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
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
Singapore's Journey to Build a National Electronic Health Record System
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    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
Singapore's Journey to Build a National Electronic Health Record System
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                                   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 Health
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    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 Health
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                                   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 Health
6

    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 Health
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                                   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 Health
Into 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

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