The opportunity for connected care with digital health never better

Bill S-5 the Connected Care for Canadians Act (CCA), is a long overdue and necessary development. This bill along with Canada Health Infoway’s 2023 Shared Pan-Canadian Interoperability Roadmap (Roadmap) need to be further refined, detailed and brought up to date. Digital health connectivity is certainly the main goal, but we need to innovate how we do it. There are strategies available to us today that were not available or mature just a few years ago.

Additionally, we must re-think our interoperability approach in Canada. We should do that by utilizing and refreshing the award-winning 2006 EHRS Blueprint – An Interoperable EHR Framework (Blueprint). Twenty years is a long time, and the current state of digital health and available enabling technologies have changed considerably. The Blueprint’s reference architecture is resilient to those changes. The Roadmap does not offer a reference architecture, therefore a roadmap without a reference architecture is a road to nowhere.

In this article I will challenge the thinking associated with these points:

1. We do need standardized data. We need to innovate on how it is shared and accessed.
2. It is not possible to connect all our systems. Linking systems to each other and having “data follow the patient” is financially imprudent, clinically deficient and technically challenging.
3. Common interoperability standards adopted across Canada will not enable connected care. Using that as the means to the end will fail, just as it has for the last 25 years.
4. We have fragmented systems and data silos and always will. We actually need those for many reasons.

The EHR to standardize data: The Blueprint’s definition of the EHR is still valid. “The EHR provides each individual in Canada with a secure and private lifetime record of their key health history and care within the health system. The record is available electronically to authorized healthcare providers and the individual anywhere, anytime, in support of high-quality care.”

The EHR is not tied to any specific digital health solution. It is populated and referenced by a range of heterogenous systems, being a centralized data store thus minimizing the cost and time to create a digitally connected care ecosystem. The cost to interconnect all our digital health systems is exponentially higher than a shared EHR approach.

The EHR as defined in the Blueprint requires a refresh to be compliant with the latest data content standards, use of Canadian approved vocabularies and use of currently available API standards. Those data standards must be mandated and adopted nationally.

Canada cannot afford to have 14 variances. The EHR as a shared repository should continue to be governed by each province or territory. Finally, it’s the most effective way to support the 2nd and 3rd strategic goals in the Roadmap, “Improving Provider Access to Patient Data at the Point-of-Care” and “Enabling Patient Access to their Health Record”.

In the spirit of Bill S-5 we need to ensure that a copy of all clinically relevant data is pushed into the EHR at the time it is being recorded in a point of service system such as a physician’s EMR or hospital record keeping system. This must include PHI from privately owned and run clinics whether under a P/T medical services plan or privately paid, something that is rarely happening today.

In other words, no data blocking of PHI by any digital system. The expansion and use of a provincial/territorial EHR is also a fantastic way to break down the walled gardens stood up by the big HIS and EMR vendors.

Words matter: The Roadmap says standardized data can follow the patient across all care settings and geographies to enable more informed care provision, leading to better health outcomes.”
At best, “data following the patient” only serves as a rallying cry. The phrase implies point-to-point interoperability which is financially imprudent, clinically deficient and technically challenging.

Think about it, does one want to follow the puck or anticipate where it is going? I’d rather anticipate the future use of a person’s Personal Health Information (PHI) and ensure it is always accessible to clinicians and patients. Having it accessible in the shared EHR, as defined above, provides the best return on investment financially and clinically.

Data silos: Some data is not clinically relevant to store in the EHR, therefore some data silos are okay. Why? Because there is a lot of data that is of no use to another clinician. Also, there is an exponential loss of data value over time, thus little value for it to be in the EHR. Finally, the data silo is required for medical/legal record keeping.

The HIAL becomes the HIAIL: The other major component of the 2006 Blueprint that needs a refresh is the Health Information Access Layer (HIAL). Given today’s focus on AI let’s rebrand it to the HIAIL – the Health Information Artificial Intelligence Layer. The 2026 HIAIL would use Agentic AI for many key functions:

• The HIAIL orchestrates read/write to the EHR Agents would handle variances in standards, e.g. HL7 v2 or v3 messaging, HL7 CDA and HL7 FHIR where the semantics, such as data contents, are the same, but the syntax is not. Therefore, we do not need any longer common interoperability standards that are adopted nationwide. Like the burger ad, systems connected to the EHR via the HIAIL “would have data served their way”.
• Use agents to improve the quality of the data going into the EHR. Data quality actions are done as data are written into the EHR. These include:
  • De-duplicate data and curate if necessary.
  • Normalization of data for comparability.
  • Extract data in SOAP notes into coded structured data store in the EHR.
  • Organize data for easy query when needed, where needed, optimized for high performance access by clinicians and patients.

Benefits for clinicians: What is the impact of this solution on the clinician’s workload and work processes? To share data, there is no impact on workload or work processes. The copy of clinically relevant information into the EHR happens automatically from their record keeping system as outlined above.

When a clinician needs data from the EHR for historically relevant data, it is a button click to initiate a filtered query. Filters may be by clinician, date, encounter, disease, diagnostic test, data category (for example, medications, lab test results, etc.) The benefit is great because they get the data they need when they need it instantly and digitally.

Conclusion: We must continue to build out a comprehensive EHR as defined in the Blueprint using current data content standards. It should be the destination for all relevant data for a person-centric health record and the first source queried by patients and clinicians when personal health data across the healthcare ecosystem are needed.

Leverage agentic AI to support data quality and interoperability to and from the EHR. For clinicians, access to a person’s historical data from the EHR will reduce their workload and improve their experience in the delivery of care.

We must require all healthcare record keeping systems to update the EHR with clinically relevant data. In other words, enforce compliance with the anti-data blocking provisions in the CCA with timely and complete data submission from point-of-service systems.

Finally, refresh the EHRS Blueprint to align with the innovations above. Use state of the art technology with an emphasis on achieving digitally connected care.

Dennis Giokas, M.Sc., is Principal, Theoria Health Innovations Inc.