Prison Medical System (PrisMS)
Singapore Prison Service; Infocomm Development Authority of Singapore

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
On average, there are approximately 13,000 inmates with a large proportion housed in the purpose-built Changi Prison Complex. As the custodian of these inmates, one of SPS’s roles is to ensure adequate medical care and facilities are made available to inmates with medical conditions. Presently, the healthcare service in SPS is outsourced to an external medical service provider comprising staff strength of more than 170 medical staff, 50 doctors and other specialists deployed to the day clinics, medical centres and sick bays. On average, about 700 inmates require medical care in prison. Due to Prison’s unique operational procedures and requirements, the medical service provider was not able to use their existing electronic medical system for prison use. The doctors and medical staff relied on hardcopy medical reports to administer medical care for inmates. Before each consultation, hardcopies of the medical records need to be prepared. After the consultation, the doctors’ notes and prescriptions were written on Inmate Medical Record (IMR) document, and medical staffs have to prepare prescription charts to record the medications that were dispensed to inmates. Because of the manual records, when inmates were transferred from institution to institution, the IMR needed to be brought together to the receiving institution. During emergency or urgent situations, the IMR might not be transferred together and in such scenario, inmates requiring immediate medical treatment could not be attended to due to lack of information. The manual processes were tedious and issues such as errors in documentation and medication dispensing were frequent. These problems have serious implications to inmates’ health and safety especially when medication was wrongfully dispensed due to mistakes made in documentation and recording. In addition, some documents were misplaced and could not be located. Keeping of hardcopy documents also presented problems on accountability as proper recording might not be done by all users and changes made to medications and updates might not be made or tracked. In all cases, these issues adversely affected the quality of inmates’ medical services provided. Other than administrative and management issues, generating statistical reports for research and study also posed a problem as it would be tedious to collate statistics and preparing reports from the hardcopy IMR. With hardcopy documentation, the number of Inmate Medical Record (IMR) gradually increased over time and was taking up physical space in various medical centres and consultation rooms all over SPS’ institutions. Besides IMR being kept in the medical centres and institutions, there was also a large number of IMR kept in storage at a remote site, incurring high storage costs. In addition, the drug inventories manually managed were also occupying physical spaces in the institutions where space was a serious constraint. Finally, the lack of an IT system meant that when the inmates are released from Prisons, their medical information, being manually kept, could not be fed into the national electronic health record system.

B. Strategic Approach

 2. What was the solution?
Upon the announcement by the Singapore Ministry of Health to establish a National Electronic Health Records (NEHR) system, SPS saw the impetus to develop an electronic medical system to achieve greater efficiency and effectively in the health care administration and management for inmates. During the conceptualisation phase, a project team, comprising staff from SPS Medical Branch, Technology Branch and medical staff, kept in mind the objectives and outcomes that the system should deliver when it was implemented. The project team was focussed on having a system that significantly improved the quality of inmate medical care and which was capable of automating clinical workflow and providing real time access to inmate’s demographic and medical information. With this in mind, four key strategies were identified and implemented to meet the desired outcomes. a) Cater To Prison Operational Requirements The medical setup adopted within the service was modified to suit the operational requirements and PrisMS was to support the unique medical setup. The project team assessed that the IT system should be able to function in both the clinic mode and hospital mode as SPS operated day clinics, medical centres and sick bays within the institutions. In addition, the system would support unique Prison processes such as sick parades, fitness screening or assessments for caning, program and labour, admission screening, medicine dispensing timings and the need to reschedule medications due to external movement (e.g. to Courts). Hence the system should have the capability and flexibility to manage and capture medical information of inmates required for staff to plan their work in administering the healthcare services. b) Use of Handheld PDA Devices The second strategy was the use of mobile devices such as handheld PDA devices during drug dispensing process to enhance tracking of medication doses prescribed and dispensed, time dispensed and by whom. This would enhance accountability and ensure the five rights of medication administration, namely right patient, right drug, right dose, right route and right time. c) Provision of Drug Reference Content Another design consideration was to link the PrisMS with the MIMS drug data (through a tie-up with UBM Medical) to track and provide alerts on drug interactions. The link to MIMS drug data provides drug reference content, with real-time prompts during prescription for safe medication decisions at the point-of-care during consultation by the doctor. Alerts like drug allergy, alert for drug to drug interaction during prescription, alert for drug to diagnosis contraindications could be determined, thus ensuring safe prescriptions by the doctor. In addition, the use of handheld device ensured that the medications prescribed and dispensed are automatically and instantaneously captured in the Prescription chart module without manual entry. Integration of the handheld devices ensured that information on drug dispensing was captured accurately without errors. d) Integration with Medicine Preparation Machine Another strategy adopted was for the system to link with the Automatic tablet machine (ATM), Wet cadet preparation machine and Medicine de-blistering machine to maximize the utilization of these machines in packing and drug inventory management. With the integration of PrisMs and these machines, the outcome was a shorter packing time and an efficient drug inventory management that reduced storage at every institution.

