Information technology and improving patient safety in Singapore hospitals: Turning ideas into action
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1 Health and Medical Practice Insurance Pte Ltd Information technology and improving patient safety in Singapore hospitals: Turning ideas into action Colleen Brooks Principal Standards Information Systems Division MOH Holdings, Singapore November 2010
2 Getting ready for the silver tsunami Pressures on Singapore healthcare system set to increase By 2030 By in 5 Singaporeans will be over 65 Singapore will be among the world s demographically oldest countries with median age of 54 A Different Pattern of Healthcare Integrated healthcare delivery system Appropriate care from the right site Better allocation of resources More cost-effective treatment and care in the healthcare continuum This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 2
3 New Directions We need to do more than building more acute hospitals... Khoo Teck Puat Hospital (2010) 550-bedded regional hospital Jurong General Hospital (2014) 700-bedded regional hospital Community hospitals, nursing homes Train and/or recruit healthcare providers Support informal care givers Address incentives, disincentives New responsibilities, accountabilities This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 3
4 Healthcare landscape of the future Strategic vision of patients moving seamlessly across the healthcare system, receiving coordinated patient-centric care at the most appropriate settings. Screening & Prevention Polyclinics FPs CH RH Rehab & support services NH Home Palliative Enabled by the National Electronic Health Record (EHR) Screening & Prevention Polyclinics FPs CH RH Rehab & support services NH Home Screening & Prevention Palliative Polyclinics FPs CH RH Rehab & support services Screening & Prevention NH Home Polyclinics FPs Palliative CH RH Rehab & support services NH Home Screening & Prevention Polyclinics FPs Palliative CH RH Rehab & support services Screening & Prevention NH Home Polyclinics FPs Palliative CH RH Rehab & support services NH Home Palliative This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 4
5 So what about IT? MOHH Information Systems Division (ISD) Provides leadership in setting strategic direction for Singapore s national health informatics strategy MOHH Master HIT Planning Organization Specific IT Capabilities Strategic Alignment National EHR & Related Integrative Projects HIT master planning supports the national agenda for an Electronic Health Record by 2010 by facilitating strategic alignment at various Levels of the Healthcare System This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 5
6 Vision of One Patient, One Record The EHR is an integrated healthcare record centered on each person. It extracts and consolidates in one record, all clinically relevant information from their encounters across the healthcare system throughout his/her life. Secure real-time access to patients EHR by authorised clinicians and healthcare providers: enable greater coordination and informed decision-making, resulting in more accurate diagnosis, better treatment and patient-centric integrated care. This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 6
7 The difference between EMR and EHR EMR Specific to a facility (institution, private office) Equivalent of its paper predecessor: includes everything recorded by the organization about a given patient Has depth but lacks breadth EHR Specific to an individual Captures a key subset of health information from multiple point of service systems Available electronically to authorized healthcare providers anytime, anywhere Designed to facilitate the sharing of data across the continuum of care, across healthcare delivery organizations and across geographies This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 7
8 Existing ehealth Systems in Singapore Multiple EMR Systems Multiple Lab & Radiology Systems Public healthcare clusters NHG and SingHealth hospitals, polyclinics and specialist clinics Ministry of Defence (MINDEF) EMR Exchange (EMRX) Hospital based EMR & CPOE National Immunisation Registry Critical Medical Information Store (CMIS) EMRX Extension to Community Hospitals Community Hospital based EMR Minimal EMR Systems Private GPs (over 400 out of more than 2,000 have a CMS) Community Hospitals GP Clinic Management Systems This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 8
9 Clinician-defined Clinical Informatics Roadmap Diverse membership of CAG and taskforces ensure national strategy is representative of broader clinical community interests Clinical Informatics Roadmap Summary Record Taskforce Co-Chairs CIO MOHH Snr Dir Healthcare Performance Group MOH Data Stewardship Taskforce Clinical Advisory Group CPOE & Medication Management Taskforce Secondary Data-Use Taskforce Diagnostics Taskforce Continuity of Medication Management Diagnostics Secondary Data Use Summary care record E-referrals & referral triage Case management tools Active medication list Harmonized drug nomenclature & codes Drug dispensing data Shared image repositories Harmonized lab nomenclature & codes Interoperability framework for clinical data repositories & disease registries EHR & Extensions This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 9
10 What our Clinicians need.. Longitudinal summary health care profiles Consolidated view of patient s current problems Consolidated view of patient s current medications Ability to share critical patient information across all providers involved in patients clinical care journey Patient information accessible at the point of care to support clinical decision making. This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 10
