0Singapore experienced rapid population growth in recent years, with the population exceeding five million. This had put a strain on its infrastructure and services. At the same time, Singapore is also facing the prospect of an ageing population where one in five will be over 65 years old by 2030. The national healthcare expenditure is expected to increase and a different pattern of healthcare is necessary; one which features an integrated healthcare delivery system with “right-sited” care, better allocation of resources and more cost-effective treatment and care.
2.12.2 Country Overview
Public healthcare in Singapore is governed by the Ministry of Health (MOH). Institutions that deliver subsidised healthcare are publicly funded through subventions and include 7 acute general hospitals and 6 national specialty centres for cancer, cardiac, eye, skin, neuroscience and dental care. In addition, there are 18 polyclinics located throughout the island that provide subsidised outpatient medical care, health screening and pharmacy services. In the next 4 years, there will be 2 new public hospitals providing additional 1000 beds.
The Intermediate and Long Term Care is provided by residential and communities which are mostly outside the public healthcare system though some facilities receive government subsidies.
In 2000, WHO ranked Singapore’s healthcare system ranked first in Asia and sixth in the world. IMD (2007) ranked Singapore’s health infrastructure third out of 55 countries. These accolades were achieved on a prudent national healthcare expenditure that is within 4% of Singapore’s GDP (a low figure among developed countries)
2.12.3 Objectives and Strategies
There had been a shift in focus from episodic care to developing holistic care to patient. The vision is to have “Hospital without walls” where the healthcare team will comprise GPs, nurses, physiotherapists beside the hospital staff. The team will deliver patient centric care through greater collaboration and partnership. Patients can be decanted more effectively in the healthcare system through the “team based care” so that acute hospitals can cater to severe cases and refer patients in recovery to step down care. This will address the capacity issues of acute hospitals especially in the context of an ageing population.
The National Health Informatics Strategy was conceptualized in 2008 with the goal of achieving greater coordination of healthcare across different providers for patients, higher adoption of Electronic Medical Record systems (EMR) amongst healthcare providers and integrating these EMRs to achieve a vision of “one patient, one medical record” in Singapore. A key part of this strategy is to develop a shared Electronic Health Record which makes available summaries of clinically relevant patient information to healthcare providers to improve the overall quality of care rendered to patients when they seek healthcare services at different points of care throughout their lives. National Electronic Health Record (NEHR) Phase 1 was implemented by 2011 as one of the key guideposts for Singapore’s longer term “One Patient – One Medical Record” vision. More capabilities to support clinician collaboration across care setting, harness the power of data via analytics as well as expansion of NEHR adoption across the entire healthcare continuum will be the focus from 2012 to 2016.
In addition, the iN2015 Masterplan by the Infocomm Development Authority (IDA) set out a 10-year plan to utilize infocomm technologies to establish a well connected society. For the healthcare sector, personalized healthcare delivery was a future envisioned to be enabled by infocomm to achieve high quality clinical care, service excellence, cost-effectiveness and strong clinical research.
2.12.4 Activities Implemented
MOH did a review of healthcare landscape and had implemented a concept known as Regional Health System (RHS). There are six RHS formed to serve the different geographic locations in Singapore. The RHS realised the vision of “Hospital without Walls” by providing integrated care to patients. The RHS will involve an acute hospital as anchor to work closely with key healthcare providers in the region i.e. General Practitioners and step down care providers such as community hospitals, nursing homes and hospices. Together, the institutions were to take a patient-centric approach, as opposed to the traditional institution-centric approach. To support the RHS concept, there will be a need to improve the healthcare ICT capability especially in the area of connectivity between institutions. NEHR will be used as a common reference to Patient Record.
2.12.5 Technologies and Solutions Deployed
National Electronic Health Record (NEHR)
To improve healthcare quality for all residents, increase patient safety, lower healthcare costs and develop more effective health policies, Singapore’s Ministry of Health (MOH) created the National Electronic Health Record (NEHR) vision – “One Singaporean, One Health Record”.
The NEHR extracts and consolidates in one record all clinically relevant information from the patient’s encounters across the healthcare system throughout his/her life. It allows for data sharing, making it accessible to authorised healthcare providers, across the continuum of care throughout the country.
With the NEHR, healthcare teams would be better equipped to provide more effective care as the system will enable more timely access to health records including diagnoses, prescriptions and allergies. This will help reduce medication errors and adverse drug events. There will also be cost savings as healthcare staff will be able to obtain a more complete and accurate picture of the patient’s health history and therefore avoid ordering duplicate or unnecessary tests.
Integrated Clinical Management System (CMS)
Launched in 2006, the Integrated Clinic Management Systems (CMS) program aims to encourage GP clinics to adopt and leverage on infocomm technologies to facilitate operations and clinical improvements in their patient care. The integrated CMS facilitates scalability of the GP infrastructure by enabling consistent and standards based interface with different healthcare provider systems. Secured and seamless information flow will allow GPs to plan the patient's treatment in an integrated and coordinated manner with other hospitals and step-down care providers. Through this program, GPs will have the capability to easily plug into the national healthcare network and achieve MOH's "One Singaporean, One Electronic Medical Record" vision.
