SYNAPSE #89

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 Products 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 1999, the Government of Canada announced the Canada Health Infostructure Partnerships Program (CHIPP). CHIPP was a two-year, shared-cost incentive program, aimed at supporting collaboration, innovation, and renewal in health care delivery through the use of information and communication technologies. In August 2000, the SYNAPSE partnership, having comple ted Phase I of SYNAPSE development, applied for and was successful in obtaining a CHIPP grant for Phase II implementation and enhancements.

SYNAPSE is a software application that collects and presents clinical and administrative information about Mental Health clients/patients in the form of an Electronic Health Record (EHR). This EHR for mental health is intended to track care episodes across the full continuum of mental health services for the seriously and chronically mentally ill, including inpatient psychiatry and emergency, outpatient, community, and residential programs, but excluding physicians' offices. The design, creation and implementation of SYNAPSE were the collaborative effort of health authorities, federal and provincial governments, research and data institutes, and individuals representing an array of content and technical expertise.

Initially the project involved the former North Shore, Coast Garibaldi, and Northern Interior Health Regions. The original version of SYNAPSE was first installed in December 2000 within the North Shore Health Region. The current version is operational within parts of the Vancouver Coastal Health Authority (VCHA), which now includes North Shore and Coast Garibaldi communities, and the Northern Health Authority (NHA), which includes Northern Interior communities.

2.0 Project Description

CHIPP is supporting 2^nd phase of a multi-phase roll-out of a regionally networked patient information system for mental health patients. With the restructuring in BC, this project now falls under the Vancouver Coastal Health Authority. The Authority, with its partners, will implement a comprehensive, standards-based electronic health record system to support the information management needs of mental health service providers.

3.0 Achievements

3.1 Goals Reached

SYNAPSE was designed to address the "critical lack of integrated information systems for mental health in Canada" as resulting in a "lack of quality information about mental health patients/clients and the services they access." Consequently, missed or incomplete referrals, inefficient and duplicate processes for managing clinical information, and incomplete or illegible information about clients, utilization, cost and outcomes were seen to pose considerable risk to the delivery and optimization of services and the well-being of clients. The goals of the SYNAPSE project as set out by the project and system developers were:

1. "To facilitate the highest quality of care to clients and patients through the provision of accurate, relevant and timely clinical information at every point of care throughout the mental health continuum."
2. "Through multi-jurisdictional implementation and ongoing collaboration, to develop a client-centered, standards-based Electronic Health Record that supports regional, provincial and national health information management strategies."

The SYNAPSE work plan, as originally approved, underwent very minor revision during the life of the project. This is truly a testimonial to the diligence of the project team, and the excellent working relationship that the team enjoyed with the CHIPP office at Health Canada. Every work plan item was either completed in full, or completed according to revised metrics established during the tenure of the project.

The key factors that led to the success of this project were as follows:

• Clear project goals and objectives
• Outstanding executive support throughout the duration of the project
• Rigorous project management, using people, tools and techniques
• Active communication amongst team members, project sponsors, project funders, and our "community of interest".

There were few obstacles and challe nges experienced by the project, and these were mitigated through the activation of risk management procedures. The only significant challenge was the underestimation of the amount of administrative overhead required to meet the reporting requirements of the CHIPP office. This was, in part, exacerbated by the involvement of no less than four (4) CHIPP project coordinators, with seamless continuity hampered by steep learning curves, extensive explanations of previously-negotiated agreements, and varying le vels of understanding of the health care "context" of the SYNAPSE project. However, at the end of the day, challenges were met with willingness to move forward, and we applaud the commitment of the CHIPP office in overcoming these potential obstacles.

3.2 Additional Successes

Beyond the original project scope and work plan, the SYNAPSE project was very active in attracting new partners during the Phase 2 time frame. The number of implemented sites doubled, with the addition of the Royal Ottawa Health Care Group and Dalhousie University's Graduate Program in Health Informatics. Evaluations versions of the software were installed at the Winnipeg Regional Health Authority and Saskatoon Health Region, with planned evaluation implementations at Regina Qu'Appelle Health Region and the Yukon Territory Mental Health & Addictions program.

In addition, the SYNAPSE Project was contracted to help another CHIPP initiative, Project Outreach, fulfill it's obligations to implement an EHR model to support telemental health. This implementation was completed according to plan.

And finally, success can often be measured by the sustainability of the project after the funding has ended. Indeed, SYNAPSE remains healthy and vital, and plans are currently underway to launch Phase III "aggressive development" activities during the upcoming year.