11 EHR Conceptual View EHR Summary Record Shared Services / Functionality Name NRIC No. Allergies Diagnoses Recent Events Date of Birth Gender Current Medications Recent Referrals Primary Provider Coordinator Immunisations Investigations Procedures Plan Link Share Data DA / ADR Module Immunisation Business Intelligence Data Warehouse Medications Reconciliation Problem List Reconciliation National Scorecard Team Details Shared Plan Programme Scorecard Referral Processing Personal Health Record (PHR) Drill Down Drill Down Detailed Reports / Images Event Summary, Referral & Screening Documents Laboratory Reports GP Event Summary SOC Event Summary Referral to SOC SOC Referral to GP Fit for Instruction Radiology Reports / Images Procedure Reports ED Event Summary Inpatient Disch. Summ. Community Hosp Disch. Summ. AIC / ILTC Referral School Screening Applications that are not a part of the EHR solution, but will be integrated with the EHR This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 11
12 Evaluating the Benefits of EHR Investment 10 Year Investment Strategy Identified the investment amount & costs of the EHR Determined financial and non-financial benefits Quantified the benefits of the investment Suggest Implementation strategy Answering the questions: Are we doing the right things? Are we doing them the right way? Are we getting them done well? Are we getting the benefits? This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 12
13 NEHR a Strategic Response This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 13
14 The Evidence: Medication Management & Safety Ann Acad Med Singapore 2004 Polypharmacy and inappropriate medication use in Singapore nursing homes Mamun K, Lien CT, Goh-Tan CY, Ang WS. 454 residents involved in study. Polypharmacy and issues with medication use were seen in 266 (58.6%) and 318 (70.0%) residents, respectively. Most common medication-related problems were the use of medication without proper indication (n = 302), significant potential for adverse drug reactions (n = 281) and drug interactions (n = 141, 30%). Pharm World Sci Koh Y, Fatimah BM, Li SC. The study population consisted of 347 patients (aged 16-97) on a mean of 7.4 +/- 2.1 medications. 10.8% of the study population had DRPs on admission: 71.9% of which were dominant reasons for admission, and DRPs contributed partly in the remaining cases. These DRPs were mostly avoidable, and can be broadly classified into non-compliance, adverse drug reactions, require synergistic therapy, inappropriate dose and untreated condition. 52% of these cases were made up of geriatric patients. 14 This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 14
15 The Evidence: Medication Management & Safety J Emerg Med Emergency department patient knowledge of medications Vilke GM, Marino A, Iskander J, Chan TC Therapeutic decisions made by Emergency Physicians are often influenced by which prescribed medications are being taken by patients. Only 48% of patients could recall or produce a list or the actual bottles of all of their medications, 39% knew the times they take their medications, and only 24% knew all the dosages. Although knowledge of medications is often critical for decision making in the ED, a significant number of patients are unable to provide this information. JAMA 1997 Factors related to errors in medication prescribing. Lesar TS, Briceland L, Stein DS. The most common groups of factors associated with errors were those related to knowledge and the application of knowledge regarding drug therapy (209 errors, 30%); knowledge and use of knowledge regarding patient factors that affect drug therapy (203 errors, 29.2%); use of calculations, decimal points, or unit and rate expression factors (122 errors, 17.5%); and nomenclature factors (incorrect drug name, dosage form, or abbreviation) (93 errors, 13.4%). 15 This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 15
16 The Evidence: Medication Management & Safety Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA Jul 5;274(1):35-43; Leape LL, Bates DW, et al 334 errors were detected as the causes of 264 preventable ADEs and potential ADEs. Sixteen major systems failures were identified as the underlying causes of the errors. The most common systems failure was in the dissemination of drug knowledge, particularly to physicians, accounting for 29% of the 334 errors. Inadequate availability of patient information, such as the results of laboratory tests, was associated with 18% of errors. Seven systems failures accounted for 78% of the errors; all could be improved by better information systems. Booz & This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission
17 Preliminary analysis suggests that ~40% of ongoing NEHR benefits are a result of better Medication Mgmt. S$ M % 189 Medication Management 128 Predominantly from avoidance of ADEs Steady State Annual Net Value by Capability Quality and Performanc e Mgmt 92 Summary Record 43 Patient Self- Management 37 Non-Med Decision Support 490 Total All Capabilities Booz & This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission
18 NEHR analysis shows that ~65% of ongoing benefits are a result of better Medication Mgmt. and Quality and Performance mgmt. S$ M Medication Management 65% 128 Predominantly from avoidance of ADEs Quality and Performance Mgmt Steady State Annual Net Value 1 by Capability 92 Predominantly from better adherence to best-practice Summary Record EHR Only Perspective 43 Patient Self- Management 37 Decision Support 490 Total + ve Capabilities 4 Identity and Access Control 75 Infrastructure & Governance 411 TOTAL 1) Steady state refers to the value generated once the program has ramped up (i.e., in 2019), Annual net value considers ongoing benefits in 2019 less ongoing costs Note: Connected and Advanced Capabilities do not accrue any quantitatively sized steady state benefits / costs - hence are excluded from this figure 18 This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 18
