Singapore's Journey to Build a National Electronic Health Record System
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Singapore’s
Journey to
Build a National
Electronic
Health Record
System
As other countries continue to grapple with the issue
of how to implement a nationwide electronic health
record, Singapore’s Ministry of Health (MOH) has
embarked on its journey to build a National Electronic
Health Record (NEHR) system that provides a common
access point for medical information for its population
of 5.1 million. It has identified some useful lessons
in its ongoing journey to improve quality of care and
health outcomes while optimizing efficiency and cost.
1 Make the complex simple
2 Value the importance of governance
3 Address operational needs with intense discipline
Accenture: Insight Driven Health
2
1
Make the complex simple
The solution blueprint for Singapore’s I. Managing data from multiple sources. Thus, the complexity of disparate
NEHR included a framework for Bringing together the various data data from multiple sources was
sophisticated business logic, analytics, sources across Singapore introduced overcome by the use of production
decision support and other services. For a host of complexities around data analysis and the decision to focus
the initial phase, however, Singapore data codification and standards. on raw data for the initial release.
focused on “Continuity of Care”. The Because of the number and diversity
requirements for achieving this initial of healthcare organizations and II. Engaging clinicians.
vision: a rich, view-only system with their clinical systems, there were By using screen mock-ups of the NEHR
clinical events, investigation reports, significant variations across the in clinician workshops, the team in
radiology reports, alerts and allergies, data. Some data were coded (using Singapore was able to identify which
immunization records, medications medical coding to denote specific features and functionalities appealed
and a host of supporting documents diagnoses or procedures); and some to end users. The project team engaged
(such as discharge summaries and were uncoded (using narrative or clinicians as early as possible in the
emergency department notes). free-form descriptions instead of a process, in order to understand their
set of widely agreed upon codes). preferences and help drive towards a
The project is led by MOH Holdings simpler and more intuitive interface.
(MOHH), the holding company of Similarly, some data and documents
Singapore’s public healthcare assets. were highly structured, while others III. Addressing functional, technical and
Over the long term, MOHH plans were unstructured, offering only large operational implications.
to incorporate new capabilities into chunks of text. Some data items were Besides engaging clinicians, the project
the system. But in the short term, well populated by one organization, team integrated the discussion of
the organization opted to think but poorly populated by another. functional, technical and operational
big but start simple. This approach T he team also encountered different issues and concerns from the very
enabled the project team to address definitions of basic concepts, such beginning. The functional, technical and
three fundamental challenges: as “movement”, “visit”, “event” and operational teams all helped to shape
“episode”. Mapping multiple hospitals’ the final solution design decisions.
approaches to a common data model An integrated approach helped to
proved an important challenge—one the ensure that the functionality and data
team had to overcome before it could could be supported operationally and
address more sophisticated analytics technically. Quite simply, the solution
and decision support objectives. had to work: it had to be able to
A deep dive of the actual production meet service level agreements, and
data from source systems uncovered it had to be maintainable in a way
many of the subtleties in codification, that was feasible and pragmatic.
structure, availability and meaning.
This drove the design team to focus
on making use of the as-is data,
rather than what the data could
potentially be. The rational was that
a system which interprets data or
provides derived data could introduce
clinical risks if the underlying data
had gaps or differences in meaning.
Accenture: Insight Driven Health
3
Singapore’s Vision
To improve healthcare quality for all residents, increase
patient safety, lower healthcare costs and develop more
effective health policies, Singapore’s MOH created
the NEHR vision – “One Singaporean, One Health
Record” – which enables patient health records to be
shared across the nation’s healthcare ecosystem.
The healthcare ecosystem in Singapore
The health ecosystem in Singapore has about 5.1 million
residents and more than 36,000 healthcare providers
across the public and private sectors. Private practitioners
provide 80 percent of primary healthcare services, and
the government polyclinics provide the balance. The ratio
changes for more costly hospital care, with the government
providing 80 percent through eight public hospitals.
Source: Singapore Ministry of Health website on September 20, 2011.
Visit www.moh.gov.sg for updated statistics.
Accenture: Insight Driven Health4
2
Value the importance of governance
In a perfect world, all data sources would I. Technical Solution—including of data fall under the same government,
provide uniform and quality data. Of course, Architecture, Security and Operations such agreements were relatively simple to
the real world is far more complicated. achieve. In other jurisdictions, where public
II. Clinical Solution—including Usability,
With that in mind, it was important to and private-sector heath organizations
User Functionality and Clinical Risk
focus on understanding up front what was intersect, these agreements would likely be
available and work within those confines to III. Information Governance—including more complex and much more critical.
aggregate data without losing meaning. Data Standards and Data Quality
Another important area was policy—including
The work in Singapore also underscored The work in Singapore reinforced the need privacy policies, patient enrollment, and data
the importance of governance in bringing for specific activities and assets to support sensitivity considerations. These policies
together organizations and systems. Three effective governance. Regional or national had to be addressed early in the process, as
types of governance were put in place: EHRs need formal data-sharing agreements the decisions would affect solution design.
that provide a legal framework for defining MOHH and Accenture also designed the
the responsibilities of the participating Singapore architecture to be inherently
entities. In Singapore, where many of flexible—making it easier to implement
the organizations, systems and sources changes as policies evolve over time.
