HIMSS 12 - Singapore EMR

Singapore’s National Electronic Health Record (NEHR) The Journey to 2012 and Beyond

Sarah Muttitt, CIO

Sari McKinnon, Director, Solutions & Architecture

Stephen Rainey, Director, NEHR Implementation Services

DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

Conflict of Interest Disclosure

Sarah Muttitt, MD, FRCPC, MBA

Sari McKinnon

Stephen Rainey

Have no real or apparent

conflicts of interest to report.

© 2012 HIMSS

Learning Objectives

• Describe Singapore’s efforts in three areas that are critical to NEHR success:

– Leadership and governance

– Architecture and standards

– Deployment and uptake

• Detail best practices and lessons learned along a NEHR implementation journey

• Discuss how to leverage foundational investments for the future

710 km2

5.2 million population

18191965

• Lies almost on the equator

• Population – 5.2 mil (Abt 74% Chinese, 13% Malay, 9% Indian and 4% Eurasians and other ethnic groups)

• Four official languages

• 74% of resident population between 15-64 years old

• 9% aged 65 years and above; projected to grow to 20% by 2030

• National healthcare expenditure of only 4% of GDP

• In 2010, WHO ranked Singapore in the world as :- 2nd for infant mortality rate (2.1

per 1000 live birth)- 9th for life expectancy (81.4 years

at birth)

Current Distribution of Healthcare Services

Employer

benefits

Medi-

saveCash*

MediShield

& Elder-

shield

Medi

fund

Government

Subvention

National Healthcare Expenditure (NHE)

Individual FinancingGovernment

Healthcare

ExpenditureKEY 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

Preparing for the “Silver Tsunami”

By 2030

By 2050

• 1 in 5 Singaporeans will be over 65

• Singapore will be among the world’s demographically oldest countries with median age of 54

“A Different Pattern of Healthcare”

• Integrated healthcare delivery system

• Appropriate care from the right site

• Better allocation of resources

• More cost-effective treatment and care in the

healthcare continuum

• Community hospitals, nursing homes, primary care

• Train and/or recruit healthcare providers (and IT professionals!)

• Support informal care givers

• Address incentives, disincentives

• New responsibilities, accountabilities

We need to do more

than building more

acute hospitals.Khoo Teck Puat Hospital 550-bedded regional hospital

Jurong General Hospital (2014)700-bedded regional hospital

New directions

Vision of Future Healthcare Landscape- enabled by the Regional Health Systems (RHS)

Rehab Centres

Family Physician

supported by CHCs

Polyclinic/ Family

Medicine Clinic

Palliative Care

Screening & Prevention

Nursing Homes

Community Hospital

Restructured Hospital

Home

Medical Centres

Strategic vision of patients moving

seamlessly across the healthcare

system, receiving coordinated

patient-centric care at the most

appropriate settings.

Organisation of the RHS, where Home is the central location for care, with primary care delivering person-centric care integrated with the rest of the care spectrum for both physical

and mental healthcare

Strategic vision of patients moving seamlessly across the healthcare system, receiving coordinated patient-centric care at the most appropriate settings.

Enabled by

National Electronic Health

Record (NEHR)

Rehab Centres

Family Physician supported by CH Cs

Polyclinic/ Family M edicine Clinic

Palliative Care


Nursing Homes

Community Hospital


Home

Medical Centres

Rehab Centres



Palliative Care


Nursing Homes

Community Hospital


Home

Medical Centres

Rehab Centres



Palliative Care


Nursing Homes

Community Hospital


Home

Medical Centres

Rehab Centres



Palliative Care


Nursing Homes

Community Hospital


Home

Medical Centres

Rehab Centres



Palliative Care


Nursing Homes

Community Hospital


Home

Medical Centres

Rehab Centres

Family Physician supported by CHCs


Palliative Care


Nursing Homes

Community Hospital


Home

Medical Centres

Healthcare landscape of the future

Vision of “One Patient, One Record”

Secure “real-time” access to patients’ EHR

by authorised clinicians and healthcare providers:

>enable greater coordination and informed decision-making,

>resulting in more accurate diagnosis, better treatment and

patient-centric integrated care.

