Opening Address by PS at the Health Informatics Summit

16 Jul 2010

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

Colleagues, friends, ladies and gentlemen,

Good morning. 

1 We are now at a significant point of our journey towards Singapore achieving the vision of one patient, one medical record.  We recently awarded the tender for the first phase of our National Electronic Health Record.  The countdown on the NEHR has definitely begun for many of us gathered here.

2 But many others outside this room are also looking forward to the safe and secure sharing of electronic records.  A retiree posted this comment on MOH’s Facebook page in March this year:  “Please do away with physical records,” she said.  “I really don’t understand why my records kept being missing repeatedly.  Can it be because I have 22 volumes in hospital A and 13 volumes in hospital B?”

3 Before I continue with the story, let me stress it is no criticism of the institutions involved.  It’s the nature of the data problem we face and hence the need to achieve a breakthrough using healthcare informatics.  And even though she gave her real name, I’m going to call this patient Mrs Tan to protect her identity.

4 Mrs Tan shared her multitude of health issues and the “nightmare” of seeing her bevy of doctors located in different departments in hospitals across our various clusters.  She was recently discharged from hospital A and went on the same day to hospital B for a prior outpatient appointment with her endocrinologist.  The doctor’s assistant could not find her volume of case notes.  And while she waited (apparently for hours), she learnt that not only did the records office not know who took the folder, but one of our national specialty centres was also looking for that very same folder.  She was under their care for a number of conditions.

5 In any case, Mrs Tan’s doctor saw her without the benefit of previous case notes and had to record his clinical findings on loose sheets.  Then the next problem – should these loose sheets be sent to the MRO and wait to be incorporated into a folder that has gone MIA? 

6 At the end of her post on Facebook, Mrs Tan said she had started  consolidating all her records with her main doctor at hospital A as the management of her conditions was getting increasingly complicated. 

7 Having incomplete view of patient records – especially those under the care of different doctors for other conditions – means patient safety and quality of care cannot be optimized.  Patients like Mrs Tan will not get the best care that we can provide when the doctors are each treating a part of her rather than doctors working together in treating her as a whole.  And her many doctors cannot treat her as a whole if they wish to, without having her records at hand.

Transforming Singapore’s Healthcare Landscape

8 It is about providing the integrated, patient-centric care that our Prime Minister spoke at last year’s National Day Rally.  With the tide of the silver tsunami surging towards us, we have to transform our healthcare delivery system.  We need have information systems and workflow processes that enable us to better manage the elderly retirees like Mrs Tan.  They take longer to recover from acute illnesses, sometimes not completely as acute conditions turn into chronic conditions.  This further complicates their care should other illnesses arise.

9 This leads us necessarily to a different vision of healthcare delivery, where, instead of patients jumping between two distinct primary and acute care sectors with very limited options in between, they will have access to a honeycomb of healthcare providers in the step-down, rehabilitation and home care space where the continuum of care revolves seamlessly around their individual healthcare needs. 

Managing Change for the NEHR-Enabled World

10 Achieving integrated care is not going to be easy, as it will involve some fundamental changes on many different levels.  We are looking at a different way of organizing healthcare for the providers, a different way of practicing medicine for doctors, a different way of interaction among restructured hospitals, community hospitals and GPs. 

11 At the systems level, the two key enablers for integrated care are the National Electronic Health Record (NEHR) and a number of key policies and approaches that need to accompany in the NEHR-enabled world. 

12 It is important to remember that the NEHR is not an IT initiative.  In developing the framework and architecture of the NEHR system, MOHH’s approach has been based on established precedents, international best practices, and most importantly, the engagement of key stakeholders throughout the process.  The form and function of our NEHR has been defined by clinicians for clinicians, answering the fundamental question of “What do you want to see on the NEHR that will help you provide the best care for your patient?”

13 In an NEHR-enabled healthcare delivery system, team-based care can only fully become a reality when accompanied by changes in policies and governance to define the rules of engagement in this brave new world.  Let me outline a few that are being reviewed right now and will affect everyone here in the run-up to the rollout of the NEHR in April 2011.

14 There will be greater clarity in the Clinical Practice Guidelines.  These will include clinical protocols and pathways for treatment of various major diseases across acute hospital, step-down care, primary care and home care.  With care involving many people in a multi-disciplinary team across different settings, clearer guidelines will be important to quality.  The NEHR will enable easier tracking of clinical outcomes, which will support the big push our clinical community is making in measuring and benchmarking their clinical outcomes to improve quality of care and patient safety.

15 We are also reviewing policies on security and data stewardship.  As I said last year, the NEHR-enabled environment requires a stronger policy on data privacy and security than what we have today.  On the technical front, data security and resilience of our NEHR to breaches must be rock solid as doctors’ confidence and patients’ trust are fundamental to its usage.  Yet, we must be mindful not to create a system so unwieldy and restrictive that renders it unusable.  The key is finding that balance.