19 Need to Unleash The Benefits of Healthcare IT Key infrastructure and technology needed Network Infrastructure High Speed Network Leadership and Governance Interoperability and Standards Enterprise Architecture National Data Standards Change Management Strengthening Analytics Exploit the power of technology This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 19
20 Interoperability Standards Establishing a suite of standards that are: Clinically-Driven Easy to Use Internationally Recognised to ensure clinical data included in the EHR can be: Shared and exchanged safely and reliably Global Standards Engagements HL7 (Health Level Seven) IHTSDO (International Health Terminology Standards Development Organization) ISO TC215 on Health Informatics for the monitoring and care of patients Used meaningfully for secondary purposes including production of clinical knowledge Standards also provide a platform for long term semantic interoperability and research informatics This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 20
21 Change Management It simply doesn t make sense that patients in the 21st century are still filling out forms with pens on papers that have to be stored away somewhere. Need to manage change as large majority of clinicians learnt their professions in the absence of automation, and continue to practice without it US President Barack Obama American Medical Association Annual Conference, 15 June 2009 Concerns Privacy of patient information Programmes & Initiatives Privacy and Security Framework Impact on efficiency of work Process redesign & workflow integration Cost of automation Quality of available solutions How to make transition from paper-based to e-documentation Subsidies and incentives Common functional requirements definition Peer network & transition support services This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 21
22 Beyond the NEHR Supporting systems that need to be in place to fully realize NEHR benefits Healthcare Continuum GP Polyclini cs Restruct ured Hospitals Commun ity Hospitals Chronic Sick Hospitals Hospices Nursing Homes Day Home Agency for Integrated (AIC) National Assessment Framework AIC IT Strategy Chronic Disease Management Programme Primary Programme GP IT Enablement Programme ILTC Programme Community Hospital Integrated (CHIC) Mental Health Programme ILTC Innovation for Hospices and Nursing Homes Home Pilot This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 22
23 GP IT-Enablement Programme Aim to support clinical transformation in GP healthcare sector: Pillar 1: Support clinical transformation within clinic practice Pillar 2: Strengthen care partnership and linkages Pillar 3: Encourage professional collaboration through trusted relationships and networks within the primary care sector 5-year Strategy Developed in consultation with 100+ GPs over past year, including international experts and professional bodies (CFPS, SMC, SMA) Phase 1 in progress Implementing CMS-EMR solution for 50 GPs This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 23
24 Community Hospital Integrated (CHIC) Aim to implement a common platform to support 6 Community Hospitals operational and clinical needs Improve patient care Enhance operational efficiency Contribute national initiatives Obtained buy-in and alignment across all 6 CHs Setup of a MOH-MOHH-CHs committee to jointly make decisions and agree on harmonised requirements Programme review in progress Alignment with regional health services (RHS) model Validating CHs needs and priorities Aligning with National EHR Enterprise Architecture This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 24
25 Leveraging National HIT for Analytics & Research National EHR National Data Standards Patient Identification Service Privacy and Security Longitudinal, Patient Centric Data Usable Clinical Data Accessible Clinical Data Ongoing Enrollment of Patients Alignment of Efforts National Health IT Initiatives Foundation Laying & Core Infostructure Accelerator Projects Engagement & Alignment Meet Current Needs National EHR Program & Core Enterprise IT Develop Future Capabilities Exploratory Projects Direction Setting Reality Checks This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 25
26 The promise of the EHR Better Clinical and Streamlined Workflows Patient information at the point of care Supports clinical decision making and workflows Enables providers involved in patient care journey to work as a team Seamless transition of patient into different care settings Better management of chronic illnesses Enables greater patient participation and supports self-help Better Practices and Greater Patient Safety Shared patient s clinical records Enforces better prescribing practices with peer reviews Reduces human errors related to handwritten records Takes the guesswork out from the lack of past records Prevents duplicate and unnecessary tests; and adverse drug events This material contains information that is confidential to MOH Holdings Pte Ltd (MOHH) and should not be circulated beyond MOHH without permission. 26
27 Health and Medical Practice Insurance Pte Ltd Thank You MOH Holdings
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