The EHR is an integrated healthcare record centered on

each person. It extracts and consolidates in one record,

all clinically relevant information from their encounters

across the healthcare system throughout his/her life.

National Electronic Health Record (NEHR)

EMR Exchange (EMRX)Hospital basedEMR & CPOE

National ImmunisationRegistry

Critical Medical Information Store

(CMIS)

Community Hospital based EMR

Minimal EMR Systems

• Private GPs (over 400 out of more than 2,000 have a CMS)

• Community Hospitals and other ILTC providers

EMRX Extension to Community Hospitals

GP Clinic Management Systems

Multiple EMR Systems Multiple Lab

& Radiology Systems

• Public healthcare clusters

NHG and SingHealth hospitals,

polyclinics and specialist clinics

• Ministry of Defence (MINDEF)

MOH Holdings Pte Ltd - Who we are ?

• Sole holding company of Singapore’s public healthcare assets (ie. Singapore Health Services, National Heathcare Group, Alexandra Health, JurongHealth Services, National University Health System and Eastern Health Alliance

• Other wholly owned corporate entities includes Integrated Health Information System, Singapore Clinical Research Institute, Agency for Integrated Care and Health & Medical Practice Insurance

What do we do ?

• Address systems-level gaps in our public healthcare system

• Provides systems-level strategizing and coordination

• Facilitates collaboration across clusters / healthcare institutions

Why ?

• Enhances overall public healthcare system performance, while ensuring closer alignment to MOH’s vision, mission and priorities

• Seeks to leverage on synergies and economies of scale across the entire public healltcare

HIT master planning supports the national agenda for an

Electronic Health Record by 2011 by facilitating strategic

alignment at various Levels of the Healthcare System

Organization Specific IT Capabilities

StrategicAlignment

National EHR & Related Integrative Projects

MOHH Master HIT Planning

Information Systems Division (ISD)

Provides leadership in setting strategic direction for Singapore’s national

health informatics strategy

MOHH Leadership & Governance

20

08 Formation of the

National Health Informatics Strategy

Formation of the clinical advisory groups and taskforces

20

09 Creation of the

goal state architecture for an electronic health record solution

Beginning of Vendor Selection

20

10 Award of contract for NEHR solution

Build and Development over 10 months

Collaborative focus group discussions on NEHR design with key clinicians and industry thought leaders

20

11 Implementation of

the production system

Integration with the legacy systems providing demographic and clinical data to the NEHR

Beginning of deployment to Singapore public healthcare

Award of contract for the delivery of a primary care solution to integrate with the NEHR

The journey towards One Health Record

Diverse membership of CAG and taskforces ensured national strategy was

representative of broader clinical community interests

Clinical AdvisoryGroup

Summary Care Record Taskforce

CPOE & Medication Management

Taskforce

Secondary Data-Use Taskforce

Diagnostics Taskforce

Data Stewardship Committee

Co-Chairs

CIO MOHH

Snr Dir Healthcare Performance

Group MOH

Clinical Informatics Roadmap

• 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

Continuity

of Care

Medication

Management

Diagnostics

Secondary

Data Use

EHR

& Exte

nsio

ns

Clinician-defined Clinical Informatics Roadmap

• Longitudinal summary health care profiles

• Consolidated view of patient’s current problems

• Consolidated view of patient’s current medications

• Ability to share critical patient information across all providers involved in patient’s clinical care journey

• Patient information accessible at the point of care– to support clinical decision making

What our clinicians wanted

Answering the questions:

• Are we doing the right things?

• Are we doing them the right way?

• Are we getting them done well?

• Are we getting the benefits?

