Eclair Case Study

Northern Region CDR

www.sysmex.co.nz

Executive Summary

Problem Definition

New Zealand may have worked out the best way toestablish an electronic medical record that is usefulfor clinicians, beginning with the development of aregional clinical data repository (CDR) to provide easy
access to laboratory results for hospital clinicians overa decade ago1.

The northern region of New Zealand’s North Island
is home to approximately 1.9 million people, over athird of the population of New Zealand. Four separate
District Health Boards (DHBs) ensure provision ofhealth and disability services to these people. The
DHBs fund 13 large hospitals, five full-service diagnostic
laboratories, five radiology clinics as well as numerous
outpatient and community facilities.

Before the appearance of enterprise-wide EMR vendors
on the scene, New Zealand embraced a realistic
attitude to implementing an electronic system forsharing patient records. Auckland health services were
the pioneers, establishing an incremental, solutionbased approach to IT adoption among the clinicianbase, using Sysmex’s Eclair CDR. Today the northern
region has achieved a regionally shared electronic
patient record used by over 3000 clinicians daily, andcontaining over 3 million patient records.
The use of standards has contributed to the success ofthe comprehensive patient record - HL7, LOINC and anational health identifier system. There is a strong
collaborative environment amongst health services andvendors, which has led to the achievement of a highdegree of interoperability across essential clinical IT
systems.
The system now integrates over 80 different sourcesof diagnostic data, building a complete clinical picture
stored patient-centrically. Clinicians have secure accessto a range of information, regardless of whether thedata was collected in hospital or in the community.
The response from clinicians has been overwhelmingly
positive. A simple, but effective, consent model has been
put in place to guard patients’ confidentiality rights.

2 | Northern Region CDR

Geographically, the northern region spreads fromthe Bombay Hills to Cape Reinga and patients often
relocate around the region or are referred to another
DHB for specialist services. Before the implementationof a CDR and electronic records, clinicians had to relyon paper records for all diagnostic information which
was often untimely and/or incomplete. Laboratory
tests and X-ray examinations were being unnecessarily
repeated - an expensive and uncomfortable exercise forthe DHBs and patients respectively.
Of particular concern were emergency situations wherea patient might present at any of the region’s facilities
requiring rapid location of previous history and relevant
diagnostic information - a near impossible task.

Case Study

High Level Solution
All patients in New Zealand have a unique identifier
number, the National Health Index (NHI). Healthcare
providers and facilities, whether in primary, secondaryor tertiary care, also have a unique identifier known as
the Health Practioner Index (HPI). These identifiers,
combined with universal health coding systems
such as LOINC and SNOMED, provide the basis for acomprehensive diagnostic record.
Additionally, HL7 messaging has been used for theelectronic transfer of laboratory results in New Zealandsince 1995, making it the ideal messaging standard.

The northern region’s Eclair
CDR, TestSafe, integrates
over 80 different sources ofdiagnostic data, holds over
3 million patient records
and is used by over 3000
clinicians daily.

Using these identifiers and coding systems, together
with a web-based user interface, a sophisticatedhigh-availability database and advanced HL7 interface
capabilities; the Eclair CDR is capable of integrating
structured and unstructured data, and offered the ideal
way forward to start consolidating key patient data
for the region. The effective aggregation of the data
together with advanced results viewing and workflow
tools was a significant step forward from manual,
paper-based methods.
The underlying standards, architecture and application
layers of the Eclair CDR have also enabled a high degreeof interoperability with other systems. This adaptability
has allowed seamless integration with third party
systems as needed.

Northern Region CDR | 3

Solution Details
Many healthcare organisations in today’s climate opt for a top-down policy, choosing to deploy a costly
enterprise-wide system for patient records. The electronic systems in New Zealand have instead taken a best-ofbreed approach, with significant success despite budget limitations. The northern region followed this strategy,
implementing their shared Eclair CDR using a staged, clinician-driven, solution-based methodology.

