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National Electronic Health Record (NEHR)
Ministry of Health
Singapore

The Problem

Before this initiative began, the public sector healthcare hospitals were generally well computerised to support its individual operations with Electronic Medical Record (EMR) systems, including computerised order entry and clinical documentation.

Singapore took its initial step towards achieving the vision of “One Patient – One Medical Record” when every Singaporean has a lifelong electronic health record that supports his or her wellbeing and healthcare needs throughout their lives in 2004, when the Electronic Medical Record Exchange (EMRX) was introduced to allow the viewing of unstructured health documents (investigation reports, discharge summaries, etc) amongst clinicians within the confines of government funded acute hospitals. From Apr 2004 to Mar 2009, EMRX was extended to include new documents, and other parties e.g. Community Hospitals. The documents include allergies, lab reports, radiology reports and medication information.

Efforts in the EMRX (Electronic Medical Record Exchange) project demonstrated the feasibility of electronic medical record exchanges within the public institutions and highlighted its difficulties and considerations to extend beyond the public sector.

The success of EMRX, albeit limited, has opened the clinical community to the potential clinical and operational benefits of health information exchange, and greater coordination of Health IT at national level. However, gaps still existed with the EMRX and there was a strong desire across the clinical community and the health authority to achieve better outcomes as listed below:

a. Performance (Technical):
•Improved responsiveness to meet anticipated mission-critical use-cases for the EHR.
•More scalable architecture to support the increasing diversity healthcare providers beyond the public sector, from acute hospitals to small GPs, from community hospitals to nursing home.
•More robust infrastructure to support round-the-clock access by healthcare providers with 7X24 operations.
•Support the sharing/viewing of non-textual EMR (e.g. diagnostic images in different modalities such as CR, CT).
b. Performance (Clinical)
•Structured data set and interoperability profiles to meet minimum requirements of specific clinical workflows, such as case management, e-referrals, basic disease management, clinical quality monitoring, and adverse drug reaction surveillance.
c. Standards
•Defined data and messaging/document standards to ensure semantic interoperability and reduced variability in how data is captured, coded and used in patient care and clinical research.
d. Analytics
•Tools and techniques that enable information mining, analysis and visualization to support performance measurement, public health surveillance and clinical research.
e. Reach
•Access by non-public sector healthcare establishments that must participate in integrated care, such as intermediate & long-term care (ILTC) institutions, and GPs.
f. Privacy & Security
•A framework that governs the usage, collection, storage, analysis and dissemination of EMR.

These learning points contributed to the formulation of a National Health Informatics Strategy, which specified the plan to put in place a National Electronic Health Record (NEHR) by 2010 as one of the key guideposts for Singapore’s longer term “One Patient – One Medical Record” vision. The National Health Informatics Strategy was approved by the Health Minister in 2008.

Solution and Key Benefits

 What is the initiative about? (the solution)
The primary goal of the NEHR Programme is to realize the concept of “One Patient – One Health Record” for all Singaporeans.

Through extensive workshops with clinical advisors and E-Health experts over six months, a taxonomy was developed to identify the core capabilities that were required to realise the full potential of this vision. These core capabilities include the following :
•Shared Summary Care Record – provides clinicians with access to summary, medical related information (e.g. event summaries) at the point of care that is potentially useful in the treatment of a patient. Also provides clinicians with electronic access to detailed pertinent procedure, laboratory and radiology reports.
•Medication Management – provides clinicians, patients and dispensaries with information to help reduce the possibility of medication related errors (e.g., details of the patients current and past medication, allergies, and basic medication related decision support).
•Decision Support – provides clinicians with access to treatment guidelines, reminders and best practices to assist with the treatment of a patient, helping them to make more informed decisions and avoid prescribing branded drugs unnecessarily.
•Patient Self-Management – provides patients with a Portal view of their electronic health record, record their own health related notes and research related topics. In addition, the capability will provide secure private patient communications with clinicians, enabling more effective participation in disease management programmes and avoiding unnecessary visits to a clinic.
•Connected Care – electronically transfers referral information from one provider to another and supports shared care plans where multiple providers are involved over time.
•Quality and Performance Management – provides a comprehensive source of de-personalised data for supporting intelligent performance reporting and monitoring. Also provides a resource to support clinical trials or academic research.
•Identity and Access Control – security infrastructure to effectively identify and authenticate providers, patients and facilities, restricting access to sensitive health related information and protecting the privacy of individuals.