GP-IT Enablement Programme
Building on the momentum of the CMS Program which has resulted in most GPs having some form of IT system in place, the GP-IT Enablement Program was conceptualized in 2010 as the next phase of GP IT adoption. It aims to support more sophisticated IT usage for GPs through introduction of an IT-enabled clinical foundation that contains linkages to the National Electronic Health Record (NEHR) and care services such as laboratory and diagnostic radiology results. GPs currently participating in the CMS Program will be transited to the IT-enabled clinical foundation when the system is implemented.
Intermediate and Long-Term Care (ITLC) IT Enablement Programme
The ILTC sector comprises residential and community-based services and is currently managed mostly (approximately 70%) by voluntary welfare organisations (VWOs), where resources are usually stretched, clinical documentation capability or management is limited, IT usage is minimal and IT expertise a scarce occurrence. To address these issues, the ILTC Programme consists of an IT strategic framework that aims to establish the core foundation for the use of technology across ILTC settings, for operational efficiency, and subsequent electronic exchange of information between care settings within the ILTC sector and nationally to the National Electronic Health Record (NEHR). In addition, an ILTC IT Adoption Model will be developed to categorise the IT adoption of different care facilities, to allow policy planning to better develop specific programmes to meet the needs of care facilities with similar maturity levels, and to increase industry interest in the ILTC sector to explore more innovative & sustainable solutions and develop more targeted products and services for the care providers and care givers.
With the increasing challenges of the healthcare sector, Singapore needs to explore more innovative ways to deliver healthcare services, and Telehealth is one such area. Telehealth is an area where ICT can improve the delivery of healthcare services and where the ability of patients to be more proactive in their health management can be enhanced, thereby increasing care accessibility, enhancing care quality and delivery, and bring more affordable care through greater operation efficiency. It aims to empower patients to better self-manage their health while collaborating with healthcare providers to ensure care continual.
The Telehealth Programme has been formulated to identify and develop remote healthcare services via ICT including mobile technologies in an affordable and sustainable manner for both patients and healthcare providers. Through this programme, it aims to increase greater Telehealth adoption through more coordinated efforts and optimized investment across the entire healthcare ecosystem.
The programme will drive the development of a Telehealth framework which will establish a tripartite relationship between the patients (with their care givers), healthcare providers, and technology as the necessary bridging platform, with an overarching governance to provide implementation guidance and oversight. It includes development of needs assessment and implementation guidelines, thus aligning and synergizing the various initiatives across the healthcare sector including institutions, government agencies and industry.
2.12.6 Changes and Outcomes Achieved
National Electronic Health Record (NEHR)
Phase 1 of NEHR completed in Jul 2012 with common patient records available to all public acute care hospitals, specialist clinics, polyclinics, selected GP clinics, five community hospitals, two nursing homes, one hospice and supporting organizations like Agency for Integrated Care (AIC), Health Promotion Board (HPB) and Singapore Armed Forces medical corps. Phase 2 of the NEHR will provide additional features and functionalities to support patient care and data analyses.
GP-IT Enablement Programme
CLEO (Clinic Electronic Medical Record and Operations), a national system developed for the primary care will comprise of an EMR and an integrated CMS (clinic management system). Phased rollout is expected to begin from 2013.
IDA had awarded a grant to Quest Laboratories to develop a system that delivers secured, electronic lab results online and to NEHR (via the General Practitioner Clinic Electronic Health Record and Operations or CLEO) that comply to the Singapore HL7 standards for messaging and LOINC international standards for diagnostic results. The system will transform a traditional, paper-based process of GP practice to one that is IT-enabled, offering timely and comprehensive electronic documentation of a patient’s health condition when integrated with NEHR. It will also leapfrog Singapore’s status as one of the few countries in the world with such high level of IT sophistication in pathology services. The system will be completed by March 2013.
MOH Holdings (MOHH) had established a programme office (Consumer Health Office) to oversee the programme. As part of the programme, Integrated Health Information Systems (IHIS), a subsidiary under MOHH, had also established a Telehealth Technology Office (TTO). The TTO will build (when necessary), implement, operate and support Telehealth solutions. By aligning and consolidating potential Telehealth initiatives across the clusters and community, TTO will assist institutions to achieve economies of scale through consolidated procurement, therefore optimising the limited manpower and financial resources.
MOHH has recently completed a local landscape study of Telehealth implementations by the different healthcare institutions. The study seeks to understand the major pain points and barriers to adoption of Telehealth. The results of the study will help to guide the programme office in developing the framework for assessing and regulating Telehealth.
