We Believe the Possibilities. Eclair Case Study: Northern Regional EMR New Zealand
Contents Executive Summary 3 Problem Definition 4 High level solution 4 Solution details 5 Business Benefits 7 Future initiatives 10 Summary 11 More information 12 Additional references 12 Copyright Copyright 2014 Sysmex Corporation, All Rights Reserved. The information contained in this document is the intellectual property of Sysmex Corporation and is protected by international copyright laws, international treaty provisions and applicable laws of the country in which it is being used. The information contained in this document is strictly confidential. No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, for any purpose, without the express written permission of Sysmex. 2
Executive Summary New Zealand may have worked out the best way to establish an electronic medical record that is useful for clinicians, beginning with the development of a regional clinical data repository (CDR) to provide easy access to laboratory results for hospital clinicians over a decade ago. Before the appearance of enterprise-wide EMR vendors on the scene, New Zealand embraced a realistic attitude to implementing electronic system. Auckland health services were the pioneers establishing an incremental, solution-based approach to IT adoption among clinicians base. Today they have achieved a regionally shared electronic patient record used by over 3000 clinicians daily. The use of standards has contributed to the success of the comprehensive patient record HL7, LOINC and a national health identifier system. There is a strong collaborative environment amongst health services and vendors achieving a high degree of interoperability across essential clinical IT systems. The system now integrates over 80 different sources of diagnostic data building a complete clinical picture stored patient-centrically. Clinicians have secure access to a range of information, regardless of whether the data 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. 1 http://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 2 http://ehealthspace.org/casestudy/new-zealand-embraces-healthcare-records 3
Problem Definition The upper region of NZ s North Island is home to over 1.5 million people, over one-third of the population of New Zealand. Four separate District Health Boards (DHBs) ensure provision of health 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. Geographically, the Northern region spreads from the Bombay Hills to Cape Reinga and patients often relocate around the region or are referred to another DHB for specialist services. Before the implementation of the electronic records, clinicians had to rely on 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 for the DHBs and patients respectively. Of particular concern were emergency situations where a patient might present at any of the region s facilities requiring rapid location of previous history and relevant diagnostic information a near impossible task. The situation sparked an initiative to build a regional EMR solution across four DHBs for the entire northern region. High level solution All patients in New Zealand, have a unique identifier number the National Health Index (NHI). Providers and facilities whether in primary, secondary or tertiary care, also have a unique identifier known as the Health Practitioner Index (HPI). These identifiers, combined with universal coding systems such as LOINC and SNOMED, provide the basis for a comprehensive diagnostic record. Additionally HL7 messaging was implemented for laboratory result transfer in New Zealand in 1995, making it the ideal messaging backbone. By using the identifiers and coding systems, together with a webbased user interface a sophisticated, high-availability database and advanced HL7 interface capabilities, a CDR capable of integrating structured and unstructured data was the ideal way forward to start consolidating key patient data for the region. The efficient and effective aggregation of the data together with advanced results viewing and workflow tools was a significant step away from manual paper-based methods. The underlying standards and architecture of the CDR and application layers have also enabled a high degree of interoperability with other systems. This adaptability has allowed seamless integration with third party systems as needed. 4
Solution details The Northern Region implemented their EMR using a staged, solution-based approach. Many healthcare organisations in t oday s climate opt for a top-down approach instead of choosing to deploy a costly enterprise-wide system. The electronic patient record systems in NZ take a best-of-breed model, with significant success despite the allocated budget limitations. Laboratory data is known to make up a significant proportion of a patient s record and is of significant relevance to clinical diagnosis. Starting with the laboratory data at Auckland s Middlemore Hospital, HL7 lab results were sent to the CDR which enabled clinicians to easily review results from ward clinical workstations. Adding interfaces for HL7 ADT messages from the patient admission systems in each hospital created further value to the CDR. The ability to electronically sign off the reports in the system eliminated paper lab report creation and manual delivery to the wards. The flow-on effect from the success of this initial electronic patient record was based on the CDR s ability to add laboratory data feeds from other hospital sites in the greater Auckland region. The benefits of the consolidated view of laboratory results were clear to clinicians who called for the addition of community laboratory data to the CDR. This created a unified view of a patient s laboratory