Healthcare IT Innovation Week Conference

02 Feb 2007

By Ms Yong Ying-I, Permanent Secretary (Health)

Venue: Grand Hyatt Hotel

Good morning distinguished guests, ladies and gentlemen. I am glad to be here. May I just say that I am glad to be speaking first today, because we have a set of very distinguished speakers coming after me. To our foreign guests, a very warm welcome. We are honoured that you have been able to come to Singapore to share your experiences and insights with us.

Healthcare and IT

Healthcare is a complex field - it is one of very personal doctor-patient relationships juxtaposed against a large system with many moving pieces. And IT in healthcare is a particularly challenged area. It is widely recognised that while healthcare is a high-technology high-skill sector, it is not one that makes extensive use of IT. We use a lot of expensive high-tech medical equipment like 64 slice CT scanners. But we have been slow to build and use systems that allow patients' clinical data to flow within and across medical institutions. Now that I have joined the healthcare sector for a year and a half, I can better understand the complexity that makes deployment a big challenge. The theme of my welcome remarks today is that "for healthcare IT to work, it must make sense in meeting the needs of patients and their doctors". That's no different ultimately from saying that a product or service must meet customers' needs. It just that these customers' needs are complex.

It is a challenge but it is one that can be tackled. I have seen usage of IT in our public sector institutions move swiftly forward in the period that I've been in the Ministry of Health. In particularly, we have made substantial progress on developing electronic medical records for patients that can be shared across departments and across public sector institutions. I have learned much about how we can move IT forward in watching this development, and I would like to share some of those reflections with you. 

Strategic Imperative - One Singaporean, One Family Physician, One Electronic Medical Record

Let me first describe why IT has become a strategic imperative for the healthcare in Singapore. This is because my ministry sees a need to evolve the way healthcare is delivered in Singapore and we need IT to do it. Historically, healthcare has been institution-based and care is largely episodic. You come in to a hospital for treatment; they solve your problem; that's one episode and it ends there. You may see the same GP over time; if so, he will keep a handwritten file on you. But he may not know if you were treated in hospital in between or what medication the hospital specialists put you on, unless you tell him when you next turn up.

We now recognise that we cannot afford to take an episodic view of healthcare. My Ministry's top priority for the year will be to push on strengthening the framework for integrated delivery of long-term care for a patient. The nationwide chronic disease management approach we launched last year encouraged Family Physicians and specialists to partner each other in providing appropriate long-term care of the patient. The fundamental logic is about right-siting of care - that for chronic diseases, it is more cost-effective and it is better medicine for the Family Physician to provide long-term care to the patient. But long-term care and coordination between GP and specialist requires IT support - it requires IT to facilitate claims for Medisave payments. It requires IT to track clinical outcomes for long-term care. GPs and specialists need to share the patient's electronic medical records.   

More broadly speaking, it will become increasingly critical with an ageing population, that we have a stronger infrastructure to support healthcare in the community setting. When patients are discharged from tertiary hospitals to step-down care or care by the GPs at home or in the community, we need the medical care to be seamless. Indeed, even for people who are generally healthy, we need to help people to get health screenings at the appropriate time and to be able to keep track of the historical results. My Minister has stated more than once his vision that every Singaporean should have his or her own Family Physician who provides him general care over the long-term. The second thing that is required is IT. The GP needs access to health screening results, medical treatments, drugs prescribed in the hospital or step-down care institution. My Minister has thus also stated that our databases must be networked. We must build a national electronic health records, and get primary care GPs, community hospitals, care centres in the community linked into this.

Historically, the primary care sector has not made great use of IT. There was essentially no need. Also it was not realistic for solo GPs or small GP partnerships to set up their own IT systems, never mind expect it to all link up nationally. However, I was pleased to note in the chronic disease programme that a huge percentage of participating GPs were keen to leverage IT. In the Medisave claim process, we provided options for paper submission. But no one used this. 100% of submissions have been electronic. Many clinics took the opportunity to upgrade their computers and clinic management systems, as well as install broadband access. This enthusiasm has given us confidence to support you further.

A Central Backbone - Common Standards

Realising our vision of One Singaporean, One Family Physician, One Medical Record would rely critically on an integrated IT backbone. This is particularly applicable to Singapore where the pattern of patient care and flows is asymmetric. 80% of primary care is provided by private sector GPs, while 80% of acute care by the public sector. The majority, about two-thirds, of admissions into our hospitals are through A&E departments. This underscores the importance of easily-accessible centralised medical records.

The Electronic Medical Records Exchange (EMRX) that we started working on in the public sectors since 2003 now links most of the medical records for the public hospitals. The EMRX has been gradually populated with useful information - inpatient discharge summaries, allergy alerts etc. It is quite comprehensive now. We are now ready to take the next step. The Government will identify and set nation-wide standards for our healthcare IT infrastructure. This common backbone should include standardised data definitions and formats for medical records to be shared. It will be cheaper and more effective for everyone if Government designs the common backbone that everyone can use - both our public sector clusters, primary care GPs, private hospitals step-down care institutions and the charity sector. But let me assure the medical sceptics that Government designing it does not mean that IT chaps are designing it; it will be championed and driven by clinicians to ensure that the builders understand the users' needs.

