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Singapore: IT Integrating Healthcare and Empowering Patients

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1 Singapore: IT Integrating Healthcare and Empowering Patients
Dr Sarah Muttitt Chief Information Officer Information Systems Division Sept 15, 2008

2 Singapore: a small country…..
4.59 million people on sq km (6,489/km2) Ethnically diverse: Chinese: per cent Malays: per cent Indians: per cent Others: per cent 35,000+ healthcare providers 11,580 hospital beds 429,744 hospital admissions (2007) Public sector out-patient visits (2007) Specialist Outpatient Clinics 3,687,910 A&E ,122 Polyclinics 3,797,953

3 Singapore’s Healthcare System
MOH’s Vision: Developing the world’s most cost-effective healthcare system to keep Singaporeans in good health MOH’s Mission: To be an innovative and people-centred organization that seeks to: Promote Good Health and reduce illness Ensure that Singaporeans have access to good and affordable healthcare that is appropriate to needs; and Pursue Medical Excellence

4 Achieving Positive Health Outcomes with Low Expenditure
Top-ranked overall healthcare system by WHO (6th overall) - World Health Report 2000 Affordable healthcare expenditure at about 3-4% of GDP (1% is government spending) 1st for infant mortality, 8th in life expectancy, 20th for health and primary education and 15th in terms of social parity in health care quality - The Global Competitiveness Report (by WEF) 3rd in health infrastructure; 4th in terms of impact of health problems (AIDS, drug, alc abuse etc) on companies - The World Competitiveness Yearbook 2007 (by IMD) 1/3 of JCI-accredited hospitals in Asia are from S’pore - All 7 public hospitals achieved JCI accreditation Clinical expertise recognized internationally with many “Firsts’ Attracted internationally known partners such as Johns Hopkins, St Jude Children’s Research Hospital, Duke University and JCI regional HQ

5 Health Expenditure vs Life Expectancy (2001-2)
“The annual health expenditure for Singapore is less than half that of many developed countries even though its citizens enjoy comparable ‘healthy’ life expectancy.” – Tucci (Watson Wyatt Healthcare Market Review, 2004)

6 Healthcare Financing in Singapore
Employer benefits Medi- save Cash* MediShield & Elder- shield Medi fund Government Subvention National Healthcare Expenditure (NHE) Individual Financing Government Healthcare Expenditure KEY GOVERNANCE PRINCIPLES Individual responsibility for health; patient co-payment to minimize moral hazard and wastage Government subsidies to keep basic healthcare affordable

7 Healthcare Financing in Singapore
National Schemes Medisave Medishield Medifund Medisave (1984) National medical savings scheme For personal or immediate family’s hospitalization, day surgery and certain outpatient expenses Typical contribution % of wages Medishield (1990) Low cost catastrophic illness insurance scheme Meet medical expenses from major or prolonged illnesses MediShield will cover an average of nearly 60% of large medical bill at Class B2 or C wards Premiums may be paid by Medisave and co- payment and deductibles can be paid using Medisave or cash. Out-of-Pocket Medifund (1993) Endowment fund set up by the Government to help needy Singaporeans Safety net for those who cannot afford the subsidised bill charges Private Insurance Employer

8 Empirical Bill Size (S$)
Subsidized Inpatient Care for Singaporeans Ward Class Subsidy Level Empirical Bill Size (S$) Median 80th Percentile 90th Percentile A Nil ($)2,390 5,150 7,820 B1 20% 1,870 4,340 6,910 B2 65% 740 1,610 2,710 C 80% 580 1,340 2,270 Means Testing to be introduced in Jan 2009: All Singaporeans can continue to choose any ward class Assessment of patient’s ability to pay will be simple – sliding scale No patient will be denied treatment because he/she cannot afford it

9 Inpatient Care Tiered Subsidies A1 Ward SGD300/day C Ward SGD 25/day
B1 Ward SGD160/day

10 Private vs Public Health Expenditure (2002)
“The key to Singapore’s efficient healthcare system is the emphasis on the individual to assume responsibility towards their own health and, importantly, their own health expenditure. The result is a system that is predominantly funded by private rather than public expenditure” – Tucci (Watson Wyatt Healthcare Market Review, 2004)

