SPEECH BY MR EDWIN TONG, SENIOR MINISTER OF STATE FOR HEALTH, AT THE OPENING CEREMONY OF SINGAPORE CONGRESS OF RADIOLOGY 2019 (SGCR) AND WORKSHOPS IN INTERVENTIONAL RADIOLOGY SINGAPORE (WIRES)

Dr Andrew Tan, President, Singapore Radiological Society

Associate Professor Tay Kiang Hiong, President, College of Radiologists, Singapore

Dr Charles Goh, Organising Chair, Singapore Congress of Radiology 2019

Dr Gavin Lim, Chair, Workshops in Interventional Radiology 2019

Distinguished speakers and guests

Ladies and gentlemen

1. A very warm welcome to all of you, especially to our overseas guests. I hope you get to enjoy our warm hospitality. I am delighted to be here at the opening ceremony of Singapore Congress of Radiology & Workshops in Interventional Radiology Education Singapore 2019, held in conjunction with the 19^th Congress of the ASEAN Association of Radiology.

   Demographic Shifts and need to innovate to move Beyond Quality to Value

2. This year’s theme, “Image, Intervene, Innovate”, with a primary focus on oncologic imaging and therapy, is timely. Let me put the Singapore context to the theme. In Singapore, we have managed to extend and prolong our life expectancy by about five years for both men and women. But this, coupled with low birth rates, means that Singapore is one of the fastest ageing countries in the world. It used to be Japan and Korea, but I was recently at the G20 summit in Japan, where studies have shown that Singapore was amongst the fastest, if not the fastest ageing in the region. What this means to us is that the demand on healthcare, healthcare costs, the different kinds of treatment, and the kind of value you will get from healthcare will change and evolve. Diseases like cancer are age-related and its incidence and prevalence will grow. Oncologic imaging and intervention play a central and integral role in the management of cancer.

3. Moreover, the elderly will usually present multiple comorbidities that only add to the complexity of the management of these oncological conditions. Therefore, a multidisciplinary approach to cancer management will require practitioners from across diagnostic and interventional radiology, nuclear medicine, radiation oncology, general surgery, radiography and nursing. The collaboration between these expert groups will promote knowledge exchange, thought leadership, know-all exchange, and this will only serve to improve patient care.

4. Another implication of Singapore’s ageing population is the increasingly small and smaller family sizes, which will mean fewer working adults supporting the elderly. This will have an impact on the broader social fabric and the makeup of Singapore’s society but also on the economy. Specifically, for healthcare, this therefore means that we must be able to operate long-term, in a financially sustainable manner. It is important to find sufficient resources, such as manpower to staff the various sectors of healthcare.

5. It is imperative and important that we innovate so that we can move beyond just providing quality healthcare. We must be able to extract maximum value in delivery of care services. Let me try to illustrate three ways in which radiology and its associated disciplines can harness value that can look at delivering quality healthcare that also commensurates with value.

   Increased Accuracy and Less Invasive Procedures

6. The first is to incorporate technological innovations in the delivery of care, not something which is game-changing or new, but something that we must always keep at the forefront of our minds. I was walking through the exhibition hall and although I am not of the same profession as most of you are, in terms of medical science and technology, medical devices will become cutting edge and a game changer in terms of leveraging the different technologies and advancements and imaging equipment to enhance the delivery of care to make it more efficient. Patients with cancers that previously required open surgeries with attendant long recovery periods in hospitals can now, with these advancements, potentially be offered minimally invasive treatments, which would require shorter hospital stays, and shorter recovery and recuperation periods.

   Minimising overuse

7. At the same time, we must apply technology judiciously. The US, as an example, spends 17% of its GDP on healthcare. We are not at that level, but as most of you would know, our healthcare spending as a proportion of our budget is high, and has been increasing over the past few years. Healthcare providers and purchasers there in the US have realised that one of the drivers of this high cost, not just high but increasingly high at a rate that is growing, is the overuse of healthcare, especially with regards to relatively new technology. The Choosing Wisely movement aims to guide patients to select care which is appropriate. An example of this guidance regarding imaging is that MRIs need not be ordered in the early stages of low back pain unless certain danger symptoms and signs are also present. This guidance has been developed because over-ordering investigations may lead to the diagnosis of pathologies which may not explain the patient’s symptoms.

