Unleashing the Benefits of a National EHR Dr Sarah Muttitt Chief Information Officer Information Systems Division [email_address] Oct 16, 2008

Singapore: a small country….. 4.59 million people on 707.1 sq km (6,489/km 2 ) Ethnically diverse: Chinese: 75 per cent Malays: 14 per cent Indians: 9 per cent Others: 2 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 752,122 Polyclinics 3,797,953

4.59 million people on 707.1 sq km (6,489/km 2 )

Ethnically diverse:

Chinese: 75 per cent

Malays: 14 per cent

Indians: 9 per cent

Others: 2 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 752,122

Polyclinics 3,797,953

Achieving Positive Health Outcomes with Low Expenditure Affordable healthcare expenditure at about 3-4% of GDP (1% is government spending) Top-ranked overall healthcare system by WHO (6 th overall) - World Health Report 2000 1 st for infant mortality, 8 th in life expectancy, 20 th for health and primary education and 15 th in terms of social parity in health care quality - The Global Competitiveness Report 2006-07 (by WEF) 3 rd in health infrastructure; 4 th 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

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 Healthcare Financing in Singapore Employer benefits Medi- save Cash* MediShield & Elder- shield Medi fund Government Subvention National Healthcare Expenditure (NHE)

KEY GOVERNANCE PRINCIPLES

Individual responsibility for health; patient co-payment to minimize moral hazard and wastage

Government subsidies to keep basic healthcare affordable

Singapore’s Healthcare Delivery Eco-system Primary Healthcare - 18 Polyclinics (22%) - Private GP Clinics (78%) Secondary & Tertiary Specialist Care - 7 Restructured Hospitals & 6 specialty centers (80%) - 16 Private Hospitals (20%) Public sector Private sector People sector Patients have freedom of choice to choose any providers of care in various sectors Step-down & Long Term Care - Voluntary welfare Organizations (70%) - Private Healthcare Organizations (30%)

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 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

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

GPs as Long Term Patient Advocates Holistic Patient Centric Care Affordable Ageing-in-Place Active Health Management What a person needs at each stage Preventive Care Individual at home Primary Care Family Physicians Tertiary Care Hospitals Step-Down Care Nursing Homes Community Hospitals Healthcare System Optimization Integration of Care and Right-siting Hospice Community Care

Public Healthcare Sector MOH Holdings National Health Group SingHealth Group

Electronic Health Records The International Scene Canada United Kingdom Australia Denmark New Zealand … and in Singapore Most industrialized countries have recognized the need to implement electronic health record solutions quickly to improve the quality and safety of patient care and system efficiency.

Canada

United Kingdom

Australia

Denmark

New Zealand

… and in Singapore

iN2015 Healthcare & Biomedical Sciences EMRX in Clusters GP Clinic Management Systems GP CDMP IT Capabilities EMRX extension to Community Hospitals 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.

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”

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”

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

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

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

Improved responsiveness, scalability and robustness

Support non-text EMR (e.g. diagnostic images)

Interoperability profiles for clinical workflows. (e.g. case management, e-referrals, basic disease management, clinical quality monitoring, and adverse drug reaction surveillance)

Data and messaging/document standards for semantic interoperability

Support for performance measurement, public health surveillance and clinical research

Access by non-public sector (GPs and ILTC)

Framework that governs the usage, collection, storage, analyses and dissemination of EMR

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.

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.

Taking the Next Step – What’s the Big Deal? A large, complex, diverse and multi-structured system Who is in charge – Ministry, doctors, institutions, payors… patients? One size or solution may not fit all – flexibility Technology has to support not drive health care reform Understanding the fundamental work flow transitions from paper to electronic The need to demonstrate clearly the benefits and value to making the change Leadership & Governance Interoperability Change Management Accountability

A large, complex, diverse and multi-structured system

Who is in charge – Ministry, doctors, institutions, payors… patients?

