Challenges in Implementing EMR: The Singapore Story


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This PPT explains about how Singapore is using IT in healthcare, Integrated Health Information Systems, Singapore's Shifting Demographics and 2020 Master Plan. For more information visit:


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Challenges in Implementing EMR The Singapore Story Dr. Chong Yoke Sin CEO, IHiS


About Singapore about Singapore and IHiS


~ 5.4 million people on 707.1 sq km (6,489/km 2 ) Ethnically diverse: Chinese: 75% Malays: 14% Indians: 9% Others: 2% 40,000+ healthcare providers 11,230 hospital beds ~450,000 hospital admissions Public sector out-patient visits Specialist Outpatient Clinics ~ 3.6m A&E ~ 800k Polyclinics ~4m Singapore is a small vibrant country


IHiS is a healthcare-IT leader, transforming patient care throu ​ gh excellence in technology. ​Our healthcare-IT professionals architect and manage the highly integrated systems across Singapore’s Regional Health Systems, public hospitals, national specialty centres and polyclinics.​ IHIS played a key role in 7 out of 8 Singapore hospitals and 1 Primary Care facilities becoming among the first public institutions in the Asia Pacific region to achieve HIMSS EMRAM Stage 6, an international benchmark for advanced technology used in patient care. IHIS works with the healthcare institutions to drive innovation so as to achieve new standards in quality care. Integrated Health Information Systems


A humble beginning … A humble beginning …

Evolution of Singapore Healthcare IT:

Evolution of Singapore Healthcare IT Stand Alone Applications Stand Alone Applications Hospital Information System and Cluster EMR Population based, Lifetime Health Record, NEHR Patient Portal, Personalized Health Record Limited Functionality Extended Functionality Full Functionality Full Functionality, Telehealth Full Functionality , Home Monitoring No interoperability Limited Interoperability, within the Health Institution More Interoperability Across Health Clusters Full Interoperability, Nation-wide Full Interoperability, Home and Community Focus: Financial, Inventory and Patient master Index Focus: Administrative, ADT, Scheduling, Lab, Rad and Pharmacy Focus: Integration of Administrative and Clinical Focus: Advance Clinical & decision Support and Business Intelligence Focus: Personal Health & Wellness, Population Enablement and Advance Analytics Patient Master Index Smart Healthcare Health Informatics Electronic Medical Record EMR eHealth


The driving force behind the change …


Our total fertility remains low and our life span is increasing Population as a whole will “age” faster in the next one to two decades. A higher proportion of Singaporeans who are 65 year old or above By 2030, one in five of us, will be 65 years and older Fewer Working-Age Adults to Each Citizen Aged 65 and above Singapore’s shifting Demographics as Singaporeans are living longer


? Healthcare 2020 Master Plan


Our Strategies …

Overview of Public Healthcare IT:

Overview of Public Healthcare IT Hospitals Information sensing Paperless Clinical & Business integration Advanced Clinical Decision support RH EMR EMR NEHR GP CH EMRX Exchanges of Images, Records Intra-Cluster Integrated Workflow One EMR One Patient Relationship Management PRM Cross-Cluster One EHR EMR for Details


Take a System-Wide View to Solutions Create an Eco-System & Culture for Solution Re-use Comply with Solution Governance: Solutions Review Board (SRB), Process and Program Steering Committee (PPSC) Better Quality, More Resiliency, Fewer Interfaces Shorter time to Deployment Lower Development & Maintenance Cost Enterprise Architecture Guidance Towards Solution Harmonisation 12

Strategy to achieve Non-Disruptive IT shared Services:

Strategy to achieve Non-Disruptive IT shared Services Federated Enterprise Architecture PHI Operating Model EMRs/NEHR/Clinical systems / Master patient index Patient Relationship Management Connect with AIC, NH, CHs , GPs, etc Interface through QDX Standardize Integrate and Optimize Architect the Roadmap Integrate the Systems Patient Centric Records

Back to Basics Data Standard and Right Channel:

ICD 10 AM SNOMED CT LOINC Structured notes Clinical analytics Clinical decision support (EMRs , NEHR) Tele-health Integrate Analytics across Continuum Intervene at the Right Channels Back to Basics Data Standard and Right Channel Common Data Standardized


About IHiS EMR Our EMR Journey …

Our EMR Journey …:

10/17/2015 16 ©2011 Healthcare Information and Management Systems Society ? Strategies 2001 2003 2005 2007 2009 2011 2013 2015 A chieving High Quality Integrated Care & Advance Clinical Analytics B uilding Clinical Capabilities, Harvest Full Potential & Benefits of EMR C onsolidation Core Systems, Harmonize Clinical Process & Workflow 2005 2001 2010 2006 2015 2011 Advance Clinical Analytics Proactive and Predictive Alerts Tele-Health, Self-Monitoring & Home Care Mobile Health – Healthcare Social Media Analytics for population care EMRAM Stage 6/7 A common EMR platform & EMRX Results Reporting and Discharge Summary Perioperative & ED Notes Cluster eRx , Film-less Clinical & Nurse Documentation Knowledge-Based Medication Management CLMM Implementation CPOE/CCOE Implementation eLab & eRad interface to EMR Cluster’s EMR The ABC of digital journey Our EMR Journey …

Our EMR Journey …:

Cluster EMR Roadmap Application Landscape EMR Building Blocks Implementation Strategies EMR Capabilities Highlights: CLMM CPOE Clinical Document Coding Standardization Statistics Benefits Challenges & Lessons Learnt Our EMR Journey …