In addition to these core capabilities, a scalable architecture is required to provide a platform for further advanced capabilities in the longer term.

NEHR Benefits:
In 2009, MOH Holdings undertook a study with the assistance of Booz & Co to establish the investment strategy associated with the implementation, maintenance, and operation of an interoperable EHR Programme. This study identified the key quantifiable and unquantifiable benefits associated with such a programme. These included quality and efficiency benefits as well as those that are non-quantifiable.

Since the commencement of the NEHR Programme, the vast majority of the benefits realised have fallen within the quality benefit category. Specifically there are four areas through which the NEHR Programme has been able to deliver improved healthcare practice amongst the healthcare providers, which will in turn benefit the patient.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
MOH Holdings led in the conceptualisation and architecting of the NEHR Programme under guidance from steering committees led by the MOH and key decision-makers in the public healthcare insitutions. The scope of work covers key capabilities to major healthcare stakeholder groups in order to realise it’s benefits. Core capabilities of the NEHR were gathered through extensive workshops with clinical advisors and E-Health experts over six months.

Careful decision has also been made to procure a EHR solution based on proven COTS (Commercial Off The Shelf) products configured as a single solution to meet the needs of stakeholders and medical informatics requirements instead of building the solution from scratch. The project was awarded to a system integrator-led consortium with proven track records of similar implementation in developed countries.
Stakeholders of NEHR Programme include -
1.Government: Healthcare related agencies, ministries and departments. Primarily this includes Ministry of Health (MOH), Health Sciences Authority (HSA), Health Promotion Board (HPB), Ministry of Defence (MINDEF).
2.Healthcare Providers: General Practitioners (GP), Polyclinics, Specialist Outpatient Centres (SOC), Public Hospitals (RH), Private Hospitals, Community Hospitals (CH), Long Term Care (LTC), Community Care and Allied Health

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
In 2008, the National Health Informatics Strategy (NHIS) was developed to take the next step towards a robust health info-structure to manage the flow of information across multiple points of care to successfully support healthcare integration, namely the National Electronic Health Record (NEHR) Programme.

The strategy comprises process components which are executed in an iterative manner as Health Informatics development is likely to evolve over the years to come, and our national health IT initiatives needs to adapt accordingly:

Component 1 : Clinical Strategy and Prioritisation
o A Clinical Informatics Roadmap was developed to define strategic focus areas which warrant allocated resources, funding over a multi-year period.
o Senior clinician participation in setting the strategic, longer term direction of the Roadmap will be sought via a Clinical Advisory Group.
o Clinician involvement would be broadened through a middle tier of clinical taskforces.
o A Privacy & Security Framework was needed to govern the flow of information, balancing between safety and convenience.

Component 2 : Technical Architecture and Data Standards
o MOH Holdings initiated a comprehensive multi-year Enterprise Architecture effort to establish an architectural process to govern the evolution of the National EHR.
o MOH Holdings assumed a leadership role in driving the adoption and development of Health Informatics standards in Singapore.

Components 3-5 : Directed Funding, IT Delivery and Evaluation
o MOHH would continually propose changes to the planning and evaluation process to ensure harmonisation with architecture and standards requirements and, more importantly, alignment with an over-arching, multi-year strategy.
o To form various advisory groups and subsidiary taskforces to play the following role :
•Define categories of IT systems investments in each sub-domain.
•Determine performance metrics for investments in each sub-domain.
•Enhance technology evaluation capability in each sub-domain.