Diagnostic results viewing and signoff
Laboratory data is known to make up a significant
proportion of a patient’s record and is often of
relevance to clinical diagnosis. Starting with thelaboratory data at Auckland’s Middlemore Hospital,
HL7 lab results (ORU) were sent to the CDR, enablingclinicians to easily review results from ward clinicalworkstations.
The addition of interfaces for HL7 ADT messages fromthe patient admission systems in each hospital ensured
that patient encounter information in the CDR was
updated in real-time. This enabled the introduction ofelectronic signoff of reports in the system, eliminating
the need for paper lab report creation and manual
delivery to the wards.
Following this initial success, laboratory data feeds
from other hospital sites in the greater Auckland region
were added to the CDR. The benefits of a consolidated
view of laboratory results were clear to clinicians, whocalled for the addition of community laboratory data to
the CDR. The accumulation of this data from different
sources across primary and secondary care was enabled
by LOINC coding, and created a unified view of apatient’s laboratory result history. Variations in reporttest result reference ranges are supported with visual
notification to the user.
The addition of interfaces between the CDR andthe radiology information systems used by hospitaland private providers allowed HL7 radiology reports
to be sent to the CDR. Embedded hyperlinks in thereports allow seamless linking to picture archiving andcommunication system (PACS) imaging databases toretrieve clinical images associated with the report.
Replacing the paper signoff processes with electronic
signout of diagnostic reports in Eclair was highly
successful. To help support the signoff process, a
Dashboard was developed in Eclair which displays thenumber of reports awaiting review and enables a ‘clickthrough’ process for more efficient management of
diagnostic report signoff.

4 | Northern Region CDRElectronic order entry
With HL7 results in place, the next step for the Eclair
CDR was the development of messaging interface
capabilities to include HL7 order messages (ORM)
from the clinical workstation for laboratory andradiology services, providing closed loop diagnostic test
management.
The roll out of electronic ordering was first
implemented for radiology tests at Auckland Hospital,
following a patient safety project to ensure 100%
acknowledgement of patient reports. During a review,
hospital management teams had found that a numberof diagnostic reports were not being reviewed in atimely manner, which, in some cases, had led to missed
diagnoses, compromising patient safety. The EclaireOrder solution included an electronic order entry
user interface to capture essential clinical details andassignment of responsible clinician. It was enhanced byan escalation module which electronically reallocates
reports for viewing and signoff when the system
detects they have not been reviewed within the predetermined timeframe.
Clinical IT and the hospital management teams werevery satisfied with the change in workflow and positive
outcomes, and the roll out of electronic ordering forboth radiology and laboratory tests has continued in astaged approach across the region.

Case Study

External laboratories

MobilityFrequently lab requests need to be sent away toexternal reference laboratories for specialist testing,for example molecular genetics, toxicology etc. Whencomplete, the results for these tests can be reported
directly to the northern region Eclair via HL7 fromthe external LIS. Where the lab’s LIS does not support
this, the laboratory has secure access to Eclair and theresults are uploaded directly to the patient record as a
PDF report. This eliminates the need for paper based
reporting and transcribing results between systems.

One of the next steps for the northern region CDR
will be the implementation of Eclair Touch, which will
provide mobile access to patient information stored in
the regional CDR, assisting clinicians at the point-ofcare and on the move.

Pharmacy dispensing data
The next phase of development for the Eclair CDR
introduced HL7 clinical document architecture (CDA)
XML standards. This enabled the CDR to receive
structured dispensing messages from pharmacy
systems; with the CDR now interfaced to nearly 400
pharmacies across the region. Benefits are realised inboth inpatient and outpatient scenarios with hospital
clinicians and pharmacists readily able to reconcile
medications dispensed in the community when apatient is admitted, and community pharmacies
becoming more involved in shared care of their patientswith better access to the information they need.

Clinical documents
A wide range of unstructured clinical documents aresent to the CDR using encapsulated binary data via
HL7. The clinical documents are from a range of sources
including cardiology, gastroenterology, respiratory,
urology, as well as discharge summaries, clinical lettersand surgical documents from the region’s secondary
care facilities. These are stored and viewed as PDFs.

Clinical forms
The northern region DHBs have made extensive useof Eclair’s Clinical Forms functionality, which enables
a range of patient information and clinical data to be
added directly to the record in Eclair. The use of ClinicalForms in Eclair has significantly reduced the need tocapture and file this information in paper records.
Examples include pre-admission assessment forms,
point-of-care observations, nutrition assessment forms,
community wound care as well as algorithms such as
surgical risk and PE Wells DVT score.

eGrowth charts
Sysmex is also working with the northern region
DHBs to implement electronic growth charts. These
interactive, dynamic charts will allow healthcare
providers such as paediatricians, physiologists,
dieticians, midwives and neonatal nurse specialists torecord patient growth data electronically and compare
it against recognised WHO standards as well as theTanis Fenton data set for premature neonates. The
charts will be stored in the Eclair CDR forming part of apatient’s medical record.

Cardiology request management andtriaging
Request management for other diagnostic services suchas cardiology is also underway. This will be supported
by a Triaging module, which enables the receiving
service to managing the request and prioritise the work
appropriately while feeding back to the clinicians on
the expected time frame for a patient’s procedure.