3.3 Unreached Goals

Of all the goals set out originally, the only ones that were not fully achieved were those involving the implementation of the Residential Assessment Instrument for Mental Health (RAI/MH). This was primarily due to delays in publication of the specifications, as well as lack of clarity regarding implementation licensing beyond the Province of Ontario. However, the project was able to successfully influence the Ontario Health Ministry and CIHI to plan a national roll-out of this tool, allowing full integration into SYNAPSE as part of Phase III.

3.4 Documents or Products Generated

While implementing your telehealth system or electronic health record solution you may have developed a number of useful tools or products.

The chart below lists some of the tools and products that you may have developed. If you have a document or product that does not appear please add it.

Please note that, as per the contribution agreement, Health Canada must receive a copy of any tools and products that were developed through CHIPP funding.

Document /Product Name	Available in Paper and/or Elec-tronic Form	Licence Fee Required for use	Previously Provided to Health Canada (Yes/No)	Appendix Name /Number
Template(s) for vendor RFP
Template(s) for vendor contract(s)
User Guide(s) and/or Training Manual(s)	Published electroni-cally on the SYNAPSE website	NO	Yes
Template(s) for equipment testing
Policy and Procedure Manual(s)	Develop-ped by imple-mentation partners VCHA and NHA	No	No	Available from implementation partners
Job Descriptions and/or recruitement material	Contract deliver-ables	No	Yes
Software Ap-plication(s), includes: EHR application Security /access alert software Telehealth scheduling software Other	Full source & object code for the SYNAPSE application	None. This product is fully available in the public domain (public health organi-zations in Canada)	Yes
Standards, include: Data (includes minimal data sets) Image Messaging Other	Data model fully available. Data mes-saging specifi-cations and impli-cations fully available.	None. This product is fully available in the public domain (public health organi-zations in Canada)	Yes
Clinical Training Protocols	Fully available on the SYNAPSE website	No	Yes
Clinical Program Protocol(s)	Fully available from Project Partners	No	Yes
Video Conference Protocols and Etiquette Guide
Quality Assurance Procedures
Confidentiality and Privacy documents	Fully available on the SYNAPSE website	No	Yes
Consent Forms	Fully available on the SYNAPSE website.	No	Yes

4.0 Main Impact

An objective of the SYNAPSE project is to promote the adoption and implementation of standards, particularly concerning data, technology and policy. Indeed, the popularity of SYNAPSE has grown dramatically over the phase funded through CHIPP, and the original expectation for implementation on a pan-Canadian level has doub led since the funding was first secured.

SYNAPSE has successfully raised awareness across Canada of the importance of the electronic health record in the diagnosis and treatment of mental health. In fact, as the healthcare industry continues to evolve, it is now apparent that SYNAPSE has equal benefit in its support of Addictions programs as well. All new implementations are moving forward based on this expanded scope.

SYNAPSE technology has also led the way towards the utilization of best practices in the creation of the EHR. The SYNAPSE service-event based data model is well-accepted in the field, as is the use of HL/7 standards to support loosely-connected integration across EHR domains, ensuring consistent semantic meaning. These successes are an integral part of the projects go-forward strategy, especially as new funding will be tied to the industry's maturity around EHR standards.

Clearly, the introduction of the EHR into Mental Health and Addictions services has had a significant impact on patient/client care. There are many anecdotal examples of persons entering the system who are assessed and treated with the benefit of appropriate information available at the point of service, where many of these cases would have previously led to long-stay admissions into inpatient Psychiatric facilities.

4.1 Human Resources Impact

The introduction of SYNAPSE had significant impact on the clinical and administrative staff working in Mental Health. The project evaluation points out the expected initial resistance to change, with the eventual reliance on new functionality. Today, staff has improved tools, better policies and a more coordinated delivery system within which to provide care, largely due to the insertion of SYNAPSE.

4.2 Privacy and Protection of Information

Early on, SYNAPSE development undertook the task of defining a Security/Privacy framework to enable appropriate information-sharing across the domain of Mental Health and Addictions services. The result was a touchsto ne document, called the Privacy/Risk Assessment Team (PRAT) Report, which set out principles that balanced the emerging legislative requirements with principles of care across a health authority. This document was produced with the full participation, and ultimate approval, of the BC Office of the Privacy Commissioner.

A Privacy Impact Assessment was conducted and filed, pursuant to BC Ministry of Health policy. The CHIPP Privacy and Security survey also assessed the SYNAPSE initiatives in this area, and provided very positive comments and feedback.