8. The second way of moving towards value is by innovations in process changes, looking at the process and the procedure, the way in which things are done, and re-evaluate that almost from a ground-up perspective. Radiologists play an increasingly important role in multidisciplinary care settings by supporting clinically appropriate and cost-effective imaging. I encourage our radiology community to think more about how all of you can contribute to team-based clinical practice in guiding both healthcare providers and also patients on the correct radiological investigations for effective clinical management.

9. You can work with their frontline clinical partners to develop the evidence for cost-effective care and also the judicious ordering investigations for their patients. An example of this is the guidance by MOH’s Agency for Care Effectiveness (ACE) on cost effective use of PET-CT for oncological scans that was issued in October last year.

   AI Pattern Recognition in Radiological Images

10. The third way of extracting value is to integrate artificial intelligence (AI) and also machine learning in clinical practice to enhance the productivity of radiologists. Harnessing AI to perform pattern recognition of radiological images for example, is especially important given that the newer technologies will produce much finer and more detailed cuts and hence, many more images for each investigation. It is not feasible to thoroughly examine every detailed image without assistance and AI algorithms could potentially enhance the accuracy of the human radiologist, and might reduce the need for double reading by radiologists to ensure quality and hence, increase productivity.

11. If AI can be effectively integrated into clinical workflows, the process itself and also the way in which it supports diagnoses, it can play a significant role to augment areas such as triaging, diagnosis and quality assurance by analysing images, reports and other clinical information. Clinical decision support is already available in breast screening, which minimises the need for a second reader to ensure quality of reporting. Our local radiological community has already been actively involved in this fast-emerging and evolving field, collaborating with universities, public institutions such as A*STAR, and also industry leaders to study and implement the latest innovations into clinical practice. A team of radiologists in Singapore has recently developed and evaluated the use of AI for automated fracture detection and localisation on wrist radiographs.

12. However, there are challenges in developing and using AI. It is a relatively new advent, one that has been introduced in many aspects, not just in the medical fraternity but in other areas as well. At the start, the collection of data in itself may be a limiting step. The data set used may or may not be representative of the local population. To the implementers of AI, the product may have been developed via a “black box” method, which means that the internal workings of the product is not so easily or not readily examinable. This gives rise to issues of validation in the clinical context and of where liability would lie if there is an adverse event.

13. Therefore, it is important that regulation catches up with innovation. To address these concerns, the Health Sciences Authority looks into regulating AI. Beyond product regulations, the Ministry of Health is working with stakeholders to obtain feedback to develop good practice guidelines for developers and implementers, such as our healthcare institutions and practitioners, to properly guide them through the safe development and rollout of AI to support safe clinical use and data protection. The guidelines will address key principles of AI such as Fairness & Ethics, Transparency, Explainability, and Accountability to bring greater clarity and assurance to the nascent AI landscape and also stakeholders.

14. It is therefore important that this year’s conference embraces these developments by featuring a dedicated track on Informatics and Innovation, with sharing from many internationally renowned experts from around the world. Being a part of these developments and conversations allows radiologists and healthcare providers to remain relevant, updated and informed of the newest technologies. Moving forward, radiologists must guide the use of these nascent but powerful and always evolving technologies to enhance productivity and find a way to gel innovation and technology to put clinical practice to work in the system so that the process integrates effectively. I look forward to see how these innovations can be properly integrated into our own models of care in the near future.

    Closing

15. As Singapore strives to continue to lead in innovation and beyond, we take active steps to promote innovation to look at how we can enhance regimes like the intellectual property protection regime patent to encourage innovation, to give incentives to people in Singapore to develop technology and to ensure that whatever is developed and innovated in Singapore, will be adequately protected. That is one of our key drivers as I marry both my Ministry of Law and Ministry of Health Acts to ensure that Singapore remains relevant and the laws will be relevant in terms of being able to produce, incentivise and continue to enhance this landscape.

16. On this note, I would like to thank the Singapore Radiological Society and the College of Radiologists Singapore for their hard work and continued dedication, and obvious passion to advancing radiology in Singapore and for supporting the skills, the thought leadership, the knowledge development and enhancement of our healthcare professionals through events such as this conference. I wish you all an informative and enjoyable congress ahead. I hope that all of you leave not only with a good exchange of information and a healthy debate on issues that confront the profession, but also make new friends around the world because ultimately, the world is getting to be a smaller place. We are a lot more global in our outlook, and the more we can exchange information with friends across the globe, the better our healthcare will be in our own countries. I wish all of you a very pleasant weekend and a very enjoyable conference.

Thank you very much.