The Inaugural Healthcare Information & Management Systems Society (HIMSS) Asia Pacific 07 Conference

16 May 2007

By Mr Khaw Boon Wan

Venue: Raffles City Convention Centre

Distinguished Guests

Ladies and Gentlemen

Introduction

I am happy to join you today. To our foreign guests, a very warm welcome to Singapore.

The Healthcare Information and Management Systems Society (HIMSS) is at the forefront of advancing the use of information and management systems for the improvement of healthcare. Singapore shares your vision, and we are delighted that you have chosen Singapore for your inaugural Asia Pacific conference.

Healthcare Policy Makers' Conundrum

Healthcare policy makers all over the world face the same conundrum: how to contain rising healthcare costs and yet ensure access to quality healthcare.

The theoretical solutions are known. We know, for example, that prevention is better than cure, and that early intervention can reduce or even avoid more costly treatment in the future. We know that chronically-ill patients can be competently treated in primary healthcare settings, community hospitals, or nursing homes, at lower cost, instead of in expensive tertiary hospitals. And we all say that healthcare providers should treat patients holistically as a team, share information about the patients, and partner one another to bring care to the patients, without duplicating efforts and replicating tests. 

Yet, the reality is sadly different. Relatively few doctors, clinics and hospitals in the world consistently practise pro-active prevention regimes. Many chronically-ill are not receiving appropriate care at the appropriate level, and continue to be treated in more expensive tertiary settings. Seamless, integrated care for patients across the whole healthcare ecosystem remains like the Holy Grail – widely sought by many, but still a distant, seemingly unattainable goal.

Simply throwing money at the problem is not the answer. Money is necessary but not sufficient in ensuring a better healthcare system. Some countries pour huge amounts of resources into their healthcare, and yet they deliver much poorer outcomes than other countries which spend much less. People who have been studying the healthcare sector know that bravely marching on, doing more of the same, even doing it better, is not the way out of the conundrum that plagues us. We need to transform healthcare. But that requires wisdom and understanding, resolve and courage, for the challenges are daunting. Changing behaviour and habits, and fundamentally re-engineering a highly complex system are never easy tasks.

Exploiting IT Maximally  

The use of IT in healthcare is a good example. We know that IT is a key enabler in healthcare transformation. We have seen how technology has transformed the other sectors of the economy. High tech manufacturing plants run by robots operate 24-7, boosting productivity many folds. Delivery of financial services has undergone sea-change. Large banking halls, for example, are becoming relics of the past, as people turn to the convenience of internet banking. But healthcare, unfortunately, remains many steps behind other sectors.

To be sure, we in the healthcare sector have made some progress. IT has permeated our healthcare institutions as the sharing sessions at this Conference will show. EMR is no longer just a concept, but a reality in many healthcare institutions worldwide. Many institutions have gone “filmless”, as radiology images are digitised. Some hospitals have adopted pharmacy systems with electronic ordering and robots doing the packing of drugs.

Indeed, we have come a long way compared to say 10 years ago. The challenge is to take things to the next level, where healthcare delivery is truly integrated nationally, between primary-tertiary-step-down care, and between public and private sector institutions.

To achieve this, inter-operability and data exchange are key, requiring the setting of data and systems standards and ensuring that they are widely adopted.  Much work has gone into this area. That you will be having numerous sessions on these issues reflects this. It is still work in progress and the standards are still evolving. But we must press on. 

Beyond technical issues, there are many other issues that need to be addressed, including system security, data protection, privacy, regulation and audit.  Difficult though these issues may be, however, we can take heart that other industries have faced the same issues and have successfully overcome them. It can be done.

On our part, Singapore has already embarked on the journey. Public hospitals in both SingHealth and the National Healthcare Group (NHG) clusters have integrated their respective EMR systems. We have put in place the EMR Exchange or EMRX to allow cross-cluster exchange of patient information such as inpatient discharge summaries, laboratory and radiology reports, drug allergies and medical alerts, and recently, x-ray images. Immunisation and school health records of children are also available to the hospitals.

Our next major steps are to set national data and IT standards and to put in place the legislative framework for data protection. These will provide the foundation on which we will build a national electronic health records database containing critical health records of every Singaporean. The goal will be to have all healthcare institutions – public and private sector hospitals, primary healthcare clinics, step-down care institutions – linked to this national database, accessing and providing real-time clinical information of the patients they are treating. Beyond care provision, the database will also provide powerful applications, facilitating clinical research as well as epidemiological surveillance.

Those who understand this business would know that this is an ambitious undertaking that will take years to achieve. But we are determined to make it happen, fully exploiting our advantage as a small compact society, with high IT literacy.

Promoting Innovation

Another major challenge in transforming healthcare is promoting a culture of innovation that goes beyond technical hardware, to changing the work processes and how care is delivered. That innovation is critical, is a truism that applies not only to healthcare but to all industries. The difficulty is actually making innovation happen. It cannot be done by central decree or legislation. Neither does constant chanting of the word, because “innovation” is not a magic mantra which when spoken often enough, will unleash awesome powers that will change the world.

What is needed is an environment which allows creative people to think out of the box, have the opportunities and resources to try out their ideas without fear of failure, and unselfish celebration of success. For those who like to see the world in orderly, fixed patterns or formulae, this will be an uncomfortable environment because it must necessarily be an environment of diversity, whether in terms of organisations, structures, or models of care delivery, where pockets of experiments or skunkworks are carried widely by various parties.