result history, seamlessly cumulating data across primary and secondary care regardless of the data source, enabled by LOINC coding. Variations in report test result reference ranges are supported with visual notification to the user. At the same time, radiology HL7 reports were interfaced to the CDR from hospital and private radiology providers. Embedded hyperlinks in radiology reports allow seamless linking to PACS imaging databases to retrieve clinical images associated with the report. Clinical IT and the hospital management teams have been very satisfied with the change in workflow and positive outcomes providing an effective solution for a problem that was occurring too frequently. The next phase introduced HL7 clinical document architecture (CDA) XML standards. This enabled the CDR to receive structured dispensing messages from pharmacy systems across the region with the CDR now interfaced to over 350 pharmacies. The benefits are gained in both inpatient and outpatient scenarios with hospital clinicians and pharmacists readily able to reconcile medications dispensed in the community when a patient is admitted, and community pharmacies are more involved in shared care of their patients with better access to the information they need. Most recently the region has added a wide range of unstructured clinical documents 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, clinic letters and surgical documents from the region s secondary care facilities. These are stored and viewed as PDF. The underlying standards and architecture of the Eclair CDR and application layers have also enabled a high degree of interoperability with other systems. This adaptability has allowed seamless integration of Eclair with third party systems as needed. Examples to date include shared care planning (HSA Global); primary care practice management systems (Houston, MedTech, MyPractice); clinical portals (Healthviews, Concerto); specialty systems, e.g. intensive care, and emergency. The core CDR is the central foundation for this successful framework. The CDR and messaging interface capabilities have been developed beyond HL7 results (ORU) to include HL7 order messages (ORM) from the clinical workstation for laboratory and radiology services, completing the electronic loop and providing sophisticated CPOE request management within the Eclair application layer. Clinical IT governance across the region implemented a patient safety project to ensure 100% acknowledgement of patient reports. Hospital management teams were finding that a number of diagnostic reports were not being reviewed in a timely manner. In some cases this had lead to missed diagnoses, compromising patient safety. The solution included an electronic order entry user interface to capture essential clinical details and assignment of responsible clinician. The solution was enhanced by an escalation module which electronically reallocates reports for viewing and signoff when the system detects they have not been reviewed within the pre-determined timeframe. 3 Ascot Radiology, Auckland Radiology Group, Horizon Radiology, Mercy Radiology, The Radiology Group. 4 http://www.sysmex.co.nz/resources/file/documents/eclair%20radiology%20orders%20and%20reporting%20system%20at%20auckland%20hospital.pdf 5 http://www.sysmex.co.nz/resources/file/documents/community%20pharmacy%20role%20in%20shared%20care.pdf 5
Fig 1. Overview of Éclair solution framework. 3rd Party App / Databases Primary care / Secondary / Shared Care Clinical workstation / Mobile Device / Consumer and Provider Portal Web Services In/Out Closes loop meds Mgmt CPOE lab, rad meds Referrals, Discharge Summaries Electronic Forms Clinical Data Repository (Structured and unstructured data) Integration Engine Pathology Imaging Pharmacy Clinical Documents IHI, HPI, HPI-O SNOMED- CT, ICD 9/10 Patient Visit Alerts Point of Care Discharge & Referrals 6
Business Benefits The journey to where the system is today has seen a number of milestones achieved including: 350 HL7 HL7 reporting of lab and radiology results to the CDR across primary and secondary care Regional clinical documents and discharge summaries plus scanned records Electronic signoff and escalation with complete audit trail CPOE CPOE for radiology, laboratory, blood products request, completing electronic loop Robust confidentiality model that allows patients to opt-off data types being sent to repository or restricted provider viewing Primary care and community pharmacy access to patient records Dispensing medication data from over 365 community pharmacies Interfacing to 4 PAS across the northern district health boards updates the patient record in real-time following the admitting journey and facilitates patient flow. Key outcomes of the Northern region system: 100% 350 100% cessation of paper reporting, full HL7 reporting and signoff over 80 Over 80 sources of diagnostic data make up the complete clinical picture, all HL7, all signed off Audit reports and follow up of unacknowledged patient results 3000 350 Current use levels across the region are reflected by 3000 unique clinical users using the system at peak time. Reduction in repeat testing and procedures between primary and secondary care and referrals within secondary care settings 7