To deliver NEHR Phase 1, MOHH chose to purchase a commercial off-the-shelf (COTS) package solution which was delivered by a system integrator-led consortium. From an initial list of vendors, a few vendors were shortlisted to submit prototypes for evaluation. These vendor consortia have provided electronic health record services in other developed countries; the deliverable and quality of these systems in these countries are known. Also, the vendors have reliable products and proven back-end capabilities in Singapore to implement NEHR Phase 1. This strategy lends better than an alternative approach to develop a custom-made solution tailored for Singapore’s EHR requirements due to the several considerations:
•The system would carry significantly greater risks such as delays in delivery time, lower certainty in the quality of the finished product, and higher chance of failure;
•It would likely cost up to 30% more than the COTS option, as attributed to the longer time needed to customize, test, and implement the system.

Accordingly, the cost of professional services and project management cost would double. Additional premium will be required to pay for the vendor to tailor a system for Singapore.
The approach of developing a system from scratch tailored for Singapore was therefore not adopted.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
In 2008, the NEHR Architecture (NEHRA) project was started with objective to ensure that the “vision” for the NEHR is underpinned by an architectural blue print and implementation roadmap to enable the realization of that vision.

The NEHRA project developed a Goal State Architecture which includes the goal state business, information, application & technology architecture and included a 4 phase Implementation Recommendation Plan:
1.Summary of Care, NEHR Foundations
2.Extended Clinical Toolset, Business Intelligences
3.Streamlined Assessment and Treatment
4.Integrated Care Across Institutions

With the above, Booz&Co was engaged to study a 10 Year Investment Strategy to Implement, Maintain and Operate an Integrated and Interoperable Electronic Health Record (EHR) in Singapore. The study showed that most of the financial benefits were the results of better medication management, and quality and performance management capabilities. The benefits would accrue directly to payers (including patients themselves) – but early adoption by private GPs would be crucial to realizing these gains.

In early 2009, an NEHR Procurement and Evaluation Framework was established based on informed industry best practice and aligns to the Singapore Government procurement policy. The Framework was intended to support a process and rationale for conducting the NEHR procurement and the inherent evaluation process to enable an open, transparent, non-discriminatory, competitive NEHR procurement. It was driven by the need for defined process and a disciplined approach that was balanced with the demands of project timelines and pragmatism.

Principles guiding Procurement are:
1.Strategically aligned to NEHR Vision
2.Effective management of vendor relationships and communications
3.Diligent yet Pragmatic
4.Open and Fair Competition
5.Tactical
6.Clear Roles and Responsibilities
7.Transparency
8.Value for Money

The NEHR Procurement process defined stages that progresses successful vendors through each stage, through a funnel process via:
1.March 2009 Open Expression Of Interest (EOI)
2.April 2009 Pre-Qualification
3.May 2009 EOI Demonstration and Evaluation
4.July 2009 Proof Of Concept (POC)
5.Aug 2009 Competitive Dialogue
6.Feb 2010 Closed Request For Proposal (RFP)
7.Jun 2010 Award successful vendor

The evaluation methodology and process ensured that objectives of each stage were achieved through defined roles and responsible parties, and necessary procedure/control and monitoring process were put in place to support this objective.

Independent evaluators and oversight committees were built into the procurement process to provide more a robust team to strengthen and validate the evaluation where a panel of international health care industry experts and local subsidiaries expertise and experience are tapped as to mitigate the risk in procurement.

All stages of NEHR procurement were subjected to external and internal audit and scrutiny.