 3. How did the initiative solve the problem and improve people’s lives?
The project team reviewed the existing manual work processes, streamlined existing process and defined new work processes for PrisMS to minimize manual and mundane activities and improve efficiency in work processes. The study gave users an in depth understanding on the current processes and identified the gaps in the current processes. There were numerous innovative approaches made to the work processes with the introduction of PrisMS. Some examples were: a) Information on Sick Leave and excuse from work were updated from PrisMS into Prisons’ IT system, thus eliminating the need for nurses to pass the medical certificates/excuse chits to Prison staff. b) Inmate medications were automatically sent to Automatic Tablet Machine for packing. There was no need for nursing staff to send over doctor’s prescription to the pharmacist for packing. With the central packing of medication by the machine, the time spent in preparing for the medication for inmates were significantly reduced. c) Inmate medication was automatically displayed on the handheld medicine dispensing device, and the nurse would be able to verify the inmate’s identity and the drugs to be administered before dispensing the medication to him. This saved the medical staff much time as there was no need to prepare the prescription charts. In addition, the process instilled accountability of the staff who dispensed the medication to the inmates as the dispensing staff’s identity is captured in the system. d) If an inmate was certified fit for medical review, the doctor would update PrisMS and the information would be automatically updated back to Prisons’ IT system. This removed the manual process for nursing staff to pass the results back to Prison staff, who in turn have to update into the Prisons’ IT system.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The development methodology of PrisMS is based on the traditional software lifecycle, with the addition of prototyping before the system design phase and very detailed system testings to ensure zero errors. During the planning, the project team met up to finalize on the scope and schedule for the project. The roles and responsibilities were clearly defined and understood by everyone. With that, each team member was able to perform his tasks effectively and minimize delays due to miscommunication in the delegation of tasks. During the requirement gathering phase, the project team conducted numerous requirement gathering sessions with stakeholders to identify their Specific Operational Requirements (SOR). The stakeholders included representatives from the nursing staff, pharmacists and medical officers, and Prison officers facilitating the medical treatments within Prisons institutions. Together with Medical Service Branch’s requirements, the SORs were cross referenced with each other. The scope of project involved converting the manual processes to a fully electronic workflow. The missing gaps and differences were sorted out during the review sessions, before signing off the first baseline of the requirement specifications. With the requirements, Tech Branch and vendor project teams met up with other IT vendors that PrisMS interface with to discuss and finalise the interface specifications as part of system design phase. These systems were Prison Operation and Rehabilitation System (PORTS), an inmate management system and the Automatic Tablet Machines (ATM). During the system selection process, the project team emphasized on attributes such as ease of use of the system and fast system response. The system should be intuitive and responsive, as these were pivotal to the users’ acceptance of the system. To mitigate the risk, the team reviewed the prototypes of PrisMS to ensure that the user interface was well-designed and easy to use. Anyone should be able to use the system without training and guidance, with most commonly used functions presented to them and completed within 3-4 clicks. Implementing a system in Prisons is unlike implementing in a typical office environment. The building infrastructure of clinics and medical centres in the Prison institutions were not suited for electronic operations. Tech Branch project team had to conduct site surveys for over 40 clinics and 3 medical centres in the 3 Prison clusters. For each site, the team identified the locations of additional network points and power points, the number of computers, printers, fax machines and scanners required. With the information, the project team had to convince the Prison management to support the changes, before working with the respective Prison cluster representatives to procure and install the equipment. As Prisons is a secure environment with the inmates’ being incarcerated, at various phases of the project life-cycle, the Prison staff at each site were engaged to facilitate the construction works and deployment of the medical software and equipment (with inmates’ presence). These activities affected Prison operations and brought inconveniences to their daily work routine. However, through careful planning and coordination by the project team, all the works at each phase were completed smoothly and without delay or time wastage. Being a medical system, having a bug in PrisMS could be life-threatening. For example, wrong drug prescription for an inmate who has severe allergy reactions or wrong diagnosis of an inmate could be result in serious consequences. To ensure the accuracy, the system goes through rigorous rounds of functionality tests and data verifications. In addition, to ensure that all medical personnel were able to operate the system effectively, the project team conducted system proficiency assessments for medical staff about 2 weeks after the training sessions were completed.