Improvements to clinical workflow and the patient journey Throughout the region, clinicians can access information from external sources and are provided with the means to electronically order, receive and review laboratory tests and radiology results. These clinical systems are also integrated to the hospital administration and financial systems. Already this process of e-enablement is speeding up patient workflow and improving the accuracy and availability of data needed at the point of care. A secondary, but crucial result is the development of the CDR. The CDR contains all of the laboratory, imaging and medication records of the patients, providing most or all of the information needed during a clinical consultation. 6 Northland Northern region Population 1.5 million Waitemata Auckland Counties Manukau Bay of Plenty Waikato Tairawhiti Nelson Marlborough Taranaki Whanganui Capital & Coast Hawkes Bay Midcentral Hutt Wairarapa West Coast Canterbury South Canterbury Southern 6 p21, http://www.nzte.govt.nz/media/553044/final_nzte_europe_whitepaper_low.pdf 8
Fig 2. Eclair data integration feeds and healthcare provider access across Northern Region Northern Regional Eclair Patient Care Episodes Secondary Care Shared Care Shared Care Primary Care Hospital A Hospital B Hospital C Pharmacist Specialist GP/Community Eclair Patient Care Data Laboratory Resultss Blood Services Radiology Reports and Images Dispensing Data Clinical Documents, Cardiology, Gastroenterology, Echo, Respiratory, Urology, Referrals, Discharge Summaries, Nutrition, Community Wound Care, plus more PMS Patient Information Admission Discharge NHI, HPI Auckland Hospital Lab Middlemore Hospital Lab North Shore Hospital Lab Waitekere Hospital Lab LabTests Healthscope Diagnostic Medlab Canterbury Reference Lab Waikato Reference Lab Kaitaia Hospital Lab Whangerei Hospital Lab Dargaville Mercy Hospital Auckland Hospital Radiology Middlemore Hospital Radiology Waitekere Hospital Radiology North Shore Hospital Radiology Whangerei Hospital Radiology Bay of Islands Hospital Radiology Dargaville Hospital Radiology 365 community pharmacies Auckland City Hospital Middlemore Hospital North Shore Hospital Waitekere Hospital Bay of Islands Hospital Kaitaia Hospital Dargaville Hospital 9
Future initiatives The next stages for the region include roll out of lab order entry across the entire region; multiplatform mobility device management (Eclair Touch); interactive dynamic growth charts; and dashboards for at-a-glance status updates of patients at a ward, patient or clinician level. The rich data source in the repository will also see in the future a number of initiatives for big data and predictive analytics. There is increasing need for access to the patient records in the Eclair CDR for specialist applications across inpatient and outpatient environments, to facilitate coordination of patient care. Some of these settings include newborn and maternity care, community pharmacies, cancer and chronic disease management. Along with this there is a demand for patients to have access to relevant, readable diagnostic reports, enhancing the standard report formats from numbers and ranges to an info-graphic style of presentation. The CDR model set in the Northern region has become a template for roll-out in an additional two regions in New Zealand, with Sysmex Eclair setting the standard in 3 of 4 regional clinical systems across all of New Zealand 10
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 4 DHBs, 13 hospitals, servicing a population of 1.5 million. The points outlined below are key to the success of the EMR in the Northern region, all of which have been achieved at a fraction of a cost of an enterprise-wide vendor CDR at the foundation Underpinning the success of the regional electronic health record is the use of industry standards and the Eclair CDR which was designed from the outset to readily integrate data which is structured and unstructured in a patient-centric manner. Single Patient record Providing a single source of patient data improves communication 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 of interoperability 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 the entire Northern region to achieve a region wide EMR through a top-down approach, the achievements have come about incrementally, building on each success. Solution-based approach Each of the steps that were implemented in the roll-out and expansion of the Eclair system has come about as a solution to a real problem in manual and paper-based systems. Working closely with the healthcare organisation to gather requirements and design and test working solutions, verified the solution and enabled it to be replicated across other sites throughout the Northern region and other health regions in NZ. 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 their record by information type or provider. Under 1% have opted off. 7 http://ehealthspace.org/casestudy/new-zealand-embraces-healthcare-records 11
Additional references http://ehealthspace.org/casestudy/new-zealand-embraces-healthcare-records http://www.scoop.co.nz/stories/ge1004/s00065.htm http://www.pulseitmagazine.com.au/index.php?option=com_content&view=article&id=761:sysmex-prepares-to-linkclinical-data-repositories-in-new-zealand&catid=16:oz-hit&itemid=227 http://www.pulseitmagazine.com.au/index.php?option=com_content&view=article&id=1358:pathology-and-radiologyin-pulseit&catid=16:australian-ehealth&itemid=328 http://www.pulseitmagazine.com.au/index.php?option=com_content&view=article&id=1313:evolution-not-revolutionkey-to-testsafe&catid=49:new-zealand-ehealth&itemid=274 http://www.hinz.org.nz/uploads/file/2013conference/measuring%20service%20utilisation%20impact%20-%20gu.pdf Sysmex Software Solutions More Information For more information about a Sysmex Eclair solution for your healthcare organisation, please contact us to arrange a full demonstration. Alternatively a visit to this reference site or another customer site can be arranged. Sysmex Australia Pty. Ltd. Marie Czarnecki czarnecki.marie@sysmex.com.au ph. +61 432 273 550 www.sysmex.com.au Sysmex New Zealand Ltd Colin McKenzie mckenzie.colin@sysmex.co.nz ph. +64 (9) 639 0405 www.sysmex.co.nz 12