To-date, NEHR Phase 1 implementation has achieved:
•Apr 2011, NEHR P1 Go-Live, 10 month from award of contract
•May 2011, successful Data Migration of patient events and clinical data
•Jun 2011, LIVE Integration Messaging for 1 Cluster
•Nov 2011, LIVE Integration Messaging for 2nd Cluster

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
The NEHR is a long-term and difficult undertaking for Singapore healthcare sector. Our earlier studies alerted us to the dangers of running huge budget and project delays due to inability to tightly manage the complexity and scale of delivery across different stakeholders groups. As such, Singapore took a cautious approach that has been based on established precedents, international best practices and, most importantly, the engagement of key stakeholders throughout the process. A clinical advisory group and multiple taskforces were introduced to inform and validate the strategy and design of the NEHR. More than 200 clinicians were engaged in driving the business and information requirements of the NEHR system. The form and function of the NEHR has therefore been defined by clinicians for clinicians with the objective of using the system to help them provide the best care for their patients.

In addition, to support the eHealth agenda, standards that are clinically driven, easy to use, and internationally recognised have been established in order to ensure that clinical data can be safely exchanged for the monitoring and care of patients and used meaningfully for secondary purposes. The relevant government authorities and agencies in Singapore have established principles and policies to address access control, consent of the data shared and security standards to ensure the availability, integrity and confidentiality of data.
At the onset, the approach to NEHR has been to leverage as much as possible on what already exists in the Singapore healthcare IT landscape, maximising all investments. To this end, the NEHR builds on the existing EMRX, thus minimising any system incompatibility issues. Synchronisation and integration of the NEHR system with all the legacy systems of the respective clusters took place early this year and, currently, the data loading exercise is underway, with the focus on populating the system with patients’ historical information that would be relevant to clinicians from the various healthcare institutions. Such information includes medication history, laboratory results, radiology results, emergency department notes and hospital inpatient discharge summaries.
In order to fully realise the benefits of the NEHR, information must be captured and shared beyond the public sector acute care facilities. However, systemic issues arise when a patient goes outside these public institutions and into private care settings. This issue is not unique to Singapore though and is also faced by other countries. To this end, IT implementation and adoption strategies are being developed for the intermediate and long term care (ILTC) and primary care sectors. At the primary care level, the IT adoption rate is still low with the major barriers to GPs’ use of computers for clinical documentation being related to funding to adopt IT, limited computer and keyboarding skills, and broadband access in their medical offices. Therefore, over the next 12-18 months, IT enablement among Community Hospitals and GP practices will progress with linkages to the NEHR.

The use of IT will support patients’ critical medical information flow from the acute hospitals to the primary and intermediate long term care sectors. In the long run, healthcare providers will be able to better develop, integrate and coordinate shared care plans to provide better quality care. The end goal is for patients to enjoy a hassle-free healthcare delivery service, with fewer repeat tests and reduced medication errors when they move from one care setting to another, with the NEHR linking up providers in the community who currently do not have electronic access to patients’ medical records.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
In Dec 2008, the Singapore Government approved a budget of S$176 million to support the National Health Informatics Strategy (NHIS) on the development of NEHR Phase 1.

MOHH’s Information Systems Department (ISD) was tasked to operationalize MOH’s strategic plan and provide governance for the national IT strategy, in partnership with Integrated Health Information Systems Pte Ltd, an MOHH subsidiary, to centralize IT resources, implement and maintain national IT initiatives. MOHH will procure, implement, and own the NEHR System.

Given NHIS goals, broad clinical stakeholder engagement has been critical; the NEHR implementation not as an IT project but a business and clinical transformation project. Clinicians based task forces were formed to define the NEHR Functional Requirements. International expertise was engaged throughout the procurement process as well as in the delivery of the NEHR Phase 1 implementation.

As MOHH ISD’s directive is to provide leadership in setting strategic direction for Singapore’s national health informatics strategy, internal resources are best match to manage vendor in the delivery of NEHR. With Singapore undertaking a programme that will catapult the country to global leadership in providing healthcare to its citizens, engaging one of the world’s largest system integrator, responsible for the analysis, design, build, test, deployment and operations for the NEHR success of health initiatives. ”Technical Go-Live” was achieved in April 2011 when the building of the NEHR was completed.