This is the kind of environment we are trying to encourage in the healthcare sector in Singapore. For example, we are building a new general hospital in Yishun, in the north of Singapore. I challenged the hospital development team to dream outside the box and not develop another hospital in the mould of those we know of today:

a. Let patients be at the centre of our focus, with technology fully exploited for their benefit and convenience.

b. Let it be a hospital where patients do not get lost or pushed around from pillar to post.

c. Let it be a hospital with minimal bureaucracy and paper work.

d. Let it be a hospital that is well-linked to the primary and step-down care providers in the neighbourhood and to which patients can be transferred seamlessly and in a way that makes the most sense to them.

e. In short, let it be a hassle free hospital.

Conceptually, these may seem to be simple, logical requirements for nobody deliberately sets out to build a “hassle-full” hospital. In reality, however, it is a tall order for not only must we get the hardware aspects right, we must put in place the supportive software.  

I am glad the hospital development team took up the challenge readily. They are working feverishly and are already trying out new ideas at the existing Alexandra Hospital, with encouraging results.

Last few months, I shared the vision of this hassle-free hospital with the family of the late Mr Khoo Teck Puat. They are excited by it. They went further and pledged a donation of $125 million towards the new general hospital: $100 million to fund part of construction costs, and $5 million per year for 5 years in a welfare fund to help poor, needy patients. Their generosity reminds me of the late philanthropist, Mr Tan Tock Seng, whose generous donation helped build the Tan Tock Seng Hospital in the 19th century. We are grateful for the generous donation of the Khoo Family and in acknowledgement, will name the new hospital the Khoo Teck Puat Hospital. We will make it a hospital which the family will feel proud to be associated with.

Changing Mindsets

At the end of the day, transforming healthcare depends on people: people who use healthcare facilities, and people who deliver healthcare. We can put the technological infrastructure in place, or create an environment that is as conducive as can be for innovation. But if the mindsets of patients and providers are not tuned and aligned to transforming healthcare, little progress will be made.

The toughest challenge in transforming healthcare, therefore, is transforming the mindsets of people.

We will need patients to take greater responsibility for their own health, be it living healthily or managing their risk factors. We will empower them, providing them with necessary information and knowledge.

Paradoxically, however, the better the healthcare delivery system, the harder it becomes to convince patients to take charge. Part of the reason may be the asymmetry of information and knowledge between patient and doctors, and thus breeding over-reliance on doctors by patients for all things related to their health. We must therefore place more emphasis on patient education, along with making as much information available as possible. It will be work for the long haul, with constant reminding, cajoling and sometimes nagging of patients to actively manage their own health.

On the part of healthcare providers, the challenge of changing mindsets is no less daunting. The medical profession, for example, is steeped in tradition and values. These are not inherently bad, for the noble values of doctors are what make the profession respected in the eyes of the people.

But being steeped in tradition can also mean reluctance to change existing ways of doing things. It may be as simple a matter as using the keyboard instead of a pen. A senior doctor once commented to me that his value was in his clinical skills, and he saw no reason to learn how to type instead of write. So for some time, he would have his emails printed out, and scribbled his responses for his secretary to type and email off. Alas, email volumes and demands for quick responses grew, and he soon found that the double handling was not practical. So now, he is a convert.

It may be a deeper issue of deep-rooted mindsets or culture of the profession. When we first launched EMRX, it was a modest step with only the exchange of inpatient discharge summaries. But a clinician who was championing the use of IT in one of the clusters made a candid and insightful observation: it may be a small step technically, but psychologically, it was a significant move because we were not only talking about sharing, but actually doing so, and across the 2 competing clusters at that.

Or, it may be a more fundamental fear of being swept by change and not being able to cope. This sentiment is totally understandable. Technological advancement and globalisation cause the same concerns in the hearts of everyone, who feel that their jobs, or the existing comfortable way of doing things are being threatened. And yet, no country can resist the tides of change.

When NHG wanted to introduce tele-radiology where radiology images are sent to India to be read, for example, there was much discomfort on the ground, even though we put in place a framework to ensure that standards were maintained and patient safety was not compromised. But we pressed on, starting with X-rays at our polyclinics. 

As a result, turnaround time has been cut to an hour or less, compared to 2 – 3 days previously. Patients save time as they no longer need to make return trips for their results. Increased competition has also led to cheaper X-rays and improved turnaround times from local radiologists. We are moving beyond simple X-rays to CT scans and MRIs. I have no doubt it will cause greater discomfort on the ground, even though it will definitely bring more benefits for the patients. 

The response cannot be digging in and resistance. I have encouraged our radiologists, where there is spare capacity, to sell high end services to buyers in developed countries. It is a growing market and we can sell tele-radiology, just as we buy it.

Moving forward, we will continue to study other applications of telemedicine and get it to work for our patients here. But I am under no illusion that it will be an easy matter to change mindsets to readily embrace any new initiatives. After we rolled out tele-radiology, when one of my staff visited a local pathology laboratory to better understand its activities and operations, the first thing he was told by his host was that tele-pathology was impossible!

Conclusion

It is clear that we will need to overcome huge hurdles to transform healthcare. Even in the area of healthcare information and management systems, it is still work in progress and the one silver bullet is nowhere in sight. Healthcare technology is evolving but remains relatively immature and not quite ready to completely meet the complex, operational needs of healthcare institutions. Complete inter-operability between systems remains a distant goal. 

As we experiment and try out new ideas, the key to overall progress is to share our experiences and what we have learned. This is what makes the HIMSS Conference such an important event, bringing together practitioners as well as those pushing the envelope at the frontiers. As we share and learn from one another, hopefully we will find the path that brings us closer to our eventual destination.