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The close collaboration among stakeholders contributed to the successful implementation of PrisMS . The Project Team comprises staff from the Medical Service Branch (MSB) and Technology Branch (TB) of SPS, vendor from Magicsoft Asia Systems Pte Ltd (MASPL), users from Parkway Shenton Private Limited (PSPL), Institute of Mental Hospital (IMH) and KK Women & Children Hospital (KKWCH). In 2010, the project team was formed to conduct a requirements gathering exercise, review existing work processes and developed new work processes to support the implementation of the system. The project team reviewed proposed solutions from several separate potential vendors, visited restructured hospitals and polyclinics and attended various talks and conferences on healthcare IT systems. A tender was launched by the team in Oct 2011 and awarded to MASPL on Jan 2012. Weekly meetings were held and subsequently the medical service provider, PSPL came on board to work on the implementation planning, testing and eventual commissioning. Many hours were spent gathering user requirements, reviewing and streamlining the processes and user training and acceptance testing by MSB and PSPL. Training was also coordinated for other stakeholders such as IMH and KKWCH. The system was commissioned on 27 Dec 2012. During the months following the launch, the team was deployed to the ground at various locations across all three Clusters troubleshooting issues, providing support, solutions and generally hand-holding the PSPL staff often late into the night. To date, the system has been running smoothly and that it has achieved what it set out to do.
 6. How was the strategy implemented and what resources were mobilized?
PrisMS was funded by the Singapore Government. The project cost approximately SGD 1 million. The cost did not include the manpower provided by Prisons to support the project, and the infrastructure cost to equip each medical centre with the computing devices. Besides the project team who was fully committed to the entire project life-cycle, there was involvement from many different branches and divisions of SPS at various phases of the project to ensure the smooth and successful rollout of PrisMS. During the requirement gathering phase, nursing staff and doctors from the medical service provider were involved. All medical staff also attended PrisMS trainings and proficiency assessment sessions before the rollout of PrisMS. Key stakeholders of Prisons were involved in providing SOR to PrisMS to ensure that PrisMS is able meets their operational needs. The respective logistics and IT branches at each cluster were also involved in setting up the required equipments in each medical clinic, to ensure that each clinic can operate efficiently when PrisMS goes live. Unlike a normal office, Prisons is a secure environment and much more logistical planning, arrangements and manpower needed when external contractors were working in Prison institutions where the inmates were incarcerated. At the various Prison institutions, the Prison staff have to allocate manpower resources to facilitate the network installation works and setting up of the necessary IT equipment. The implementation of PrisMS could not have been so smooth without the dedication and cooperation from all involved parties. They took bold steps in changing existing processes and modus operandi. During the initial few weeks, operations were affected due to unfamiliarity of the medical staff of the new workflow. Ad-hoc fine-tuning changes have to be made to make up for lost time. Nevertheless, with perseverance and conviction, within weeks, the overall efficiency of the medical processes greatly improved and Prisons began to benefit from this initiative.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
PrisMS has significantly increased staff productivity. The medical staff saved considerable time as they need not prepare the hardcopies of medical records before each consultation, nor need to prepare prescription charts or to transfer medical records across prison institutions. All medical staff is able to access and update medical information of inmates anytime within the Prison premises. With the system, errors arising from manually recording and transcribing are eliminated. It also eliminated hardcopies lost in transit. The reduced movement of medical staff carrying hardcopy files and notes also improved the security of Prisons, as there was reduced opening and closing of the prison gates for staff movement. The integration of PrisMS with Automatic Tablet Machine (ATM) has greatly reduced the time required to prepare the medication for inmates. Instead of manually packing the dosage for each inmate, the ATM received the prescription from PrisMS, and packed them automatically. SPS have successfully replaced the manpower required for packing with the use of the ATM. Currently, 6 pharmacists could pack over 6000 medicine sachets for more than 3000 inmates each day. With the use of handheld devices for medication dispensing, the medical staff need not prepare manual prescription charts, saving time and manpower in the process. PrisMS could generate the statistical reports and medical reports with ease. Time was saved by having to collate the statistics and preparing these reports for submission and preparation of the medical reports. The report generated from PrisMS provide greater accuracy than the manual reports as not all medical staff would record the statistics correctly, due to the other numerous tasks on hand. In addition there is reduced need for physical storage spaces to storage thousands of hardcopy files and drugs inventories in all the institutions. PrisMS’ data interface with the other Prisons’ IT system not only improved efficiency, it also provided better management of medical in confidence information. Only authorised Prison staff are shown relevant information required for their management of inmates. The system provides real time alerts to doctors when there are drug allergies or contra-indications to the diagnosis or other medications. Thus PrisMS has ensured the safety and high quality of medical service provided to inmates.