To-date, the project has delivered on-time, within budget and is on track to full deployment to institutions (public hospitals, community hospitals, polyclinics and nursing home) with trainings as planned.

Given the above resource mobilization, Singapore can continue to develop local competencies, continue to iN2015 and beyond goals to match the demands of sectoral transformation of a personalized healthcare delivery system to achieve high quality clinical care, service excellence, cost-effectiveness and strong clinical research.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
The initial setup costs of NEHR programme are fully funded by the Singapore Government. It is expected that there will be an initial period during which the Government will fully fund the NEHR system, until the change management and service transformation at the various healthcare institutions have stabilized and attained a level of maturity. Thereafter, MOH shall evaluate the subsequent funding mechanism.

The approach adopted & experiences gained through the implementation of the NEHR programme are great learning points that other country planning to implement a NEHR can benefit from.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
This initiative has brought about the following benefits to the entire healthcare sector in Singapore:

1.Cross-institution collaboration (among all public healthcare institutions) for change to better meet the needs of clinicians, care providers and patients.
o Throughout the planning and development of the NEHR, clinicians from different institutions across various care settings (who used to work in silos) have come together to collaborate and articulate their needs for a system which can help them provide better, safer and more efficient patient care.

2.Better quality information
o As part of planning and development activities of the NEHR, insights into patients’ health data from different institutions’ source systems have unveiled data issues, which could potentially result in wrong medications being administered to the patients, or critical clinical information being missed when diagnosing. This discovery avail opportunity for the patient data quality issues to be identified and addressed. The effort will contribute significantly to the quality of patient data which public healthcare institutions can use to enhance patient care.

3.Creation of new jobs and expertise
o More than 100 jobs have been created within MOHH to support the National Health IT Strategy planning and execution, of which NEHR is the first piece to be implemented. New skill sets, health informatics knowledge and competencies for national-level planning and execution has been developed, and the expertise will continue to be deepened as MOHH moves onto future phases of NEHR as well as other programmes.
o Beyond MOHH, the health IT expertise and experience have also increased amongst professionals who worked on the related interfaces with NEHR from the healthcare institutions and in the relevant vendor companies. As a result, Singapore has attained new recognition as an innovative leader to exploit health informatics successfully at a national scale.

Lessons learned:
1.To maximize all IT investments, NEHR builds on the existing EMRX. It took more resources than initially estimated for the integration of the NEHR system with all the legacy systems of the respective clusters with the focus on populating the system with patients’ historical information that would be relevant to clinicians from the various healthcare institutions. Such information includes medication history, laboratory results, radiology results, emergency department notes and hospital inpatient discharge summaries.

2.Additional challenges were faced during data profiling of clusters’ source data, not technology related, as data quality is an impetus to system performance. Resolutions of these data issues correct the state as-is and the road ahead is to establish a source data strategy to promote data quality at source and not at the point of use.

3.As with any new system deployment, stakeholder management is key, right from requirements gathering to implementation and change management. NEHR is not just an IT project but a business and clinical transformation project. Stakeholder managements spanning clinicians, clusters CIO/CTO/CEO, System Integrator partners, regulatory and policy makers, steering committees and institutions’ boards of directors have proven very beneficial for the NEHR journey.

Contact Information

Institution Name:   Ministry of Health
Institution Type:   Government Agency  
Contact Person:   Karen Wong
Title:   Deputy CIO, MOH Holdings  
Telephone/ Fax:   68181190/67206380
Institution's / Project's Website:   http://www.mohh.com.sg
E-mail:   karen.wong@mohh.com.sg  
Address:   MOH Holdings Pte Ltd, 1 Maritime Square, #11-25 HarbourFront Centre
Postal Code:   099253
City:  
State/Province:  
Country:   Singapore

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