Accenture: Insight Driven Health5
NEHR First Steps: Unifying clinicians’
view of patient data
In April 2011, MOHH completed the first release of its
EHR implementation. The EHR has these capabilities:
1. National Health Identification
A 4. Access to Health Data in
Service (NHIS). National Registries.
The NHIS is a patient master index Singapore’s NEHR also serves as a
that enables the EHR to match doorway to accessing health data
patient records received from across residing in existing national registries
the health domain in Singapore. It for immunization, medical alerts and
enables users to uniquely identify allergies. This capability also leverages
people through a combination of Singapore’s Electronic Medical Record
factors—including the national Exchange (EMRX) system to enable
identifier, name, date of birth, address access to older clinical documents.
and other demographic information. 5. Privacy and Security.
2. Summary Care Record. Privacy and security are critical to
The NEHR delivers a summary care the NEHR. In Singapore, the system
record for each patient. A summary incorporates role-based access, data
care record provides a concise sensitivity classification, as well
overview of the most recent clinical as “break-the-glass” functionality
activities of an individual. These can (which enables clinicians to access
include recent laboratory results, patient information outside of
medications and the most recent normal security and privacy settings
health events—in other words, a high- if needed in an emergency).
level overview of the patient’s health. 6. Audit and Logging Capability.
From here, clinicians can navigate to The Singapore system includes
more detailed data and documents. full audit logging capabilities—
3. Access to Discharge and capturing who has accessed the
Event Summaries. information, when, where and how.
These documents provide high-level
overviews of specific clinical episodes
(such as hospital admissions).
Accenture: Insight Driven Health6
3
Address operational needs with intense discipline
From the beginning, MOHH and the I. User provisioning and developing The project also underscored the
project team took a disciplined approach clear procedures for granting importance of the following:
to security operations, technical role-based access to the system III. Change coordination and management
operations and service management. In II. Ongoing data integration operations across different systems
addition, operational areas specific to It was critical to understand the
an EHR were defined. These included: - Investigation of message failures
plans for source system upgrades
or data discrepancies
and enhancements, as these
- Synchronization of data patching changes could have significant
between the data sources impact on the EHR system.
and the national EHR
IV. Ongoing analysis of production data
- Synchronization and ongoing This was performed for historical
management of code sets between the data load and in the initial stages of
data sources and the national EHR message integration and was key to
anticipating the types and frequency of
errors, and the possible risks.
Accenture: Insight Driven Health7
NEHR architecture: Starting with the end in mind
Working with Accenture, MOHH invested in the development
of a goal-state architecture. This architecture serves as
the blueprint for achieving the short-term and long-
term goals of the NEHR and for addressing the needs
and goals of three core stakeholders (see Figure 1).
At a high level, the blueprint includes four core elements:
1. Access Channels, which enable nationwide EHR data to be viewed in a format
appropriate for clinicians and, in time, for patients and researchers. Singapore’s
solution relies on two core channels: a clinical portal and integration with existing
electronic medical records (EMR) systems. These channels separate the access and
display from the rest of the solution.
2. Data Sources, including clinical and supporting systems, which provide patient and
clinical data through the nationwide EHR. In Singapore, the primary sources are the
public hospitals’ and polyclinics’ EMR systems, registration systems and ancillary
systems. National registries also provide data to the EHR.
3. EHR Information Exchange, which is a set of services and repositories to facilitate
the sharing of information. Singapore’s solution relies on an enterprise service bus to
enable the exchange of patient and clinical information among the nationwide EHR
system, the data sources and the data consumers. The architecture is designed to
enable the nationwide EHR to be a producer, consumer and supplier of data.
4. Technology infrastructure, which provides the supporting platforms, integration,
security and operations capabilities.
Figure 1 stakeholders
Figure 1: EHR
Stakeholder Definition EHR Objective
Clinician Doctors, nurses, To transform the way clinicians
pharmacists, diagnostic make decisions and deliver care
clinicians, allied health and through better information and
clinical support staff who cognitive support
provide services to patients
in care delivery settings
Health Ministry of Health, health To gather information that will
Administrator statutory boards, hospital aid future resource allocations
executives/management and through deeper understanding of
health insurance companies healthcare needs
Patient Individuals who receive To improve the overall health
care from the Singapore of the population through
healthcare system, including better targeted interventions
citizens, permanent and confidence that clinicians
residents, work permit have immediate critical
holders and others information available to
deliver high-quality care
Accenture: Insight Driven HealthInto the future
Achieving Singapore’s goal to build and
deploy a robust NEHR is an ongoing
process that began with the country’s “One
Singaporean, One Health Record” vision
where patients are able to move seamlessly
within an integrated care system. Despite
its challenges, the journey stands as an
example of efforts that can be made to
improve quality of care and health outcomes
while optimizing efficiency and cost.
For more information, please contact:
Corissa Leung
Singapore
corissa.g.leung@accenture.com
Copyright © 2012 Accenture Accenture: Insight Driven Health About Accenture
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