Singapore: IT Integrating Healthcare and Empowering Patients Dr Sarah Muttitt Chief Information...

Singapore: IT Integrating Healthcare and Empowering Patients

Dr Sarah MuttittChief Information OfficerInformation Systems [email protected]

Sept 15, 2008

This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 2M O H H o l d i n g s P t e L t d

Singapore: a small country…..Singapore: a small country…..

4.59 million people on 707.1 sq km (6,489/km2)

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


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

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

Singapore’s Healthcare SystemSingapore’s Healthcare System


Achieving Positive Health Outcomes with Low ExpenditureAchieving 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 (6th overall)

- World Health Report 2000

Top-ranked overall healthcare system by WHO (6th overall)

- World Health Report 2000

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 2006-07 (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


Health Expenditure vs Life Expectancy (2001-2)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)


Employerbenefits

Medi-save Cash*

MediShield& Elder-shield

Medifund

GovernmentSubvention

National Healthcare Expenditure (NHE)

Individual Financing Government Healthcare Expenditure

KEY GOVERNANCE PRINCIPLESIndividual responsibility for health; patient co-payment to minimize moral hazard and wastageGovernment subsidies to keep basic healthcare affordable

Healthcare Financing in SingaporeHealthcare Financing in Singapore


National Schemes

Medisave

Medishield

Medifund

Medisave (1984)National medical savings schemeFor personal or immediate family’s hospitalization, day surgery and certain outpatient expensesTypical contribution 6.5-8.5% of wages

Medifund (1993)Endowment fund set up by the Government to help needy SingaporeansSafety net for those who cannot afford the subsidised bill charges

Medishield (1990)Low cost catastrophic illness insurance schemeMeet medical expenses from major or prolonged illnessesMediShield 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.

Healthcare Financing in SingaporeHealthcare Financing in Singapore

Private Insurance

Out-of-Pocket

Employer


Subsidized Inpatient Care for SingaporeansSubsidized 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 classAssessment of patient’s ability to pay will be simple – sliding scale No patient will be denied treatment because he/she cannot afford it


B1 Ward B1 Ward SGD160/daySGD160/day

A1 Ward A1 Ward SGD300/daySGD300/day C Ward C Ward SGD 25/daySGD 25/day

Inpatient CareInpatient CareTiered SubsidiesTiered Subsidies


Private vs Public Health Expenditure (2002)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)


Singapore’s Healthcare Delivery Eco-systemSingapore’s Healthcare Delivery Eco-system

Primary Healthcare

- 17 Polyclinics (20%)

- Private GP Clinics (80%)

Secondary & Tertiary

Specialist Care - 7 Restructured Hospitals

& 6 specialty centers (80%)

- 16 Private Hospitals (20%)

Step-down & Long Term

Care

- Voluntary welfare Voluntary welfare

Organizations (70%)Organizations (70%)

- Private Healthcare

Organizations (30%)

Public sector

Private sector

People sector

Patients have freedom of choiceto choose any providers of care in various sectors


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 DriversHealthcare Drivers


More capacity

Sustained excellence

Better capabilities

Healthcare Budget

Increasing manpower

New or expanded infrastructure

Exploitation of ITIntegration

of Care

Medical excellence and specialization

Translational and Clinical Research Healthcare

financing reforms

New governance structures

Continuing and Growing Government Investment in HealthcareContinuing and Growing Government Investment in Healthcare


Public Healthcare SectorPublic Healthcare Sector

MOH Holdings

National Health Group SingHealth Group


Serving as a Value-Multiplier to

Singapore’s Public Healthcare SystemMO

HH

Mis

sio

n

CentraliseTreasury

Corp FinAdvisory

Compliance& Risk Mgt

InformationSystems Division

(a) EHR roadmap & architecture

(b) Standards governance, data privacy & security

(c) Program mgt, Knowledge mgt

(d) Manpower capabilities

(e) Approval, oversight and financial mgt of RH IT projects

LegalStructuring

Restructuring& CentralServices

Systems Coordination

Human Capital

Manpower Facilitation & Recruitment

Talent Development & Management

Leadership College

Remuneration & Benefits

Branding &Marketing

Build Brandwidth

InternationalMedia Outreach& Events

Strategic Global Channel

Financial & Corporate Governance


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

StrategicAlignment

National EHR &

Related Integrative

Projects

MOHH Master HIT PlanningMOHH Master HIT Planning


iN2015 Healthcare & Biomedical SciencesiN2015 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.

EMRX in Clusters

GP Clinic Management Systems

GP CDMP IT Capabilities

EMRX extension to Community Hospitals


EMRX - HistoryEMRX - 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”


EMRX - TodayEMRX - 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

EMRX Access Statistics

0200000400000600000800000

1000000

2004 2005 2006 2007


Where We Are NowWhere We Are NowCurrent 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


Taking the Next Step (MSM April 2008)Taking the Next Step (MSM April 2008)

1. Singapore requires a national integrated electronic health information system based on a common enterprise architecture, data standards and privacy and security guidelines.

2. A shared electronic health record (EHR) can be delivered by 2010.

3. Broad stakeholder engagement is needed. The EHR is not an IT project but a business and clinical transformation project.

4. 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

5. Measuring of success of the national EHR with regards to health care quality, safety, and productivity.


Our ApproachOur ApproachClinical 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 areaTaskforce Clinical ObjectivesSummary 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


The Roadmap will articulate Clinical Focus Areas, Objectives

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

… 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

EH

R &

Exten

sion

sClinical EngagementClinical EngagementClinical Informatics Roadmap


Privacy & SecurityPrivacy & 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


Enterprise ArchitectureEnterprise ArchitectureDesign and Implementation

Health Informatics Health Informatics ArchitectureArchitecture

Clinical Informatics

Privacy & Security

Nat

ion

al S

tan

dar

ds

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


Standards PlansStandards 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)


Timeline OverviewTimeline OverviewIntegration of Workstreams

Identity ManagementEHR Business Case

2009-13 Block Budget for HITGP IT Adoption Strategy

Community Hospitals EMRNational eHealth Portal

Research Informatics StrategyNational Drug Dictionary

IT for new ‘hassle-free’ hospitalLeverage national IT infrastructure

& systems


ISD Timelines & DeliverablesISD Timelines & Deliverables3-year Projection

FY08Clinical & Business Strategy

Information Architecture

FY09Funding Model

Data Stds Implementation

FY10National 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


Standards for InteroperabilityStandards 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), SingaporeHealthcare IT Innovation Week, Opening Speech, 1 February 2007

Thank You

[email protected]

Singapore: IT Integrating Healthcare and Empowering Patients Dr Sarah Muttitt Chief Information...

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