16 To raise the performance achievements of our health system further, we need to go further in our data management efforts.  When Dr Glenn Stelle, CEO of US’ Geisinger Health visited Singapore recently, he argued strongly for the bringing together of 4 info streams to improve cost-effectiveness and clinical outcomes.  We need to blend together the clinical quality data with unit cost data, revenue data, and utilization data.  Analysing these is essential to improve our understanding of where best to devote resources and the implications of the choices we make.  We hope to tap on Geisinger Health’s experience and learn from them.

Harnessing the Power of Infocomm

17 I’d now like to switch tacks and speak on the broader possibilities of harnessing the power of infocomm for healthcare.  I have just returned from a brief visit to Europe with a team from IDA to look at developments there in IPTV.  Essentially, internet to the TV has become a reality because of widely available broadband.  Images with high bandwidth requirements can now be easily sent over the internet.  Second, the iPhone and iPad phenomena have shown how new internet-enabled devices can transform the way the world lives, works and plays. The next iPad will definitely have a camera built-in.  And TV is just another end-user device to receive data, voice and images, in high definition and in 3D.  Electronics and IT companies are now aggressively developing home automation where gadgets in the entire house can be “connected” and made smart. 

18 These innovation trends offer huge potential to transform and disrupt healthcare delivery.  Healthcare is an area which requires high bandwidth because of imaging.  Electronic medical imaging technologies for example, digital radiology, multi-slice CTs and full-body MRIs, require clear images to be transmitted real-time, say, from a radiology facility to an ordering physician in a clinic across the island.  This will soon be possible with Singapore’s Next Generation Network, a high-speed fibre optic network that will support up to 1Gbps.  We have already covered about 35 percent of homes and buildings in Singapore so one-third of you in this room should already have it reach your homes. We are well on track to reach 60 percent coverage by the end of this year, and 95 percent by 2012.  The key is that broadband pricing will be affordable.  Likewise, electronic gadgets for use by the broad base of consumers will be affordable. Affordable pricing is important to exploiting possibilities for day to day use.

19  These changes should allow telemedicine to take off.  Let me mention various possibilities.  In the Next-Gen Network marketing video, there was a scene in which a polyclinic doctor treats a patient by talking to him and examining the inside of his mouth over a TV screen.  While doctors may not be entirely comfortable with this for first appointments, I can certainly see this being comfortably used for routine follow-ups.  Home care also becomes affordable if a GP need not visit physically each time, but can consult on the phone with a nursing aide who is visiting the patient, aided by visual contact with the patient on high-definition TV.  These can be complemented with an array of home monitoring devices like sensors.  MOH’s Health and Wellness Office is working with companies to test-bed med tech, IT and other innovations in our healthcare system.  This is a joint venture between MOH and EDB.

20 The Government has identified med-tech as the 2nd main BMS research area to nurture, after pharmaceuticals and drug development, because it believes med-tech has big economic potential.  With our strong electronics manufacturing history, S’pore is well placed to be a good test-bed for these innovative electronic diagnostics.  At the CommunicAsia expo a few weeks ago, I saw a local company demo-ing a PDA-type hand-held device which can show and transmit the ECGs of patients holding the device.  This had been developed by a group of cardiologists at Mt Elizabeth, and they can monitor their patients daily for follow-up during the sensitive period immediately after hospital discharge.  This provides much peace of mind to patients and higher quality care.  This includes managing international patients who may have even returned home.  This has important social and economic implications for Singapore, including strengthening our position as a global medical hub.  

21 I likewise am optimistic that Singapore can grow the IT services capability that can make an impact globally.  Given the complexity, the degree of specialization in skills and the need for integration, MOH amalgamated the IT departments of all our hospitals into a shared services entity called Integrated Health Information Systems (IHIS).  Today, IHIS is the largest specialized healthcare information company in Singapore.  After it participates in setting up the NEHR, and has a proven track record of deployments in Singapore, I see no reason why it cannot expand further to take on commercial deployment contracts in health systems elsewhere in the world.  There is a big demand for this, not easily met, as it is a specialized area.  What we are de facto doing is investing in capability building that has economic potential. 

Key Milestones in the Journey Ahead

22 There is an ancient Chinese quotation that says the journey of a thousand miles begin with a single step.  I would add that the journey of a thousand miles is completed by taking each and every step forward. 

23 Collectively we have taken more than the first few steps.  Today, I like to acknowledge the key milestone of the completion of the design and procurement phases of the NEHR, and the start of the all-important implementation phase.   Thank you to the stakeholders in both public and private healthcare, and the clinician leaders of our Clinical Advisory Group and various taskforces, for working closely with the MOHH team in getting here.  And as we take further steps forward, there will no doubt be challenges to tackle. I hope we do not lose sight of our common goal when different points of view get into play.  And not lose heart when change becomes uncomfortable.  Let’s keep our eyes focused on the reason why we are on this journey – creating a healthcare delivery system where we all work collaboratively in the best interest of our patients.  Safe, cost effective, holistic and hassle-free. 

24 I look forward to your continued participation, and I look forward to us all reaching the next milestone where Phase One of NEHR goes live next year.  For the next two days, I wish all of you a fruitful and enjoyable summit. Thank you.