Evaluating the benefits of EHR investment

10 year investment strategy identified areas with the most positive gain

Quantifying potential benefits

NEHR – Towards A Fully Integrated Care Record: Providers are “on the same page”

Acute Hospital

Emergency Department

Pharmacist General Practitioner

Nursing Home

Community Hospital

Laboratory

TestsRadiology

Tests

Demographics

Discharge

Summary

Events

History

Medication

History

NEHR


Acute Hospital



Nursing Home

Community Hospital

Laboratory

TestsRadiology

Tests

Demographics

Discharge

Summary

Events

History

Medication

History

NEHR

EMR Electronic

Medical Record

Provider Centric, Institution Based,

Episodic

EHRElectronic Health

Record

Patient Centric, Cross Institution,

Longitudinal

Primary Care

CLEO

Nursing Home

NHELP

Community Hospital

CHIC

Acute Hospital



Nursing Home

Community Hospital

Laboratory

TestsRadiology

Tests

Demographics

Discharge

Summary

Events

History

Medication

History

NEHR


Acute Hospital



Nursing Home

Community Hospital

Laboratory

TestsRadiology

Tests

Demographics

Discharge

Summary

Events

History

Medication

History

NEHR


StandardsSNOMED CT

SDDLOINC

Identity Management

NHIS

NEH

R F

ou

nd

atio

ns

Governance and Accountability

Architecture and Standards

Clinical Change Management

Pill

ar 1

Expanding outreach and access of quality records

Facilitating seamless transitions of care

Linking with Personal Health Record

Pill

ar 2

Supporting reconciliation of clinical standards, treatment care & goals at key clinical checkpoints

Enhancing clinical decision support & clinical collaboration

Pill

ar 3

Providing analytic capabilities for insights into:- clinical quality- care effectiveness & outcomes- alignment to clinical needs, initiatives & governance

Desired Outcomes

Better Health, Care, Value & Future for All

One Patient, One Record, One Health

Better Quality Care through Smart Tools

Building Intelligence and Knowledge

NEHR Phase 2: Strategy and Approach - (FY2012-FY2015)

Reaching and touching the patient viaMulti-access Channel, Multi-modal Means

National Call Centre•Triaging•Case management for CDM•Healthcare services (e.g. PCPS)

Personal Health Management•Self management•Patient empowerment, education/literacy•Shared repository of patient-entered data•Web and mobile applications for CDM, wellness•Open platform

PhoneWeb, Mobile

Telehealth•Remote monitoring and consult (telehealth)•Telemedicine : provider to provider, mobility, specialist care delivery (e.g. Teleoptometry)•Call for collaboration

Devices and Network

The Next Wave: Transforming Healthcare Through Innovative Use of Technology

Reaching and touching the patient viaMulti-access Channel, Multi-modal Means

National Call Centre•Triaging•Case management for CDM•Healthcare services (e.g. PCPS)Personal Health

Management•Self management•Patient empowerment, education/literacy•Shared repository of patient-entered data•Web and mobile applications for CDM, wellness•Open platform

PhoneWeb, Mobile

Telehealth•Remote monitoring and consult (telehealth)•Telemedicine : provider to provider, mobility, specialist care delivery (e.g. Teleoptometry)•Call for collaboration

Devices and Network

Supported by

NEHRA Patient Centric

Longitudinal Record

The Next Wave: Transforming Healthcare Through Innovative Use of Technology

The Vision is Universal

1 Enable the sharing of critical patient information across providers

2 Enable transformations in way care is delivered

3 Improve the health care journey for patients

4 Make our clinician lives easier with access to patient information from anywhere

The Singapore Advantages

1 A city state 2 Rich technology foundations

3 Support of the government 4Will of the people

5 Less legal contraints 6‘It will be done’

Adaptive Architecture

30

?

Enterprise Architecture – Value Approach

2/19/2012 31©2011 Healthcare Information and Management Systems Society

Passive Architecture

Passionate Vs. Passive Architecture

2/19/2012 32©2011 Healthcare Information and Management Systems Society

Build the EA Organization

Build the Principles

and Blue Prints

Develop Governance Blue

Prints

Mandate Uptake

Committees and boards

Passionate Architecture

PassionBusiness Analysts, Solution

Architects Enterprise Architect

Meaningful & Credible

ArchitectureAnalytic

Explore

“The Art of Possible”

Involvement

Excite & Encourage

You may make a mistake, but don’t make the same mistake twice

BalancingGoals & Objectives

Principles

Buy not Build To buy where ever possible

Portal based Provide access from anywhere – with additional toolsets as appropriate

