Singapore: IT Integrating Healthcare and Empowering Patients

1. Singapore: IT Integrating Healthcare and Empowering Patients Dr Sarah Muttitt Chief Information Officer Information Systems Division sarah.muttitt@mohh.com.sg Sept 15, 2008

2. 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

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 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

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. National Healthcare Expenditure (NHE) MediShield & Elder- shield Employer benefits Medi- save Medi fund Government Subvention Cash* Healthcare Financing in Singapore 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 • Medisave (1984) • National medical savings scheme • For personal or immediate family’s hospitalization, day surgery and certain outpatient expenses • Typical contribution 6.5-8.5% of wages National Schemes Medisave • 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. Medishield Medifund 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. Subsidized Inpatient Care for Singaporeans • 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. Step-down & Long Term Care - Voluntary welfare Organizations (70%) - Private Healthcare Organizations (30%) Singapore’s Healthcare Delivery Eco-system Patients have freedom of choice to choose any providers of care in various sectors Secondary & Tertiary Specialist Care - 7Restructured 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. 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. Better capabilities More capacity New governance structures Integration of Care Exploitation of IT Medical excellence and specialization New or expanded infrastructure Increasing manpower Translational and Clinical Research Healthcare financing reforms Sustained excellence Continuing and Growing Government Investment in Healthcare Healthcare Budget

14. MOH Holdings National Health Group SingHealth Group Public Healthcare Sector

15. Serving as a Value-Multiplier to Singapore’s Public Healthcare System MOHH Mission 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 NowCurrent Gaps

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 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 area

23. Clinical EngagementClinical Informatics Roadmap The Roadmap will articulate Clinical Focus Areas, Objectives … and corresponding Health IT capabilities (illustrative) EHR & Extensions • 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

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. Health Informatics Architecture Enterprise ArchitectureDesign and Implementation • 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 OverviewIntegration 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

28. ISD Timelines & Deliverables3-year Projection

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), SingaporeHealthcare IT Innovation Week, Opening Speech, 1 February 2007

30. Thank You sarah.muttitt@mohh.com.sg