11 Singapore’s Healthcare Delivery Eco-system
Step-down & Long Term Care - Voluntary welfare Organizations (70%) - Private Healthcare Organizations (30%) Patients have freedom of choice to choose any providers of care in various sectors Secondary & Tertiary Specialist Care - 7 Restructured Hospitals & 6 specialty centers (80%) - 16 Private Hospitals (20%) Primary Healthcare - 17 Polyclinics (20%) - Private GP Clinics (80%) Public sector Private sector People sector

12 A balanced and sustained approach required for the long-run
Healthcare Drivers Aging population - By 2030, 1 in 5 Singaporeans over age 65 (three-fold increase) Changing diseases – more chronic and emerging infectious diseases Increasing public expectations Rising prices of drugs and equipment Yet, limited resources Global shortage of healthcare professionals Lack of facilities A balanced and sustained approach required for the long-run

13 Continuing and Growing Government Investment in Healthcare
Better capabilities Sustained excellence More capacity Healthcare financing reforms New governance structures Integration of Care Medical excellence and specialization Translational and Clinical Research Increasing manpower New or expanded infrastructure Exploitation of IT Healthcare Budget

14 Public Healthcare Sector
MOH Holdings National Health Group SingHealth Group

15 Serving as a Value-Multiplier to Singapore’s Public Healthcare System
MOHH Mission Serving as a Value-Multiplier to Singapore’s Public Healthcare System Financial & Corporate Governance Systems Coordination Information Systems Division EHR roadmap & architecture Standards governance, data privacy & security Program mgt, Knowledge mgt Manpower capabilities Approval, oversight and financial mgt of RH IT projects Legal Structuring Human Capital Manpower Facilitation & Recruitment Talent Development & Management Leadership College Remuneration & Benefits Branding & Marketing Build Brandwidth International Media Outreach & Events Strategic Global Channel Restructuring & Central Services Centralise Treasury Corp Fin Advisory Compliance & Risk Mgt

16 MOHH Master HIT Planning
National EHR & Related Integrative Projects Organization Specific IT Capabilities Strategic Alignment HIT master planning will support the national agenda for an Electronic Health Record by 2010 by facilitating strategic alignment at various Levels of the Healthcare System

17 iN2015 Healthcare & Biomedical Sciences
These national initiatives have opened the clinical community to the potential clinical & operational benefits of HIE & greater coordination of Health IT at the national level. GP Clinic Management Systems GP CDMP IT Capabilities EMRX in Clusters EMRX extension to Community Hospitals

18 EMRX - History Both clusters have adopted IT extensively and have their own EMR systems Before 2004, there was no mechanism to allow patient clinical information to be shared across the two public healthcare clusters electronically For example, a clinician at SHS is not able to view the current patient’s previous medical records at NHG, and vice versa In 2004, the Ministry of Health (MOH) implemented EMRX Started with in-patient discharge summary sharing between the two clusters Align with the vision of “One Singaporean, One Medical Record”

19 EMRX - Today Over 100,000 clinical documents shared monthly
Major types of clinical information being shared through EMRX Hospital Discharge Summaries Laboratory Test Results and Radiology Reports Medication information Immunisation Records Drug Allergy, Medical Alerts and Adverse Drug Report Operating Theatre and Endoscopy Reports Current participants in EMRX for information exchange Public Health Clusters - SHS and NHG Community Hospitals Government Agency - Ministry of Health, Health Promotion Board, Health Science Authority and Ministry of Defence

20 Where We Are Now Current Gaps
Performance (Technical) Improved responsiveness, scalability and robustness Support non-text EMR (e.g. diagnostic images) Performance (Clinical) Interoperability profiles for clinical workflows. (e.g. case management, e-referrals, basic disease management, clinical quality monitoring, and adverse drug reaction surveillance) Standards Data and messaging/document standards for semantic interoperability Analytics Support for performance measurement, public health surveillance and clinical research Reach Access by non-public sector (GPs and ILTC) Privacy & Security Framework that governs the usage, collection, storage, analyses and dissemination of EMR

21 Taking the Next Step (MSM April 2008)
Singapore requires a national integrated electronic health information system based on a common enterprise architecture, data standards and privacy and security guidelines. A shared electronic health record (EHR) can be delivered by 2010. Broad stakeholder engagement is needed. The EHR is not an IT project but a business and clinical transformation project. Governance and accountability is necessary to align strategic intent with implementation. National strategy and implementation plan Funding mechanisms to encourage consistent, coordinated and continuous investment in health IT Skilled resource capacity Measuring of success of the national EHR with regards to health care quality, safety, and productivity.