Real Time As real time as possible to support clinical care processes

Role based Enable clinical / user access requirements in a secure and authorized way

Loosely coupled Support flexibility and extensibility over time

‘Hybrid’ Central repository summary health care information, access to detailed reports / images via record locator service

Service orientated approach

Services based approach to support plug and play and extensibility over time

Leverage Leverage existing systems and investments where possible

Iterative Iterative and phased implementation – targeting key clinical capabilities

Data Integrity Data integrity through transmission – ensuring data is sent and received as intended

Adaptable Adaptable to new business processes and technologies

Extensible & Scalable Extensible to include future EHR participants and higher usage.

What do we really, really need?

EHR Information Exchange

EHR Services

Access Channels

BI ToolsNational Health

Portal - PHR

Patient Clinician Researcher

Clinician Portal

EHR Viewer

Provider

EMR Systems

Summary Care Record Shared Services

DemographicsPrimary Care Provider

Care Coordinator

Allergies

Diagnoses Medications Investigations

Events Referrals Care Plan

Investigation & Procedure Rpts

EventSummaries

Referral Docs

Detailed Documents

AuditScorecards

Shared CDS

Shared Care Plan

Medications Reconciliation

Problem List Reconciliation

BI Enablement

Data Sources

EMR

Radiology

Laboratory

Patient Admin

Pharmacy

OT

NIR

Clinical &

Supporting

Systems

National SystemsProviderGateway

RegistriesTransformation

ServicesIntegration Services

Technology Infrastructure

Extraction

Doc Retrieval

Patient

Clinician

Facility

Record Locators

Structure Mapping

Terminology

Data Quality

Error Workflow

Data

Collection &

Validation

Data Retrieval &

Document

Retrieval

Interaction & Integration

Portal

App Server & Batch

Messaging & ETL

ESB & Orchestration

Doc Mgmt & Workflow

Reporting

Security

AuthenticationEncryption &

SignatureAudit Logging

Operations Development

Standards & Processes

SDLC Methods & Tools

Environments

Platform & Availability

Replication, Archival

Backup & DRClustering,

Load BalancingServer Network Storage

System Monitoring & Management

Provider On-boarding

Clinician Support Usage Audit

User Rights Admin

Data Error Resolution

Registry Updates

2nd

Data Use Support

Notification

Extraction

Pseudo-

anonymisation

Subscription &

Notification

Prog Eval Scorecards

Clinical

Data

Access &

AuditTerminology

Registry

Data

EMRX

CMIS

NEHR Solution View

NEHR Product Suite

NEHR Phase 1 (2009-2011)

Administrative

systems from

SHS, NHG, NUHS

& JHS

SHS Electronic

Medical Records

system

Clinical Data

Repository from

NHG, NUHS & JHS

Ministry of

Defence (MINDEF)

Demographics

Events

Lab / Rad

Meds Order

Meds Dispense

eHIDS

Procedures

Community

Hospital/ ILTC

institution (P1/P2)

GP Clinics (P1/P2)

Sources Data Capabilities Deployment

Restructured

Hospitals

Specialty Centres

Selected

Community

Hospitals

Polyclinics

Selected GP

Clinics

Ministry of

Defence (MINDEF)