One size or solution may not fit all – flexibility

Technology has to support not drive health care reform

Understanding the fundamental work flow transitions from paper to electronic

The need to demonstrate clearly the benefits and value to making the change

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

Serving as a Value-Multiplier to

Singapore’s Public Healthcare System

Information

Systems

Division

EHR roadmap & architecture

Standards governance, data privacy & security

Program mgt, Knowledge mgt

Manpower capabilities

Approval, oversight and financial mgt of publc sector HIT projects

MOHH ISD Leadership & Governance Role of MOHH Information Systems Division (ISD) Provide leadership in setting strategic direction for Singapore’s national health informatics strategy Key Objectives of ISD IM/IT strategic and thought leadership Effective IM/IT governance and policy development across public health sector including appropriate quality assurance and risk management of IT initiatives Identification and implementation of ‘best practices’ to support health IT deployment and uptake Rationalization of health IT resources Technical and semantic interoperability to ensure seamless exchange of health information across providers and settings to support patient care Appropriate and secure access to high quality health information/data to support secondary uses (research, system performance/planning)

Role of MOHH Information Systems Division (ISD)

Provide leadership in setting strategic direction for Singapore’s national health informatics strategy

Key Objectives of ISD

IM/IT strategic and thought leadership

Effective IM/IT governance and policy development across public health sector including appropriate quality assurance and risk management of IT initiatives

Identification and implementation of ‘best practices’ to support health IT deployment and uptake

Rationalization of health IT resources

Technical and semantic interoperability to ensure seamless exchange of health information across providers and settings to support patient care

Appropriate and secure access to high quality health information/data to support secondary uses (research, system performance/planning)

MOHH Master HIT Planning 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 Organization Specific IT Capabilities Strategic Alignment National EHR & Related Integrative Projects

Clinical Leadership Clinical Quality & Informatics Partnership Co-chairs CIO MOHH Snr Dir Healthcare Performance Group MOH

Clinical Leadership Clinical Informatics Roadmap The Roadmap will articulate Clinical Focus Areas, Objectives … and corresponding Health IT capabilities (illustrative) Summary care record E-referrals & referral triage Case management tools 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 EHR & Extensions 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

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

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

Support initiatives to reduce medication error

Increase effectiveness of adverse event surveillance

Support patient safety initiatives

Enhance operational efficiencies for diagnostics services

Improve data comparability, reliability and timeliness

Support data analysis across cycle of care for core measures

Interoperability Enterprise Architecture Clinical Informatics Privacy & Security National Standards 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 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

Illustrative Focus for EHR Illustrative Contribution of Acute Journey to EHR Outpatient Primary / Community Booking GP Referrals Presentation & Triage Care Delivery Testing Care Delivery Discharge Co-ordination Transition Post Acute Care Testing Care Delivery Testing Arrival Emergency Inpatient Rehab. Event Summary Updated Meds, Problem List, etc Primary / Community eReferral Discharge Summary Initial Shared Care Plan (with self mgmt) Updated Meds, Problem List, etc Discharge Summary Updated Shared Care Plan Updated Meds, Problem List, etc Default notification Event Summary Test results Updated Meds, Problem List, etc

Event Summary

Updated Meds, Problem List, etc

Discharge Summary

Initial Shared Care Plan (with self mgmt)

Updated Meds, Problem List, etc

Discharge Summary

Updated Shared Care Plan

Updated Meds, Problem List, etc

Default notification

Event Summary

Test results

Updated Meds, Problem List, etc

Interoperability Standards 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)

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)

Change Management The large majority of clinicians have learned their professions in the absence of automation, and continue to practice without it Concerns about the following prevail: Privacy of patient information Privacy & Security Framework Impact on efficiency of work Process redesign & workflow integration Cost of automation Subsidization & incentives Quality of available solutions Common functional requirements definition Understanding how to make the transition from paper-based to electronic documentation Peer network & transition support services “ The most remarkable feature about twenty-first century medicine is that we hold it together with nineteenth century paperwork.” US Secretary Tommy G. Thompson, Washington, D.C., May 6, 2004.

