be trained first on the use of computers.

Turning to the case management systems that were introduced with cost-sharing from CHIPP, efficiencies were captured as a result of the software. For example, in NL, anecdotal information indicates that the staff time required to complete the child profile form was reduced by 30% with the introduction of the computer application, thus freeing up valuable staff time to devote to patient care.

In the case of Tele-i4, demand for the technology has increased with the introduction of Tele-i4. Service providers are also using the technology to improve their working conditions. For example, there is a shortage of radiologists in some parts of Nova Scotia. With the introduction of Tele-i4 and the provincial network, radiologists in Antigonish and New Glasgow are now sharing their on-call schedules as the technology allows them to push the images to the other location. HIA anticipates that as the technology becomes more widely used over time, physician recruitment and retention strategies will be positively affected.

For each of the project components, staff and physician providers, were trained on the new technology. These skills are specific to the individual applications but generally speaking this increases the computer skill set of the staff and their comfort level with computer applications and viewing images and other information on line. Further, position requirements have changed for specific positions and some positions were reallocated to accommodate the introduction of the technology. In other cases, new positions have been created for administration and support.

It is not known at this time if job satisfaction has changed. However, for the Tele-i4 initiative, the radiologists are very pleased with the technology. Prince Edward Island, for example, was able to recruit two new radiologists as a result of this technology. Further, with the other project components, staff have indicated in a variety of different ways that they are pleased with the automation. As staff and physician providers become more comfortable with the technology, it is expected that productivity will improve.

4.2 Privacy and Protection of Information

Privacy and the protection of personal information is a critical issue for all provincial health care systems. In general, how provinces protect personal information is established in provincial legislation and also reflected in the professional code of ethics of the providers. With the HIA Project, existing processes were automated; therefore, no new processes were required for either patient consent or for the sharing of clinical information across regional and provincial boundaries. For example, for Tele-i4, x-ray film is routinely transferred between hospitals, within provinces, and across provincial boundaries using courier systems and, in some cases, taxis. Tele-i4 automated this process and introduced the ability to capture and transfer digital images across secure networks between hospitals and across provincial boundaries. The case management applications also automated existing processes but more extensive planning was done to determine who could access the record and under what circumstances. In addition, some provinces requested changes in the software to ensure that an audit trail existed so that it could be determined who had looked at the information stored on the record. Also, consent can be captured and noted in the electronic system. For example, the PEI case management application prints the patient consent for the patient to sign and once signed, a flag is set in the software to indicate that it has been signed.

4.3 Policy and Research Implications

It is difficult to assess at this point in time the policy and research implications except to note that with the development and introduction of decision support systems for the common client registry and case management projects that the needs of the decision makers will be addressed is a far superior way than they were in the past. In the case of Tele-i4, it is clear that easy access to the historical data residing in a provincial archive will improve the ability of clinicians to monitor a patient's progress but it will also support improved research on specific diseases compared to the past. Further, the availability of radiological images in an archive will also support improved training of radiologists over time.

5.0 The Future

One of the key criteria for funding under the Canada Health Infostructure Partnerships Program (CHIPP) was the commitment to ongoing operational funding. HIA was very careful to address this point in the preparation of their application for funding by ensuring that the projects selected were based on the key priorities of the provincial health care systems in Atlantic Canada. HIA's priorities were derived from the key priorities of each of the Atlantic Provinces to ensure sustainability over time. HIA had support from the key stakeholders in the health care system in advance of preparing and submitting the application to CHIPP.

Tele-i4 has been rolled out in selected sites across the four provinces and staff have been hired who are responsible for the maintenance and support of the application and its users. The implementation of Tele-i4 across Atlantic Canada has increased the demand for this technology to the extent that some jurisdictions contributed additional funds to enhance the planned deployment. Further, at least one jurisdiction reviewed and updated the provincial plan for deployment of this technology and planned for its integration with other applications including the use of the provincial network. Other provinces reevaluated and increased their existing bandwidth requirements to ensure that it could meet the needs of Tele-i4.

PEI's approach for its case management application was somewhat different from the other provinces in that they plan to implement the same case management application to the entire community-based services sector which encompasses over 15 program areas and more than 40 services. The CHIPP component of the project included only one of these program areas going live but over the next 2 years the remaining program areas will be implemented and operationalized.

6.0 Communications

Methods	Date	Audience	Documents	Appendix
Conference	1. Atlantic Health Information Systems Conference, September 2001 "Health Infostructure Atlantic and the HIA Project Portfolio"	Health IT/IM	On Website	1
Conference	2. GTEC Conference, October 2001 "Health Infostructure Atlantic and the HIA Project Portfolio"	Government IT	On Website	2
Conference	3. Canadian Evaluation Society Annual Conference, May 2002 " Panel Presentation"	Evaluation Experts	On Website	3
Conference	4. Atlantic Health Information Systems Conference, October 2002 "Integrated Services Management Overview" "Health Infostructure Atlantic: Case Management Project" "Nova Scotia Case Management Project" "Tele-I4 Initiative: The HIA Project Portfolio"	Health IT/IM	On Website	4 5 6 7
Conference	5a. Canadian Society for Telehealth"Lessons Learned for Telehealth Evaluation", October 2002 5b. Canadian Society for Telehealth "Challenges with Interoperability" 5c. Canadian Society for Telehealth "East Meets West: Comparisons in Telehealth"	Telehealth Telehealth Telehealth	On Website On Website On Website	8 9 10
Conference	6a. Canadian Institute for Health Information, November 2002 "Health Infostructure Atlantic: Tele-i4 Standards Development and Implementation" 6b. Canadian Institute for Health Information, Spring 2002 " PEI Approach to Common Client Registry"	Health IT/IM Health IT/IM	On Website On Website	11 12
Conference	7. e-Health May 2003: "The HIA Success Story"	Health IT/IM	On Website	13
Future Presentations	1.Canadian Society for Telehealth, Oct. 2003 "Health Infostructure Atlantic and Atlantic Canada Convergence"	Health IT/IM	Will be on Website
	2. Atlantic Health Information Systems Conference, Oct 2003 "The HIA Project Portfolio and Lessons Learned Through Collaboration and Evaluation"	Health IT/IM	Will be on Website
	3. Government in Technology, Oct 2003 "Health Infostructure Atlantic: A Regional Success Story"	Government IT	Will be on Website
Media Events	CHIPP Announcement by Health Canada, May 2001	Public	On Health Canada Website
Publications	2 publications in Health Care Information and Communications	Health IT/IM	On Website
Open House	1 Sept, 2001 HIA Project Office	NSDOH Staff
Marketing / Advertisement	1. Pamphlets and Brochures in French and English	Health IT/IM
	2. Video in French and English	Public; Health; Health IT/IM
Website	www.gov.ns.ca/health/hia/

7.0 Other

This has been a large, complex and challenging project for the Atlantic region that was implemented on time and on budget and even exceeded expectations. Through this project, HIA has demonstrated the value in working together collaboratively to implement health information technology to the benefit of Atlantic Canadians. HIA has also demonstrated that it is possible to put in place the basic building blocks for an interoperable electronic health record based on the adoption of common standards.