Selected ILTC

Institutions

Others: AIC, MOH,

HPB, HSA

Solving Wicked Problems: Source Data & Operations

39

To Enable Transformation and Innovation

40

Moving Forward

• Phase 1– One-way sharing with limited integration

partners

– Information viewed via NEHR Portal

• Phase 2– Increased Integration, Bi-directional information

flows

– More information and data sources

– Reconciliation services

– Increased Portal Access

Integration Services

Business Services

Access Channels

BI ToolsNational Health

Portal - PHM

Patient Clinician Researcher

Clinician Portal

NEHR Viewer

Provider

EMR Systems

Summary Care Record Shared Services

DemographicsPrimary Care Provider

Care Coordinator

AllergiesDiagnoses

Medications

Investigations

Events Referral Events

Detailed Documents

Investigation &

Procedure Rpts

Event

Summaries

Referral Docs

BI Enablement

Audit

Scorecards

Shared CDS

Shared Care Plan

Medications Reconciliation

Problem List Reconciliation

Integration Partners

NIR

ProviderGateway

Registry Services

Transformation Services

Integration Services

Infrastructure & Technology

Extraction

Doc Retrieval

Patient

Care provider

Facilities

Relationship

ServiceStructure Mapping

Terminology

Communication

brokering

Error Workflow

Data validation

Data

transformation

Interaction & Integration

Portal

App Server

& Batch

Messaging

& ETL

ESB &

Orchestration

Doc Mgmt &

WorkflowReporting

Security

AuthenticationEncryption &

SignatureAudit Logging

Operations Development

Standards &

Processes

SDLC Methods

& Tools

Environments

Platform & AvailabilityReplication,

ArchivalBackup & DR

Clustering,

Load BalancingServer Network Storage

System Monitoring & Management

Provider

On-boarding

Clinician

SupportUsage Audit

User Rights

Admin

Data Error

Resolution

Registry

Updates

2nd

Data Use Support

Extraction

Pseudony-

misation

Message

Interception

Prog Eval

Scorecards

Clinical

Data

Access &

AuditTerminology

Registry

Data

EMRX

CMIS

Legend

New functionality

To be retired

CHCS

CLEO

IRIS

MINDEF

PHM

Endpoint

resolution

Updated functionality

Existing functionality

Message

Exchange

Pattern

Service Proxy

Audit

Secondary uses

data replica

Radiology

Images

Integrated Care Capability Maturity Model (ICCMM)

1.Capability Areas for Integrated Health

2.Consumer Segmentation

3.Care Continuum

Three dimensional

Integrated Care Capability Maturity Model

First Dimension

1. Capability Areas for Integrated Health

A set of similar processes and functionsto cover the key enterprise capabilities required for a seamless patient-centric journey in an integrated healthcare ecosystem.

Integrated Care

Capability

Patient Administration

Consumer / Partner Services

Clinical Functions

Corporate Functions

Reporting / Analytics

Ancillary Functions


Second Dimension1. Capability Areas for Integrated Health

A set of similar processes and functions to cover the key enterprise capabilities required for a seamless patient-centric journey in an integrated healthcare ecosystem.

2. Consumer Segmentation

Hierarchy that classifies the consumer groupings in the provision of healthcare service.

IndividualFamily

Community

Nation

IndividualFamily

Community

Nation


Third Dimension





3. Care Continuum

An comprehensive system of care that provides health care for individual, family, community and population health, through an array of health services spanning all levels of intensity of care.

Confidential to MOH Holdings Pte Ltd. 46

Integrated Care Capability Maturity ModelThree dimensions:





3. Care Continuum

An comprehensive system of care that provides health care for individual, family, community and population health, through an array of health services spanning all levels of intensity of care.

47

Individual

Family

Community

Nation

Individual

Family

Community

Nation

Integrated Care

Capability


Consumer / Partner Services

Clinical Functions

Corporate Functions


Ancillary Functions

Capability Areas and CapabilitiesClinical Functions


Corporate Functions

Ancillary Functions

Consumer / Partner

Services


1 Care Plans Appointment

Scheduling

Human Resource

Management

Bloodbank & Donor

Management

Multi Channel

Contact CenterClinical Quality

2 Clinical PathwaysHealth Financing

Management

Supply Chain

ManagementPharmacy (Rx)

Social Media /

Consumer Collaboration

Population Health

Analytics

3Referral

Management

Ward / Bed

Management

Financial

ManagementLaboratory Care Coordination

Health Information

Research

4Virtual Care

(Telehealth)Patient Registration IT Management

Radiology & Medical

Imaging

Consumer Health

ServicesServices Quality

5Clinical Care

DocumentationQuality Management

Operations

Monitoring

6Medication

Management

Project Portfolio

ManagementFinancial Analytics

7 Order ManagementPartner Relationship

Management

8 Results ManagementMarketing &

Communications

9 MonitoringHealth Information

Management

Implementation

The NEHR and thechallenges ahead

1. Predictable quality and risk

2. Repeatable delivery and quality

3. Reliable operation and quality

50

Implementation Goals

• Predictable quality and risk

– Understanding the path ahead, the interdependencies and the influence of the client and the stakeholders.