The privacy/security work undertaken during the CHIPP-funded portions of SYNAPSE had the following benefits:

• raised general awareness of the importance of appropriate privacy/security policies and procedures;
• helped to harmonize consistent policies across the full health care continuum, across the entire health authority domain;
• demonstrated that significant sharing of clinical information could, in fact, be accomplished within the boundaries imposed by PIPEDA and various provincial legislation and policy;
• garnered the support of Privacy Commissioners in BC and in other jurisdictions;
• no significant privacy/security concerns have been raised since SYNAPSE was first implemented at VCHA in December 2000, nor were any patient complaints lodged;

4.3 Policy and Research Implications

The SYNAPSE project had no major policy and/or research findings to report at this time.

5.0 The Future

SYNAPSE has undergone extensive planning for sustainability post-CHIPP. Most significantly, ongoing funding requirements were divided between "sustainability funding" and "aggressive development funding". This allowed the ongoing commitment of major stakeholders to support ongoing management and maintenance of the system, while simultaneously allowing for the attraction of grant funding to support major initiatives. The SYNAPSE project has been functioning on this basis since December 2002.

Sustainability for pan-Canadian initiatives has a number of barriers that must be overcome, and these were outlined in a recent article published by this author¹:

Challenge #1: Governance in a pan-Canadian Environment

Originally, as a health authority initiative, the governance of SYNAPSE was simply based on an accountability model that vested "ownership" with the senior leadership of the region's mental health program. However, as the project quickly grew into a "collaborative venture" amongst several health authorities, this model became inappropriate. In fact, to ensure a collaboration based on equally-shared benefit and risk, it became necessary to move the SYNAPSE project team to a "shared management" model, where direction was based on the collective wisdom of all the partners.

Had the project been restricted to BC-based partners, the architects of BC's newly-restructured provincial health system would have likely suggested that SYNAPSE governance and management rest with the Provincial Health Services Authority, "...the umbrella health authority responsible for health care agencies and programs that serve patients across the province."^a However, with the target domain clearly pan-Canadian, this model, too, is inappropriate.

Which raises the issue, what infrastructure exists within Canada to provide governance to a pan-Canadian initiative? Health Canada... not their business. CIHI...; perhaps, but not really aligned with their business either. WHIC^b and HIA^c... the right idea, but currently only regional collaboratives. And what about Infoway... the jury is still out, but owning and managing pan- Canadian initiatives is not currently one of their stated objectives.

Of course, the SYNAPSE partners could always elect to set up a national, not-for-profit society to own and operate the assets, and this option is currently being seriously considered by the SYNAPSE Steering Committee. However, there remains no existing national infrastructure that is clearly in place to provide governance to pan-Canadian initiatives.

Challenge #2: Sustainable Funding

As SYNAPSE transitions from a "project" to a "sustainable EHR application", there are new challenges to maintaining sustained financial stability.

Common to many projects recently funded by "one-time" grants, continued success depends largely on the successful implementation of an on-going funding program that allows both maintenance of existing function, together with continued growth.

The model selected by the SYNAPSE Steering Committee is a hybrid model, addressing both the above-stated needs. The first envelope is described as "Sustainability Funding", and is targeted essentially towards maintaining the status quo (including function & number of installed sites), with provisions for on-going maintenance, "minor" enhancement, system & implementation support, and helpdesk services. It is felt that partners and stakeholders are best engaged over time only when there is a direct stake in the operation and funding of the system, and for this reason Sustainability Funding is borne entirely by the organizations that use and benefit from the system.

The other envelope is called "Aggressive Development Funding", and covers the further pursuit of standards for data, technology and policy, as well as a program of rapid deployment Canada-wide. Funding this component is considered a series of capital (one time) expenses, and is best suited to grant funding. The SYNAPSE team is currently pursuing Infoway as a primary source of capital funding

Challenge #3: pan-Canadian Interoperability

The premise of a "virtual EHR" composed of slices is predicated on the rigorous implementation of a standardized approach to "integrating the slices". In healthcare, this clearly rests within the domain of HL/7^d, and its international HL/7 affiliates.

SYNAPSE has implemented HL/7, in the form of an "HL/7 transaction processor/parser" companion product, also available freely within the public domain. Currently, this interface is used to tie SYNAPSE to the "HIS" products at partner health authorities, as well as to provincial repositories in B.C. providing client registry/eligibility and Pharmacy services.

The growth of SYNAPSE to a pan-Canadian EHR component will, by definition, require tremendous expansion and adoption of the HL/7 tools required to universally connect systems. There is a growing movement to adopt the Version 3 standards of HL/7, which are based upon the fundamentals of a Reference Information Model (RIM) that is not unlike the Canadian Conceptual Health Data Model^e under which SYNAPSE was built. With the added acceptance and use of XML tags for communication of messages, applications will truly interoperate as a single, logical entity. A few years from now, SYNAPSE will need to connect to health authority "enterprise EHR" systems, as well as to various data stores maintained by every province and territory, and even nationally.

