Challenges in Implementing EMR: The Singapore Story

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Challenges in Implementing EMRThe Singapore
Story
Dr. Chong Yoke Sin
CEO, IHiS
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about Singapore
and IHiS
About Singapore
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Singapore is a small vibrant country

• 5.4 million people on 707.1 sq km (6,489/km2)
• 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
• AE 800k
• Polyclinics 4m

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Integrated Health Information Systems
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
Singapores 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.
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A humble beginning
A humble beginning
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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
Electronic Medical Record
Smart Healthcare
Health Informatics
eHealth
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The driving force behind the change
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Singapores shifting Demographics as Singaporeans
are living longer

• 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

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Healthcare 2020 Master Plan
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Our Strategies
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Overview of Public Healthcare IT

• Hospitals
• Information sensing
• Paperless
• Clinical Business integration
• Advanced Clinical Decision support

• Intra-Cluster
• Integrated Workflow
• One EMR
• One Patient Relationship Management PRM

• Cross-Cluster
• One EHR
• EMR for Details

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Enterprise ArchitectureGuidance Towards Solution
Harmonisation
Better Quality, More Resiliency, Fewer
Interfaces Shorter time to Deployment Lower
Development Maintenance Cost

• 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)

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Strategy to achieve Non-Disruptive IT shared
Services
Architect the Roadmap

• Federated Enterprise Architecture
• PHI Operating Model

Integrate the Systems

• Interface through QDX
• Standardize
• Integrate and Optimize

Patient Centric Records

• EMRs/NEHR/Clinical systems / Master patient
  index
• Patient Relationship Management
• Connect with AIC, NH, CHs, GPs, etc

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Back to BasicsData Standard and Right Channel
Common Data Standardized

• ICD 10 AM
• SNOMED CT
• LOINC

Integrate Analytics across Continuum

• Structured notes
• Clinical analytics

Intervene at the Right Channels

• Clinical decision support (EMRs, NEHR)
• Tele-health

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Our EMR Journey
About IHiS
EMR
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Our EMR Journey
Strategies 2001 2003 2005 2007 2009 2011 2013 2015
Achieving High Quality Integrated Care Advance Clinical Analytics
Building Clinical Capabilities, Harvest Full Potential Benefits of EMR
Consolidation Core Systems, Harmonize Clinical Process Workflow
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

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2010 2006

• Clinical Nurse Documentation
• Knowledge-Based Medication Management
• CLMM Implementation
• CPOE/CCOE Implementation
• eLab eRad interface to EMR

2005 2001

• A common EMR platform EMRX
• Results Reporting and Discharge Summary
• Perioperative ED Notes
• Cluster eRx, Film-less

3/5/2019
2011 Healthcare Information and Management
Systems Society
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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

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The EMR Architecture
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Patient Safety, Our First Priority
Closed Loop Medication Management (CLMM)
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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
• 1st 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

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WHAT are the CLMM components

• Electronic Prescription System
• Patients 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

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HOW the CLMM works
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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

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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 patients
  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.
• Labeling 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

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Better Communication, Quality Reporting, More
Effective Patient Care
Clinical Documentation Standard
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EMR Clinical Documentation Implémentation
Stratégies

• 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

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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

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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
• Evidence of patient care

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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
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Challenges in Clinical Documentation
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

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Lessons Learnt

• 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 clinicians 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

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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

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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

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Dr Chong Yoke Sin

• chong.yoke.sin_at_ihis.com.sg