 8. What were the most successful outputs and why was the initiative effective?
The entire project was managed using ISO 9001:2008 Quality Management System (QMS) adopted by Singapore Prison Service. The QMS is effective in guiding the project team in the project life-cycle of PrisMS and in ensuring the project was completed on time. The project phases and the deliverables at each stage were clearly defined. There were guidelines on how to manage the project through proper record keeping and documentation and sign-off from the System owner and Ops manager. The project structure, roles and responsibilities of each team member were also clearly identified. It enforced regular meetings and feedback sessions with proper notes documented. The vendor submitted monthly progress report for SPS to monitor their activities and for adherence to the project schedule. All involved parties were fully aware of the project progress and critical timelines of the project. Hence the QMS system has greatly contributed to the success rollout of the system. As part of QMS, the project team has also implemented a risk management System. The risks identified were constantly reviewed and updated at each project meeting to ensure that every risk is adequately mitigated. The risk management system has helped the team to identify issues early in the project and take appropriate actions to minimize the impact or likelihood of the risks occurring. Thus, the team has successfully avoided potential pitfalls that may incur high recovery cost, additional time and resources or the need for more funding. The PrisMS project had undergone and passed 2 QMS audits to date. The first audit was conducted during the tail end of development stage, before the User Acceptance Test phase. The second audit was conducted 6 months after system roll-out.