The large majority of clinicians have learned their professions in the absence of automation, and continue to practice without it

Concerns about the following prevail:

Privacy of patient information Privacy & Security Framework

Impact on efficiency of work Process redesign & workflow integration

Cost of automation Subsidization & incentives

Quality of available solutions Common functional requirements definition

Understanding how to make the transition from paper-based to electronic documentation Peer network & transition support services

Accountability Develop the Business Case for HIT Investment Must answer questions in four areas: Are we doing the right things? What is proposed, for what business outcome and how does the project contribute? Are we doing them the right way? How will it be done, and what is being done to ensure that it will fit with other current and future capabilities? Are we getting them done well? What is the plan for doing the work, and what resources and funds are needed? Are we getting the benefits? How will the benefits be delivered? What is the value of the project?

Must answer questions in four areas:

Are we doing the right things?

What is proposed, for what business outcome and how does the project contribute?

Are we doing them the right way?

How will it be done, and what is being done to ensure that it will fit with other current and future capabilities?

Are we getting them done well?

What is the plan for doing the work, and what resources and funds are needed?

Are we getting the benefits?

How will the benefits be delivered? What is the value of the project?

EHR: Overall benefits and value Access Reduced wait-times for diagnostic imaging services Improved availability of community based health services Reduced patient travel time and cost to access services Increased patient participation in home care Quality Improved interpretation of diagnostic and laboratory results Decreased adverse drug events Decreased prescription errors Increased speed and accuracy in detecting infectious disease outbreaks Productivity Increased access to integrated patient information Reduced duplicate tests and prescriptions Reduced physician prescription call-backs Reduced patient and provider travel costs Capital cost: $10 billion – $12 billion Benefits: $ 6 billion – $ 7 billion in savings annually Source: Canada Health Infoway; Booz Allen Hamilton

Reduced wait-times for diagnostic imaging services

Improved availability of community based health services

Reduced patient travel time and cost to access services

Increased patient participation in home care

Improved interpretation of diagnostic and laboratory results

Decreased adverse drug events

Decreased prescription errors

Increased speed and accuracy in detecting infectious disease outbreaks

Increased access to integrated patient information

Reduced duplicate tests and prescriptions

Reduced physician prescription call-backs

Reduced patient and provider travel costs

Accountability Measure the Benefits The framework articulates the link between the systems in which you invest and the resulting benefits, providing a basis for measurement. Use Use Behavior/ Pattern Self Reported Use Intention to Use NET BENEFITS Quality Patient safety Appropriateness/ effectiveness Health outcomes Access Ability of patients/providers to access services Patient and caregiver participation Productivity Efficiency Care coordination Net cost Source: Delone and McLean IS Success Model; Canada Health Infoway User Satisfaction Competency User Satisfaction Ease of Use Service quality Responsiveness Information quality Content Availability System quality Functionality Performance Security

The framework articulates the link between the systems in which you invest and the resulting benefits, providing a basis for measurement.

Patient safety

Appropriateness/

Health outcomes

Ability of patients/providers

Patient and caregiver

Efficiency

Care coordination

Net cost

Source: Delone and McLean IS Success Model; Canada Health Infoway

Timeline Overview Integration of Workstreams Identity Management EHR Business Case 2009-13 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

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

The Promise of the EHR Well-managed chronic illness Improved access to care Fewer adverse drug events Better prescribing practices Reduction in duplicate or unnecessary tests Reduced wait times Increased patient participation in care A young boy waiting at A&E, Tan Tock Seng Hospital

Well-managed chronic illness

Improved access to care

Fewer adverse drug events

Better prescribing practices

Reduction in duplicate or unnecessary tests

Reduced wait times

Increased patient participation in care

Thank You [email_address]