IDA had launched the Telehealth Call For Collaboration (CFC) earlier in March 2012 to invite the industry to develop new models of distance care for the elderly - at home, within the community or at institutions such as nursing homes - assisted by ICT. Launched in collaboration with the Ministry of Health, it is hoped that the CFC will encourage healthcare providers to review existing care models and care processes, to ensure sustainability through appropriate change management, manpower training and benefits measurement and demonstrate viable business models for longer terms deployment of Telehealth services. It is predicted that Telehealth will be a key enabler behind strategies that are being adopted to enable “ageing-in-place” as Singapore prepares itself for a rapidly ageing population. Results of the CFC will be announced in early 2013.
2.12.7 Challenges and Success Factors
National Electronic Health Record (NEHR)
As there are six clusters and over 30 institutions in Singapore, it is a challenge to take in the data, process and display accurate and meaningful data. 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. The data includes information which is non-clinical such as information used to identify people, organizations, locations and departments etc. A national strategy was developed to govern the creation, implementation and management of standards in health information exchange.
The journey and results of any delivery are predictable if the challenges ahead were identified and dealt with. When deploying the NEHR to new institutions, the project team was able to re-use product, process and people, supported by tried and trusted methods.
There were a number of telehealth projects led by the various health institutions. These initiatives include; National Healthcare Group (NHG) Diagnostic’s remote radiology reading service, and Khoo Teck Puat Hospital (KTPH) nursing home-geriatrician video-consultation initiative. These projects demonstrate that effective and clinically-led sustainable Telehealth is possible in Singapore. There was however challenges that will need to be tackled such as lack of sustainable business models, clinician support being hampered by liability. Other concerns such as lack of IT infrastructure, patient billing, provider reimbursement issues, security and privacy concerns, and lack of standards will need to be addressed as well.
The challenges will be systematically addressed by the MOHH Consumer Health Office. For example, to address the business model and sustainability issues, the project assessment criteria will include the presence of a viable and validated business model.
Unlike other countries where telecommunication infrastructure is a key barrier, Singapore is well equipped for adoption of Telehealth given our high mobile penetration, excellent network connectivity and high speed broadband, and increasingly empowered population. Coupled with clinical leadership and commitment, Singapore can push towards greater Telehealth adoption across the care continuum and position as a Telehealth thought-leader within Asia Pacific.
2.12.8 Lessons Learned and Next Steps
The full implementation of NEHR is an iterative one and will take years to complete, allowing each deployment cycle to refine and improve on the previous one.
Singapore’s adoption of the NEHR will change the healthcare landscape in the country for the better. The NEHR is a journey to transform the mindset of healthcare providers and patients, so as to bring about better quality care. Once the NEHR is fully implemented, the possibilities of future development in areas of prevention and treatment are vast. In addition to contributing to high quality care and service excellence, the NEHR will bring us closer to achieving our vision of “One Singaporean, One Health Record”.
NEHR Beyond Acute Hospitals
IT implementation and adoption strategies for the intermediate and long term care (ILTC) and primary care sectors are being developed. While the IT adoption rate is still low at the primary care level, IT enablement among GP practices and Community Hospitals will progress with linkages to the NEHR.
The use of IT will enable patients’ critical medical information flow from the acute hospitals to the primary and intermediate long term care sectors. There will be support for Community Hospitals (rehabilitation hospitals) to modernise patient administrative, pharmacy and clinical systems. Upgrading, enhancing and improving of systems in nursing homes, day rehabilitation centres and home nursing providers are also underway.
In the long run, healthcare providers will be able to better develop, integrate and coordinate shared care plans to provide better quality care. The end goal is for patients to enjoy a hassle-free healthcare delivery service, with fewer repeat tests and reduced medication errors when they move from one care setting to another, with the NEHR linking up providers in the community who currently do not have electronic access to patients’ medical records.
For patients, it means better prescribing practices, reduced waiting times and better management of the quality and cost of healthcare by ensuring the most appropriate care setting for their conditions.
Over the past few years, there have been multiple efforts in Telehealth exploration by various healthcare institutions and government agencies; with varying results. These range from government-funding programmes such as IDA Yr 2006 CFC to ground-up institutional initiatives such as video conferencing partnerships. However, these efforts are largely sporadic and relatively unsustainable. One key factor was an overall lack of coordination in pushing forward the adoption and innovative use of Telehealth in Singapore. As such, it is hoped that the establishment of a Telehealth framework will help coordinate the various Telehealth efforts and guide its implementation.
The Telehealth Framework aims to identify services that will deliver remote healthcare services via ICT including mobile technologies in an affordable and sustainable manner for both patients and healthcare providers. Through this framework, it will set the directions for Singapore Telehealth adoption across the entire healthcare ecosystem and identify low-hanging or high-potential areas to which more coordinated efforts and investment can be delivered.
This will also establish a consistent assessment framework for Telehealth efforts, thus aligning and synergizing the various initiatives across the healthcare sector including institutions, government agencies and industry. As part of the framework, a set of implementation principles will be developed to help guide the implementations and facilitate subsequent best practices sharing.