Challenge #4: Data Interchange amongst Health Authorities

At present, any health authority can implement pieces of the EHR that meets their specific, internal needs. The future, however, will see a shift to more "system" view, whereby health authorities will be acting in concert regarding the sharing and exchange of information. This is best illustrated by recent developments of "minimum data sets" (MDS).

The premise the MDS is simple: a patient or client who presents at Health Authority "A" will have their "basic" clinical history available to the responding clinician, no matter where previous care episodes occurred. This "basic" data is defined through the universal acceptance of the MDS standards, and the EHR tools must have the ability to retrieve the appropriate data from the various remote sources. SYNAPSE has already built the required tools to communicate using HL/7 however the adoption of MDS standards is not presently well-developed across the country.

Challenge #5: Primary Care Integration

There is great interest, and significant funding available, to pursue methods of integrating the EHR with "slices" traditionally only available in the primary care setting. These EMR systems were originally designed to assist physicians with practice management and billing, however there is a growing expectation that primary care systems and health authority EHR systems will soon be required to exchange clinical information with one another.

SYNAPSE is currently addressing only the first steps in primary care integration... access to the clinical mental health record from the primary care setting. There have been some discussions with EMR vendors about full interchange of "appropriate" clinical information, however the debate as to the extent of information sharing is still in its infancy.

Challenge #6: Implementation & Training

Supporting users across large geographies has always been a challenge. However, in an environment where public domain software needs to be implemented and maintained at the lowest possible cost, traditional methods are no longer acceptable. With SYNAPSE already implemented coast-to-coast and expanding rapidly, the imperative is clear.

So, what methods are available to cost-effectively implement and train across the Canadian pan-scape?? The SYNAPSE Project has effectively shrinkwrapped the software installation scripts, so that new sites can be up and running quickly, and with minimal technical resources. Training tools (including manuals, PowerPoint presentations, and exercises) are continually being improved by training staff.

One of the most effective techniques being deployed is a streaming webcast, available merely by clicking a link on the SYNAPSE website, and within the application itself, which "walks" a user through a 9-minute system overview. Targeted at new users needing orientation, as well as prospective health authorities evaluating SYNAPSE, this tool combines audio, video, full-motion screen capture, and Powerpoint slides to provide a broad "look and feel", without the need for staff to travel to remote locations.

Challenge #7: Ongoing Collaboration with other EHR Initiatives

The CHIPP funding envelope encouraged EHR projects collaborate with one another, although this was typically limited to the community of CHIPP-funded initiatives. Up to now, SYNAPSE has successfully enjoyed collaboration with Project Outreach, Provider Registry, the SSIMS Project, and the Public Health Information System (PHIS) initiative funded by Health Canada but outside of CHIPP.

New opportunities for collaboration abound. The suite of Infoway-funded projects are intended to work together in some kind of integrated fashion. Other initiatives coming out of WHIC, CIHI^f, health authorities and other collaboratives need to be linked together to ensure consistent focus, leading to (hopefully) eventual interoperability. Finding ways to bring initiatives together is a necessity of the pan-Canadian domain, and these might include workshops, registries, and conformance certification. Today's champions must be brought together with tomorrow's leaders, in order to maintain a pan-Canadian context under which to evolve the electronic health record.

As mentioned previously, SYNAPSE continues to flourish under Phase 3. Funding levels are sustained by the partners, and the number of partners continues to grow. Significant attention is currently being directed towards obtaining funding through Canada Health Infoway Inc., to support ongoing initiatives such as:

• Integration of the CDA standard into SYNAPSE;
• Imbedding the RAI-MH instrument
• Creation of a French-language version of the software
• Integration with messaging and scheduling systems

6.0 Communications

Methods or Tools	Date	Target Audience	Documents or Presentations Produced	Appendix Name /Number
Conference	10-12 presentations	Health infor-maticians, standards experts, mental health professionals, psychiatrists, government information architects, security /privacy experts, etc.	All available on the synapse website: www.synapse-ehr.com.
Media Events	SYNAPSE launch, UBC	general media
Publi-cations	Many documents, including reports, presen-tations, articles, etc.	general public, healthcare professionals (clinical, admin-istrative, IM/IT, etc.)	All available on the synapse website: www.synapse-ehr.com
Open House
Marketing/ Adverti-sement
Website (please provide the Website address)	Yes. www. synapse-ehr.com	general public, healthcare professionals, "community of interest".	All available on the synapse website: www.synapse-ehr.com

7.0 Other

No issues to report.

References