22 Our Approach Clinical Informatics
To identify focus areas with realizable clinical, business benefits and facilitate allocation of resource, effort Build Clinical Informatics Roadmap with defined strategic focus areas Form Clinical Advisory Group to set direction for the Roadmap Broaden clinician involvement by creating a middle tier of clinical taskforces for each focus area Taskforce Clinical Objectives Summary Care Record & Continuity of Care Ensure continuity of care during transfers of care Improve efficiency of care coordination Incentivise behavioural change for lifestyle risk factors Strengthen patient-care coordinator relationships Medication Management & Computerized Physician Order Entry (CPOE) Reduce incidence of medication error Increase effectiveness of ADR surveillance Decrease inadequate follow-up for test results Secondary Data-Use Taskforce Improve comparability of outcomes data Enable data analysis across cycle of care

23 Clinical Engagement Clinical Informatics Roadmap
The Roadmap will articulate Clinical Focus Areas, Objectives … and corresponding Health IT capabilities (illustrative) Continuity of Care Support continuity of care during care transitions Facilitate patient access to relevant care, and patient – care coordinator relationships Improve efficiency of care coordination for large patient cohorts, disease management Medication Management Support initiatives to reduce medication error Increase effectiveness of adverse event surveillance Diagnostics Support patient safety initiatives Enhance operational efficiencies for diagnostics services Secondary Data Use Improve data comparability, reliability and timeliness Support data analysis across cycle of care for core measures Summary care record E-referrals & referral triage Case management tools EHR & Extensions Active medication list Harmonized drug nomenclature & codes Drug dispensing data Shared image repositories Harmonized lab nomenclature & codes Interoperability framework for clinical data repositories & disease registries

24 Privacy & Security To govern the flow of information for sharing of EMR, balancing between safety and convenience Establish the principles and policies that govern the sharing of healthcare information, including areas of appropriate use, access, retention, etc Develop a Privacy & Security Framework that covers access control, consent of the data shared and security standards to ensure the availability, integrity and confidentiality of data

25 Enterprise Architecture Design and Implementation
Health Informatics Architecture Outputs of Clinical Informatics and Privacy & Security constitute the Business Architecture Business Architecture drives the Information, Solution and Technical Architectures Engagement with private sector and vendors via National Standards bodies Clinical Informatics Privacy & Security National Standards

26 Standards Plans Global Standards Engagements
HL7 (Health Level Seven) Singapore launched the HL7 Affiliate in June 2008 to build up local expertise in HL7 standards IHTSDO (International Health Terminology Standards Development Organization) Singapore to join IHTSDO as a national member & participate actively in SNOMED-CT development internationally ISO TC215 on Health Informatics IHE (Integrating the Health Enterprise) Develop a framework for the coordination of Health Informatics standards activities at the national level Governance process & methodologies for the evaluation, development & maintenance of standards Standardization of International Classification of Diseases (ICD) & Diagnosis Related Groups (DRG)

27 Timeline Overview Integration of Workstreams
Identity Management EHR Business Case Block Budget for HIT GP IT Adoption Strategy Community Hospitals EMR National eHealth Portal Research Informatics Strategy National Drug Dictionary IT for new ‘hassle-free’ hospital Leverage national IT infrastructure & systems

28 ISD Timelines & Deliverables 3-year Projection
FY08 Clinical & Business Strategy Information Architecture FY09 Funding Model Data Stds Implementation FY10 National EHR Phase 1 Implementation Constitute advisory groups, taskforces Develop allocative funding projections for each functional area Longitudinal health record with summarized, aggregate data Articulate clinical priorities, informatics roadmap & enterprise architecture Monitor data standards implementations True semantic interoperability through standards based data model Develop core business, clinical-usage scenarios Develop business, clinical usage scenarios for emerging clinical services (e.g. AIC) Robust, extensible access controls & security framework Initiate harmonization activities for key data standards Centralized, scalable infrastructure Develop data privacy, security policies Dovetail with ongoing implementations Involve ongoing implementations in harmonization activities

29 Standards for Interoperability
“The Government will identify and set nation-wide standards for our healthcare IT infrastructure. This common backbone should include standardized 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.” Ms Yong Ying-I, Permanent Secretary (Health), Singapore Healthcare IT Innovation Week, Opening Speech, 1 February 2007

30 Thank You

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