Interoperability with third party systems
The underlying standards, architecture and application
layers of the Eclair CDR have also enabled a high degreeof interoperability with other systems. This adaptability
has allowed the northern region to take a best-of-breed
approach, integrating the regional CDR with third party
systems as needed.
Examples of Eclair integration to third party systems(in the northern region and across other Eclair sites)
include shared care planning (Whanau Tahi); primarycare practice management systems (Houston,
MedTech, MyPractice); clinical portals (Healthviews,
Concerto); specialty systems, e.g. intensive care, andemergency.

Northern Region CDR | 5

A Community
Perspective

Benefits Outside theRegions

Community based, registered healthcare providers in
the northern region have access to the region’s shared
Eclair CDR via a secure web portal. Depending on who
they are, community healthcare professionals withapproved access can view either all, or a subset of thedata contained in the CDR.2

The shared regional CDR not only benefits patients wholive in the northern region, but also patients from otherparts of the country. Healthcare providers outside theregion can be given access to view the medical recordsof their patients who have received care in the northern
region, such as children who have travelled to Auckland
for specialist treatment at Starship Children’s Hospital.

GPs are the main group of community users. GP patientmanagement systems, MedTech, MyPractice andHouston, all have inbuilt integration to the Eclair CDR.
The implementation of single sign-on authentication
through My Practice and MedTech has allowed GPs toview their patients’ medical records in the Eclair CDR
simply by clicking an icon within their PMS, without theneed to log-in a second time.
Community pharmacists are another group that findconsiderable value in having access to the regional
CDR. The ability to see what medications have beendispensed to a patient (in hospital or the community),in conjunction with relevant lab results and hospitaldischarge summaries, empowers pharmacists toprovide patients with more comprehensive advice on
their healthcare plan. It has also helped to prevent
instances of prescription fraud.
Pharmacists can also add and view the results ofany point-of-care-testing (POCT) they conduct. For
example, some pharmacies now offer INR tests forpatients on anti-coagulation medication. Pharmacists
can upload the INR results via a direct interface to theEclair CDR from the POCT device. This has enabledpharmacists to be closely involved in the patients’ care,
medication adherence and dosage management.
Private hospitals also access the shared CDR, providingthem with a more complete medical history for theirelective surgery patients.
The community user base has continued to expand,and now includes many ancillary care services suchas school nurses, midwives, specialists, hospices,paramedics and rest homes. Giving rest homes accessmeans visiting GPs can easily view the medical recordsof patients at the rest home, even if they are not within
the GP’s usual practice.
Throughout the community, the regional CDR has
facilitated the sharing of patient information giving
healthcare providers a more complete picture of theirpatients.
6 | Northern Region CDR

Case Study

Business Benefits
The journey to where the northern region Eclair CDR is today has seen a number of milestones achieved including:

HL7 reporting of lab and radiology
results to the CDR across primary andseconday care

Clinical documents, discharge
summaries and scanned records

Electronic report signoff and escalation
with complete audit trail

Closed loop diagnostic test
management for radiology andlaboratory

Robust confidentiality model thatallows patients to opt-off data types
being sent to the CDR or restrict
provider viewing

Primary care and community pharmacy
access to patient records

Dispensing medication data fromnearly 400 community pharmacies

Interfacing to 4 PAS across thenorthern region, updating the patient
record in real-time

Key outcomes of the northern region Eclair CDR include:

Full HL7 electronic reporting andsignoff

Over 80 sources of diagnostic data,
making up a complete clinical picture

Audit reports and follow up of
unacknowledged patient results

Current use levels across the region
are reflected by 3000 unique clinicalusers accessing the system at peaktime

Reduction on repeat testing andprocedures between primary andsecondary care and referrals within
secondary care settings

Northern Region CDR | 7

Fig 1. Eclair data integration feeds and healthcare provider access across Northern Region

Northern Regional Eclair
Laboratory
Auckland DHB
Counties Manukau DHB
Waitemata DHB
Northland DHB
LabTests Auckland
Auckland Pathology Services
Canterbury Reference Laboratory
Waikato Reference Laboratory
IGENZ / DNA Diagnostics

Radiology
Auckland DHB
Counties Manukau DHB
Waitemata DHB
Northland DHB
Mercy Hospital
Ascot Radiology
Auckland Radiology Group
Horizon Radiology
The Radiology Group

Pharmacy
400 community pharmacies

Hospital (ADT and clinicalservices)
Auckland DHB
Counties Manukau DHB
Waitemata DHB
Northland DHB

Data Integration
Feeds

Radiology

Laboratory

Reports and image accessResults and orders

ADT Patient Information

Medication

Admission, discharge, NHI, HPI

Dispensing information

Patient
Care Data

Clinical Documents and Forms
Cardiology, gastroenterology, echo, respiratory, urology, referrals,
discharge summaries, nutrition, community wound care, etc.

