Guest editorial: national eHealth record systems – the Singapore experience
First, some context. Singapore is a small, densely populated and ethnically diverse island. It has 4.6 million people on 707.1 square kilometres (6489 people per sqm). Seventy-five per cent of the population is of Chinese descent, 14 per cent Malay, nine per cent Indian and an array of others make up the remainder.
Public hospitals and specialist centres in Singapore have been restructured by the government to be run as private companies, but wholly owned by the government. There are seven restructured hospitals and six specialty centres providing 80 per cent of hospital care. Sixteen private hospitals provide the remaining 20 per cent. Singapore is also a regional centre for the provision of healthcare to international patients.
Eighty per cent of primary care medical services are delivered by private GP clinics or practices, while 17 public polyclinics provide the remainder. Government community hospitals provide intermediate healthcare for the convalescent sick and aged. Other residential and community-based health services for the elderly are provided by voluntary welfare organisations (70 per cent) or private operators (30 per cent). The Health Promotion Board is the main driver for national health promotion and disease prevention programs.
Singapore has been constantly reforming its health system over the last 25 years, taking an ‘adopt and adapt’ approach to meet changing needs and conditions.
A series of major reforms launched around five years ago included the introduction of co-payments and means-testing, and the clustering of services geographically to provide more integrated care. Competition between the clusters provides supply-side incentives for efficiency, service and quality.
Singapore’s health system faces similar challenges to those in other highly developed societies. Demand-side factors include an ageing population, greatly increased incidence of chronic and lifestyle-related diseases, and rising public expectations.
Supply-side issues include global cost factors (e.g. related to medical technologies), legacy service models that are insufficiently integrated to meet today’s challenges and health workforce shortages.
Singapore has a strong platform of health information technology (HIT) across its public sector, although the use of IT for clinical care in other settings is lower, particularly in primary care.
Nationally, there is a range of significant capabilities and initiatives. From the early stages of HIT adoption, the Singapore government adopted a pragmatic approach focused on implementing immediate goals rather than a holistic one that encompassed all foreseeable needs and concerns.
To enable operational interoperability between clusters, the Ministry of Health (MOH) implemented an EMR Exchange (EMRX) system in 2004, enabling secure health information exchange between clinicians in the public sector.
EMRX was continually enhanced with the sharing of an expanding list of clinical information, including in-patient discharge summaries, diagnostic reports, medications, immunisation and school health records, operating theatre reports, endoscopy reports, and cardiac and emergency department reports. The EMRX was extended to all community hospitals in 2008.
Another initiative was the development in 2006 of a national repository of critical patient information such as medical alerts and drug allergies. This Critical Medical Information System (CMIS) allowed direct reporting by doctors of their patients’ drug allergies and key alerts, such as a patient on anticoagulation therapy, and could be integrated to the e-prescription systems of the respective hospitals/clusters for automated alerts. Adverse drug reaction reports were also generated and routed to the pharmaco-vigilance unit of the national drug regulatory agency.
However, a range of ICT barriers to health reform were also identified around this time. Specific barriers included the inability to include medical images within the EMRX framework due to technical incompatibilities between imaging systems, and the inability to apply decision support because of structural and semantic inconsistencies between EMRX documents.
In 2008, a new health ICT strategy was developed, with core themes including:
- Singapore required a national, integrated eHealth system based on common enterprise architecture, data standards and a privacy and security framework
- A shared electronic health record (EHR) could be delivered
- Broad stakeholder engagement was needed. The EHR should not be seen as an ICT project, but rather as an enabler of business and clinical transformation
- Greater ability for the public to manage their own health, emphasising the public’s access to their own health information as well as improved health system logistics such as appointments, scheduling and notifications
- Strong support for clinical and health services research.
This strategy was then translated into a five- to 10-year blueprint that clearly spelled out the steps to achieve the goal state. The architecture is reviewed every two to three years to take account of new trends, developments and learnings and the next set of steps is articulated.
It is based on a comprehensive, agreed eHealth architecture which is supported by all key health system decision makers and guides the further development of their own information flows and systems as well as those of national infrastructure.
An initiative to support the deployment of standardised GP desktop systems has commenced – only about 15 per cent of GPs used clinical systems in 2010.
Development of a unified web portal for empowering individuals and their care-givers with health and medical information and preventive or monitoring tools for personalised health management is in progress.
A second phase of NEHR (2012-15) is now being architected. This phase will provide extensions to the services provided to clinicians, establish capabilities required for the NEHR to service consumers and other MOH programs and address some architectural lessons learned from the first release in order to provide a truly responsive and evolvable set of healthcare services.
Singapore’s NEHR is an electronic record for health service providers rather than a PCEHR. Nonetheless, some of the learnings from Singapore’s last decade of nationally driven health ICT resonate in Australia.
Singapore’s national eHealth program has been clinically led from day one. The NEHR initiative was effectively launched in mid-2008 at a workshop involving some 160 clinicians who were guided through the vision, issues and approach, and harnessed to help direct the clinical and business transformations which the NEHR would support.
A long-term vision is in place, intimately connected to healthcare reforms and other enabling initiatives. It is realised through the development and regular refreshment of national eHealth architecture, including detailed migration planning – meaning the pathways to the long-term vision are clear.
Stakeholder engagement is enhanced by delivering meaningful and operationally useful components regularly along the way and evolving them, which is possible because of the architectural approaches taken. A focus on operationalising has been maintained – working through how each component will actually work in practice, with the people who will be affected.
Political and bureaucratic leaders and funders were and still are under no illusions that eHealth would be any easier than other structural reforms, and while urging ambitious targets have fully engaged with the philosophy that it’s better to get it right than introduce excess risk. They have provided unwavering and visible support.
The implementation of the NEHR system has provided an even stronger spotlight on issues such as standards and data quality, as previously unknown inconsistencies and data defects from a variety of catchments flow into a unified record. Ongoing strategies to address these issues are also now high on the agenda.
David Rowlands B.Ec.(Hons), G.D.B.A., FACHI, AFACHSM
Managing Director: Direkt Consulting
David Rowlands is managing director of Direkt Consulting, a management consulting company with offices in Australia, Hong Kong and Singapore. He is heavily involved in health informatics in Australia and internationally.
Posted in Asia Pacific Health IT