The EMR Architecture:

The EMR Architecture


Patient Safety, Our First Priority Closed Loop Medication Management ( CLMM)

WHY Closed Loop Medication Management:

Value to Patients Improve patient safety through reducing medication errors Value to Hospitals / Staff Remove waste, improve system efficiency Technology Innovation 1 st in Asia with a complete end-to-end closed-loop solution Scalability Implemented in KKH, NUH and TTSH Average Unit Dose Serving / year KKH - 3.9m of unit dose drugs for 65,000 patients NUH - 5.5m of unit dose drugs for 92,000 patients TTSH - 6.6m of unit dose drugs for 110,000 patients WHY Closed Loop Medication Management

WHAT are the CLMM components:

WHAT are the CLMM components Electronic Prescription System Patient’s medication prescriptions Clinical Decision Support System (CDSS) Enterprise wide Business Intelligence to support clinical care Packaging Robot Unit dose Packaging Nursing Administration System Bar-code technology to serve drugs correctly


HOW the CLMM works


CLMM ensure 5 RIGHTS Right patient Right drug Right dose Right route Right time Enhanced Medication Safety Process Improve patient safety Efficiency of ward processes Reduce turn around time for medication stock On-time, on-demand serving (urgent medication order) No more faxing of prescription Improve the billing process Billing is done upon medication administration

Lessons Learnt:

Lessons Learnt Robot technology for filling medication according to orders from EMR system eliminate human errors and enhanced patient safety. The 2D barcode is capable of storing more information and also ensure higher degree of accuracy compared to one dimensional bar code. If the unit dose packaged medication is not consumed or when the doctor change the patient’s medication, it can be returned to pharmacy for the next patient. For the medications bundled with a ring, it helps to speed up the cart-fill and enable the pharmacy staff to spend more time for other clinical activities. The robot is capable of packing mini-bottle medicine but not big bottles. L abeling medications with 2D barcode enables clinicians to scan and verify medication administration at the point of care, helping to ensure the ‘5 rights’ of medication administration. Filling the robot for unit dose packing has to be observed very closely for patient safety


Clinical Documentation & Standard Better Communication, Quality Reporting, More Effective Patient Care


Organization Support Effective systems to support accurate and concise documentation of practice in medical records Appropriate policies and procedures in relation to effective documentation systems, practices and management of patient health information The provision of adequate time allocation to document appropriately and review previous documentation as part of patient care Leadership Involve clinical staff in decision making in relation to selecting, implementing and evaluating documentation systems Implementing quality improvement processes related to effective documentation Promote documentation as an integral and core part of practice and professional responsibility Resources Access to an appropriate physical environment that supports and increases efficiency and confidentiality of documentation Reliable , accessible and appropriately maintained equipment EMR Clinical Documentation Implémentation Stratégies


Engage all clinical chiefs and administrators on the new clinical documentation Conduct roadshow for all doctors to create awareness Set up ‘sandbox’ with feedback system for clinicians to trial the new clinical documentation Implement clinical documentation in outpatient settings first as it is less complex than the inpatient settings Implement clinical documentation with a group of related stakeholders Deploy additional IT support staff on site during the rollout EMR Clinical Documentation Implémentation Stratégies

Benefit of Clinical Documentation:

Benefit of Clinical Documentation Appropriate documentation promotes A high standard of clinical care Improved communication and dissemination of information between and across service providers An accurate account of treatment, intervention and care planning Improved goal setting and evaluation of care outcomes Improved early detection of problems and changes in health status E vidence of patient care

Challenges in Clinical Documentation:

Challenges in Clinical Documentation Clinicians’ Adoption - Integrated with consultation workflow - Balance between Structured and Free Text - Minimal clicks/ data entry - Auto-retrieved Allergy, Health Issues, Lab / Rad Results and Medication - Incorporate CPOE into document - Incorporate CDSS into document - Short and concise printout - Reduce duplicate entry


Standardisation and Governance Same Coding standards for Clinical Decision Support and Analytics Same Data items for same observations in all documentation to facilitate future analytics e.g . Smoking History, Pain score etc Same look & feel across institutions for ease of use, particularly for junior doctors rotating from institution to institution Challenges in Clinical Documentation


Improve Clinician Engagement EMR becomes a common platform for information sharing and real-time reporting, resulting in greater communication and partnership among different clinical teams and improved patient outcomes. Accountability Demonstrates the clinician’s accountability and records their professional practice. Communication The basis for communication between health professionals about the (a) Care provided, (b) treatment, (c) Care plan, (d) outcome Quality Should be clear, concise, correct, contemporaneous, complete, collaborate, patient-focused Confidentiality Must maintain confidentiality Lessons Learnt

Data Standardization:

Data Standardization Adopt SNOMED-CT for Problem List and Diagnosis Problem List and Diagnosis can be set as ‘General’, ‘Chart’ and ‘Visit’. SNOMED-CT coded Problem List and Diagnosis facilitates Decision Support. SNOMED-CT coded Problem List and Diagnosis assist in Analytics

Governance Process :

Governance Process Involve clinicians from all institutions for requirement study so that clinical notes for same specialty are standardised across institutions Change Control Committee (CCC) comprising of IT representatives from different clinical document teams to review data items for new clinical document Core Clinical Design Team (CCDT) comprising of clinicians, nurses and IT to review the new clinical document

Dr Chong Yoke Sin:

Dr Chong Yoke Sin

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