 9. What were the main obstacles encountered and how were they overcome?
Accuracy in Capturing & Usage of Medical Information The capturing and usage of the medical information in PrisMS was critical in inmates’ medical diagnosis and their medication dispensing. Thus accuracy in the system was critical. Many rigorous tests were conducted on PrisMS and system interfaces to eliminate system errors and to ensure that the system function accurately to achieve its intended purpose. In all cases, human verification would be the last defence to eliminate any possible errors that might arise. For medication dispensing, parallel runs for the prescription chart was also done to test the robustness of the integration of the system with the ATM and handheld devices when packing and dispensing medication. At the various stages of project, the team worked closely with all stakeholders highlighting and resolving issues and system bugs. Prisons’ Operational Constraints The unique Prisons operations constraint was another main obstacle when implementing the system. The project team conducted site surveys to understand current setup and existing work processes and had to work around Prisons operations constraints. As PrisMS is a new system replacing manual existing processes, many innovative approaches and business process reengineering had to be done. New streamlined processes were developed and hence change management was done extensively to ensure adequate briefings and trainings. Unfamiliarity with the System As PrisMS was developed and implemented by SPS, the new Medical Service Provider was unfamiliar with it. Given that the medical service provider was to provide medical service to the inmates in SPS, it was critical that they be familiar with the system and able to utilize the various functions to perform their work. Various trainings and assessments were conducted for the medical staff and doctors. Additional manpower from Medical Service Branch was provided during the initial period at various locations across all three Clusters to provide support, to troubleshoot when there were issues and generally hand-holding the service provider often late into the night. As it is a new system with new workflows, much effort was put in to “sell” the new capabilities to soften resistance from ground officers. In addition, strong senior management support was instrumental to ensure commitment from all staff and has resulted in a smooth implementation of the system.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The benefits to SPS are as follows: Free Up Storage Space The successful implementation of PrisMS frees up physical space currently use to store hardcopy medical records in SPS as well as eliminate the need to incur costs to store them in remote storage. Over time, the number of paper Inmate Medical Records (IMR) has increased and was taking up space in various medical centres and consultation rooms all over SPS as well as kept in storage at a vendor site. With PrisMS, the physical space freed up space could be utilized for other purposes in inmates’ management and rehabilitation. Proper Documentation & Accountability The problems with illegible handwriting were eliminated. Proper recording might not be done by all users and changes made to medication and updates might not be made or tracked easily. With information captured electronically, the issues concerning medical staffs’ illegible handwriting could be addressed and there was also more accountability. With PrisMS, there was ease of traceability and accountability of medical services. The system records all transactions and updates by all users and reasons for the change. This accountability helps ensured high quality medical services provided to the inmates. Statistical Reporting There was also ease of data mining for studies. PrisMS could generate the statistical reports and medical reports with ease. Time was saved having to collate the statistics and preparing these reports for submission and preparation of the medical reports. The report generation from PrisMS provided greater accuracy than the manual reports as not all medical staff would record the statistics correctly, due to the other numerous tasks on hand. Enhanced Medication Dispensing With PrisMS, there was also ease of tracking medication doses prescribed and dispensed, time dispensed and by whom. The implementation of Automatic Tablet Machine (ATM) has greatly reduced the time required to prepare the medication for inmates. Instead of manually packing the dosage for each inmate, the ATM receives the prescription from PrisMS, and packs them automatically. With the use of handheld devices for medication dispensing, the medical staff would not need to prepare manual prescription charts, saving time and manpower in the process. Enhanced Information Availability All medical records were instantaneously available eliminating the need to recall IMRs previously stored upon inmate’s discharge. With the medical information available electronically, much time savings for medical staff was achieved as they do not need to prepare the hardcopies of medical records before each consultation, and do not need to transfer medical records across prison institutions. All medical staff was able to access and update medical information of inmates anytime within the Prison premises. It also eliminated the possibility of hardcopies to be lost in transit. The reduced movement of medical staff also improves the security of Prisons, as there is reduced opening and closing of the prison gates for staff movement.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Since the inception of PrisMS, all medical staff are trained to use PrisMS as the primary IT system to contain all medical information and procedures performed on the inmates. Within few weeks of implementing PrisMS, the manual work processes were fully converted to PrisMS for all Prison institutions. The benefits and improvements brought about by PrisMS were apparent to all parties, and it was effortless to request all medical staff in using PrisMS. The low running cost for PrisMS ensures the funding from Government has been made available for the next 5 years. PrisMS has attracted the attention of the other law enforcement and defence agencies in Singapore including the Singapore Armed Forces, Civil Defence Force and Home Team Academy. The system was showcased to the Home Affairs Technology Committee (TECOM) on 20 Aug 2013 attended by the CIOs of all Home Security Team agencies for the purpose of IT sharing. The system uses a commercial off the shelf product and SPS has implemented the best practices in medical care. Although it is used in unique correctional institutions environment, the learning could be transferred to other agencies where medical services are provided. PrisMS has won the Futuregov Awards 2013 (Service Innovation category) on 23-25 Oct 2013 held at Phuket, Thailand in recognition for excellence by public sector organisations in their application of technology to drive service levels, productivity and governance.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The experience in implementing this project have been exciting and fulfilling. Most importantly, it has given SPS a great sense of achievement in implementing a fully electronic medical system, catering to the unique constraints of the Prisons environment at the same time. PrisMS is one of the few systems in the world, if not the first that covers the entire spectrum of medical processes including doctor’s consultation and prescription, blood test and X-ray ordering and results entry, automated drug packing process and administering of 5 rights during medicine dispensing using a handheld device. In addition, it caters for specific Prisons requirements including interfacing with SPS’ inmate management system to obtain inmate information and sending operations related information such as medical leave, Prison admission health screening and review of fitness for caning and other activities. From this project implementation, we learnt that there are 3 important aspects of project management to maximise the success in implementing projects, namely early planning, effective communication and management support. The project team planned and mapped out all the activities and schedule. Once the activities and schedule were effectively communicated to the affected parties, and time was given for them to prepare. There were no last minute surprises. With proper planning and effective communication, it was easier to obtain management support for the initiative since they could see the competency of the team in planning and communication. With the support, their users would be more committed and cooperative. With the co-operation from the stake-holders and management support, the project activities were smooth and there were no major issues that could not be discussed and sorted out. In the IT project implementation, it is hard to apply a one size fits all project implementation technique as every project faces different constraints and priorities. During the earlier phases of the software development life cycle, the project may seem very complex and difficult to achieve. However, we learnt that complicated projects could be implemented with proper QMS control.

Contact Information

Institution Name:   Singapore Prison Service; Infocomm Development Authority of Singapore
Institution Type:   Government Agency  
Contact Person:   Kuai Ser Leng
Title:   Senior Assistant Director, Tech Branch, SPS  
Telephone/ Fax:   +65 65466839/+65 65427254
Institution's / Project's Website:  
Address:   Prison Headquarters, 407 Upper Changi Road North
Postal Code:   S(507658)
City:   Singapore
State/Province:   Singapore

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