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