Healthcare
Provider Access
GP / Community

Primary Care

PharmacySpecialist

Shared Care

Hospital

Secondary Care

Patient Care
Episodes8 | Northern Region CDR

Case Study

Northern Region CDR | 9

Summary
Sysmex has collaborated closely over the past ten years with the northern region of New Zealand to achieve a
regional electronic clinical system shared amongst four DHBs and 13 hospitals, servicing a population of 1.9 million.
The points outlined below are key to the success of the system, all of which have been achieved at a fraction of acost of an enterprise-wide vendor.

CDR at the foundation

Solution-based strategy

Underpinning the success of the regional electronic
patient record is the use of industry standards andthe Eclair CDR which was designed from the outset toreadily integrate structured and unstructured data in apatient-centric manner.

Each of the steps that were implemented in the roll-out
and expansion of the Eclair system has come about as asolution to a real problem in manual and paper-based
systems. Working closely with the healthcareorganisations to gather requirements and design andtest working solutions, verified the solution andenabled it to be replicated across other sites
throughout the northern region and other healthregions in New Zealand.

Single patient record
Providing a single source of patient data improvescommunication across multiple providers and enables
each organisation to rapidly respond to changes, deliver
new clinical workflows and collaborate with other
healthcare providers on shared patients.

Interoperability
The architecture of Eclair allows for a high degree ofinteroperability which has supported a best-of-breed
approach integrating to existing third party systems,
removing any need and associated expense of system‘pull and replace’.

Incremental approach
Instead of choosing to implement a system across theentire northern region to achieve a region-wide EMR
through a top-down approach, the achievements havecome about incrementally, building on each success.

10 | Northern Region CDR

Patient confidentiality
A simple and pragmatic consent model has been put
in place to guard patients’ confidentiality rights using
an opt-off model. Patients can choose to opt-off their
entire record or restrict access to certain parts of theirrecord by information type or provider. Under 1% have
opted off.

Case Study

Future Initiatives
for Eclair
Sysmex is continuing to develop Eclair in response toclinical needs and advances in technology, guided by the
New Zealand Ministry of Health’s digital health strategy.
This strategy includes a focus on the introduction ofelectronic health records for all New Zealanders, thepromotion of digital hospitals, as well as a move towards
a regional approach to health information access - areas
where the northern region Eclair CDR is already setting
the standard.
With its electronic ordering capabilities, Eclair is helping
hospitals to move away from paper-based test ordering
processes towards closed loop diagnostic request andresult management. The roll-out of eOrders continues
to be a focus for the northern region and other Eclairsites around the country.
Demand for mobile healthcare applications is increasing,and Sysmex is expanding the Eclair Touch portfolio toincorporate new applications and further core Eclair
functionality for results management, laboratory orders,clinical forms and collection management.
The future development of Eclair is underpinned by
FHIR, which provides greater capabilities forinteroperability between different clinical systems,
facilitating the sharing of key health data. This will help
ensure that Eclair can interoperate with third party
systems as required to provide seamless access topatient information in alignment with the NZ Ministryof Health digital health strategy.
SNOMED CT diagnostic coding standards will be
implemented in conjunction with the adoption
framework set by the Ministry of Health.
The successful model set by the shared CDR in thenorthern region has become a template for roll-out in an
additional two regions in New Zealand, with Sysmex’s
Eclair forming a key component of three out of four
regional clinical systems across all of New Zealand.

Northern Region CDR | 11

References
1
2

https://www.pulseitmagazine.com.au/index.php?option=com_content&view=article&id=1313:evolution-not-revolution-key-to-testsafe&catid=49:new-zealand-ehealth&Itemid=274
http://www.careconnect.co.nz/testsafe/healthcare-providers/provider-specific-information/

Additional references
https://www.pulseitmagazine.com.au/new-zealand-ehealth/3682-careconnect-consolidates-on-one-site-as-gps-get-single-sign-on-to-testsafe
http://www.pulseitmagazine.com.au/index.php?option=com_content&view=article&id=1358:pathology-and-radiology-in-pulseit&catid=16:australian-ehealth&Itemid=328
http://www.pulseitmagazine.com.au/index.php?option=com_content&view=article&id=761:sysmex-prepares-to-link-clinical-data-repositories-in-new-zealand&catid=16:oz-hit&Itemid=227
http://www.scoop.co.nz/stories/GE1004/S00065.htm

Sysmex Australia Pty Ltd

info@sysmex.com.au | www.sysmex.com.au

Sysmex New Zealand Limited

info@sysmex.co.nz | www.sysmex.co.nz© 2018 Sysmex Corporation. All rights reserved.
**Eclair is not a medical device as it does not have a therapeutic purpose.**