Singapore’s Journey to Build a National Electronic Health Record System

MOH Holdings has embarked on its journey to build a National EHR system. What can others learn from Singapore’s experience?

To improve healthcare quality for all residents, increase patient safety, lower healthcare costs and develop more effective health policies, Singapore’s Ministry of Health (MOH) created the National Electronic Health Record (NEHR) vision—“One Singaporean, One Health Record”—which enables patient health records to be shared across the nation’s healthcare ecosystem. In 2009, MOH Holdings (MOHH), the holding company of the nation’s public health assets, initiated the project to develop the NEHR system.

As other countries continue to grapple with the issue of how to implement a nationwide EHR, MOHH has embarked on its journey to build its NEHR system to provide a common access point for medical information for its population of 5.1 million. Additonally, the healthcare ecosystem in Singapore has more than 36,000 healthcare providers across the public and private sectors. Private practitioners provide 80 percent of the primary healthcare services, and the government polyclinics provide the balance. The ratio changes for more costly hospital care, with the government providing 80 percent through eight public hospitals.

MOHH initially engaged Accenture to develop an architecture blueprint for the NEHR system which detailed the business, information, application and technology architectures. In 2011, Accenture and MOHH began deploying the NEHR to provide clinicians with a summary care record for each patient including problem lists, medications, discharge and event summaries.

MOHH has identified some useful lessons in its ongoing journey to improve quality of care and health outcomes while optimizing efficiency and cost.

The first phase of the NEHR system went live in April 2011 and included putting in place the entire technical solution, all physical system components, and data centre equipment in fully tested and approved state. This was followed by the synchronization and integration of the NEHR system with existing legacy systems. The long term goal of the NEHR is to allow primary-, acute- and community-care clinicians access to shared clinical data that help to enhance medical treatment and improve safety and in the future help analyze health trends and better manage disease.

More specifically, the initial release offers the following capabilities:

• A National Health Identification Service (NHIS), or patient master index to match patient records across the health domain.
  
  
• Summary care records, which provide a concise overview of individuals’ most recent clinical activities.
  
  
• Access to discharge and event summaries, which provide high-level overviews of specific clinical episodes (such as hospital admissions).
  
  
• Access to health data in national registries; Singapore’s NEHR also serves as a doorway to access health data residing in existing national registries for immunization, medical alerts and allergies.
  
  
• Privacy and security, including role-based access, data sensitivity classification and “break-the-glass” functionality for use during emergencies.
  
  
• Audit and logging capabilities, which capture who has accessed information, when, where and how.
  
  

NEHR Architecture: Starting with the End in Mind

Working with Accenture, Singapore’s MOHH invested in the development of a goal-state architecture—which serves as the blueprint for achieving short-term and long-term goals. At a high level, the blueprint includes four core elements:

• Access channels, which allow nationwide EHR data to be viewed in a format appropriate for clinicians and, in time, for patients and researchers. Singapore’s solution relies on two core channels: a clinical portal and integration with existing electronic medical records (EMR) systems. These channels separate the access and display from the rest of the solution.
  
  
• Data sources, including clinical and supporting systems, which provide patient and clinical data through the nationwide EHR. In Singapore, the primary sources are the public hospitals’ and polyclinics’ EMR systems, registration systems and ancillary systems. National registries also provide data to the EHR.
  
  
• EHR information exchange, which is a set of services and repositories to facilitate the sharing of information. Singapore’s solution relies on an enterprise service bus to enable the exchange of patient and clinical information among the nationwide EHR system, the data sources and the data consumers. The architecture is designed to enable the NEHR to be a producer, consumer and supplier of data.
  
  
• Technology infrastructure, which provides the supporting platforms, integration, security and operations capabilities.
  
  

In its ongoing journey to improve quality of care and health outcomes while optimizing efficiency and cost, Singapore’s MOHH has identified some useful lessons:

1. Make the complex simple. The solution blueprint for Singapore’s NEHR includes a framework for sophisticated business logic, analytics, decision support and other services. This framework will let MOHH incorporate new capabilities in the future. For the initial phase, however, Singapore focused on “Continuity of Care.” The requirements for achieving this initial vision: a rich, view-only system with clinical events, investigation reports, radiology reports, alerts and allergies, immunization records, medications and a host of supporting documents.

With this approach, MOHH was able to successfully address three key challenges:

• Managing data from multiple sources
• Engaging clinicians
• Addressing functional, technical and operational implications



2. Value the importance of governance. In a perfect world, all data sources would provide uniform and quality data. Of course, the real world is far more complicated. With that in mind, it was important to focus on understanding up front what was available and work within those confines to aggregate data without losing meaning.

The work in Singapore also underscored the importance of governance in bringing together organizations and systems. Three types of governance were put in place:

• Technical Solution—including Architecture, Security and Operations
• Information Governance—including Data Standards and Data Quality
• Clinical Solution—including Usability, User Functionality and Clinical Risk



3. Address operational needs with intense discipline. From the beginning, MOHH and the project team took a disciplined approach to security operations, technical operations and service management. In addition, operational areas specific to an EHR were defined. These included:

• Ongoing data integration operations
• Change coordination and management across different systems
• Ongoing analysis of production data
• User provisioning and developing clear procedures for granting role-based access to the system