It is also important that we are practical in our approach. I think we have built a sensible system where we are not trying to standardise all hospital systems nor try to share everything with everyone. Strong championship from clinical leaders has helped us think through what subset of data needs to be shared or standardised nationally. Beyond that, we can give institutions the flexibility to build tailored systems for their needs that will ride on the common backbone. There are "soft" components as well as the "hard" components - Government will also put in place "soft" components such as a comprehensive framework that safeguards patient confidentiality.  We will need processes for audits, workflows and so on.

iDA has identified the healthcare sector as one of the key sectors that it will support in its vision iN2015.  iDA's CEO will share with you some of his thoughts on iDA's vision and plans when he speaks after me. What iDA can bring to the table and provide critical leadership on is the launch of support schemes for sector-wide development. With appropriate funding incentives, architecturing and operational roll-out expertise, I believe that iDA can partner the Ministry of Health to bring the huge number of entities in healthcare into a nationally integrated framework. Equally importantly, we welcome and need other partners. In particular, we will need to work closely with the College of Family Physicians, the Singapore Medical Association and the other professional healthcare bodies amongst others. 

Implementation is everything

I said earlier that the theme of my remarks was that "for healthcare IT to work, it must make sense in meeting the needs of patients and their doctors". I've just explained why we need IT to support our approach to patient care at the national level going forward. Let me now speak briefing on another angle, that of implementation. Healthcare IT implementation is extremely challenging, because it requires the people building the system to really understand how doctors work and what they need. If the builders build systems where the workflow design does not support doctors to work efficiently and effectively, they will naturally not wish to use the system. The healthcare IT only works if it makes sense.

From our own implementation experiences and studying the experiences of the US and UK, let me offer a few insights. First, it is difficult for pure IT folk to understand the intricacies of clinical systems. Hence, clinicians must champion and participate intensively in any implementation that involves clinical applications. It is easier for clinician to understand IT. Second, we have to build broad-based consensus amongst users. That takes skills to do and those are not technical skills. Third, it may not be possible to define very clearly on day 1 what we will do in a massive project. Of course we must have some specs to start, but it is necessary to continually review and evolve the plan as we learn on the way. Pilots are a good way to learn what the teething problems are and resolve them. That gets us faster down the road of clinician buy-in. Hence a big bang approach to projects may not work well in healthcare. Fourth, and I know I will upset many people in the audience by saying this; just buying systems from vendors is not going to get us integrated systems. Essentially, the technology is not mature enough. We thus need to be able to work with vendors on co-development.

Telemedicine - the next frontier

I would like to end by saying a few works about the possibilities of IT to transform the way we deliver healthcare. We have changes at the hospital level like RFID tracking in Tan Tock Seng Hospital or wireless patient monitoring in Changi General Hospital. Beyond this, IT can be a disruptive enabler. We have started buying teleradiology services from India. X-rays from our polyclinics are now being read in India in under an hour, when they used to take 2-3 days previously. Patients are happier because x-rays are cheaper and patients no longer need to make another trip to receive their results. Increased competition has improved the turnaround times of our local radiologists. Soon, we may see CT scans, MRIs and Ultrasounds also read overseas.  In the meantime, I am glad that some of our own radiologists are exploring business opportunities to sell services to the world. I strongly encourage that. IT is both a competitive threat and an opportunity. Which it is depends on who chooses to respond and leverage the opportunity. I hope our local players will seize the opportunity.

Still on India, my Minister told me recently the story about Jiva Institute's TeleDoc project. This Indian eHealth program brings medical care directly to the poor in rural India. By tapping on Java-enabled mobile phones, it enables diagnostics in rural areas and e-consultations by a central panel of doctors. Patients benefit from reduced travelling time and doctors' workloads are optimised. 

So will teledoc and home health work in Singapore? I go back to my theme of "does it make sense"? I personally doubt that the Jiva Institute Teledoc idea would work in Singapore because our conditions are different. We are an urban city where people can get to a GP easily. But home health may work for follow-ups where the patient is saved the need to travel to a clinic. Would broader home health work? For instance, I have seen vendor products that demonstrate how cardiac patients resting at home could be wired up for emergency response if it should be needed. Or how online portals can guide users to manage their health. The fundamental issue is economic viability of the service. Will patients pay to be wired up? Might there be a more cost-effective solution to the patient or to whoever is expected to foot the bill. In selected areas, it may make business sense. So IT innovations have to pass the test of "does it make sense cost-wise". 

CONCLUSION

Clearly, healthcare IT is a challenging area of complexity. But that's what makes it at once fascinating, frustration and rewarding. I wish you a stimulating and enjoyable seminar. May it also inspire you to new innovations. Thank you very much.