– Establishing strict quality methods and acceptance criteria required by each of the main deliverables.

– Identifying risk, both qualitative and quantitative. This baseline becomes the measure of what you can see – but only at that point in time, and is already out of date….

– Document your assumptions, and assign every qualified risk to a milestone, or if possible, a deliverable.

51


• Repeatable delivery and quality– Dyed in the wool processes – proven to work, and measurable

against industry norms

– Plagiarism is the greatest form of flattery. Remember what worked well for you before, so why re-invent the wheel?

– Embed quality measurement as a safety assurance check. If it does not pass quality review, it does not pass.

– Closing the loop on defect identification, their correction, and pushing impact of correction through the documentation cycle. Remembering that most deliverables spawn or are spawned by many others, so updates to one means multiple risk to others.

52


• Reliable operation and quality

– With predictable quality, repeatable processes, the operational reliability of the solution is therefore known

– However, as a solution, other factors come into play such as integration, load, stress, behaviors, and a catalogue of non-functional requirements.

– The drive for reliable operation by providing predictable quality in its components, means the baseline for quality is elevated and focus returns to the key elements of the solution which provide the greatest risk.

53


54

Controlling the delivery

• Gate (usually at end of a Stage/Phase)

– Milestone1 (number of milestones within a Stage)

• Deliverable 1 (pre-defined – artifacts, documents, code)

– PARCI (including Product Description, Acceptance Criteria etc)

– Draft issued for review (Main deliverables are presented)

– Formal review comments

– Issue for contractual approval (Formal point of delivery)

– Acknowledgement Notice through contract Mailbox

– Evaluation Notice (decision – Positive/Negative)

• Acceptance Certificate (Full/Conditional/Fail)

– Milestone Acceptance Certificate

• Gate Closure Report – Full/Conditional/Fail

55

Audit trail of Accountability

What this actually means….• A predicted deliverable which has a defined criteria, linking it to

other predicted deliverables, has met the prescribed acceptance criteria that was agreed for the deliverable, artifact or product.

• It has contributed to a Milestone, which (assuming all deliverable states are the same) has been met contractually

• The Gate recognizes the Milestone achievement, but also assesses the capability of the project to meet the next Milestone.

• This forward projection of risk, protects the business, before hitting an issue.

• It also encourages a mind-set to look forward on what is to come, rather than look backward at what has happened.

Placing skills

Functions Plan Analyze Design Build Int & Test Operate

Identity Mgmt X X X X X X

Security & Policy X X X X X

National Standards X X X X

Enterprise Arch X X X X

Solutioning X X X X X X

Tech Requirements X X X X X

Architecture (Goal State)

Identity & Security Services Enterprise Architecture National Standards

57

58

Setting the Governance

60

Project Vendor Financial Report

Governance and information

Challenge #1: Synergy in IT enablement

• With 6 Clusters and over 30 institutions and organizations, and with such a fast-paced changing IT landscape within Singapore healthcare, it is imperative that controls exist to;

• Understand the state of investments within each area

• Understand the objectives of our Stakeholders regarding IT enablement in health

• Understand the Work plans for the future

Challenge #2: Data, Data, Data

• The main aim is to take, process, display accurately, meaningful data

• Essential we have a national strategy for the creation, implementation and management of standards in health information exchange

• Data also includes information which is non-clinical, such as information used to identify people, organizations, locations, departments etc

Challenge #3: Predictability, Repeatability, Reliability

• The journey and the results of any delivery are predictable. Understand what challenges we face ahead of, not when, they arrive.

• Important that when a project is delivered, when a deployment to a hospital is planned, that the results are repeatable, through re-use of product, process, and people, supported by tried and trusted methods

• Since the overall challenge is about getting benefit to patients and clinicians, the reliability of what we do in Singapore cannot be understated

[email protected]@[email protected]

Thank You!

And see you in SingaporeHIMSS Asia Pac

17-19 September, 2012

mailto:[email protected]



