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Healthcare services have seen several changes throughout the years to respond to changing demands of the population. The present key drivers and issues that stakeholders (patients, healthcare providers, vendors and government) in the healthcare sector face are ageing population, increased burden of chronic conditions, rising public demand/expectation for quality healthcare, fragmented and uncoordinated healthcare services and rapid advances in information technology.
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At present, information technology is considered a “strategic necessity” by world class organizations instead of just a supporting tool. To obtain a competitive advantage in an environment with intense competition, it is vital for organisations to use more sophisticated information technology tools to address the challenges of building and deploying system in the short term and the identification, research and design of future system.
Information technology (IT) is rapidly becoming integrated with healthcare to improve processes and communications, support decision making, reduce inaccuracies, and improve patient safety. The advancement of medical science through the years has made possible the use of more expensive equipment and the latest technology. This will allow healthcare providers and patients to gain access to health information easily and thus has the potential to improve the quality, safety, and efficiency of health care. As the healthcare industry is information intensive and knowledge intensive, there is also a need to publish health care information and knowledge.
Healthcare systems vary from country to country but they all have a common aim that is to meet the healthcare needs of target populations. In this report, I will be focusing on healthcare IT in Singapore context.
Healthcare System in Singapore
Singapore has a dual health care system where individuals can choose between public and private providers. The government through Ministry of Health (MOH) manages the public healthcare system. MOH plays a major role in formulating national health policies, coordinating the improvement and planning of the public and private healthcare sectors and regulating health standards. MOH’s mission is to promote good health and reduce illness, to ensure Singaporeans have access to good and affordable healthcare and to pursue medical excellence (Ministry of Health, 2007). MOH’s vision is to develop the world’s most cost-effective healthcare system to keep Singaporeans good health.
Healthcare services in Singapore are provided by different types of providers from primary care to tertiary care and to step-down care.
Primary care includes primary medical treatment, preventive healthcare and health education (Info-communications Development Authority of Singapore, 2009). In Singapore, primary health care is provided through outpatient polyclinics and private medical practitioner’s clinics. 80% of the services are provided by private practitioners while the remaining 20% by government polyclinics.
Conveniently located in town centres all over the island, polyclinics are one stop health centres which offered services such as outpatient medical care, maternal and child care health.
Secondary and Tertiary Care
For the secondary and tertiary care, 80% of the hospital care being provided by the public sector and the remaining 20% by the private sector.
This public sector is organised into two vertically integrated delivery networks, National Healthcare Group (NHG) and Singapore Health Services (SingHealth) – that operate as not-for-profit private companies. Having these two groups enable more integrated and better quality healthcare services through greater cooperation and collaboration among public sector health care providers. Each cluster consists of both general hospitals that provide multi-disciplinary healthcare services and specialised hospitals in various disciplines e.g. obstetrics and gynaecology and ophthalmology.
The private sector provides similar specialist disciplines and comparable facilities to the public clusters. The two main providers are Raffles Medical Group and Parkway Group Healthcare (Info-communications Development Authority of Singapore, 2009).
Voluntary welfare organisations (VWOs) provide most of the step-down care services. They run nursing homes, inpatient hospices, community hospitals and chronic sick hospitals. Four of the public acute hospitals also provide geriatric units (Info-communications Development Authority of Singapore, 2009).
Public Healthcare Delivery Structure
One of the objectives of forming the two clusters is to facilitate integration of healthcare services at the various levels. The clusters have begun introducing measures to integrate primary healthcare at the polyclinics and secondary care at the hospitals.
A Vision for 21st Century Healthcare
Intelligent Nation 2015 (iN2015) is a 10-year masterplan to help Singapore realise the potential of infocomm. The vision of iN2015 is “An Intelligent Nation, a Global City, powered by Infocomm”. The goal for the Healthcare and Biomedical Sciences sectors is “To accelerate sectoral transformation through an infocomm-enabled personalised healthcare delivery system to achieve high quality clinical care, service excellence, cost-effectiveness and strong clinical research”. (IDA, 2006) Refer to Figure 1 in Appendix to see how it will look like. Key drivers of change in Singapore’s healthcare sector were identified and a number of likely shifts and changes to the system were predicted (IDA, 2006).
Ageing population of chronic conditions
Focus on prevention, health promotion and wellness care
Rising public expectations of healthcare services
Integrated and patient-centred system of delivery
Fragmented and relatively uncoordinated healthcare services
Consistent widespread application of evidence-based medicine
Very rapid advances in infocomm, medical science and technologies and biomedical research
Greater role of members of the public in managing their own health
Greater facilitation of data flows between healthcare sector and biomedical sciences
Strategies and Programmes
The targeted outcome is a well-integrated quality healthcare, cost effective healthcare services and greater ability of public to manage their health. To bring about successful business change using IT, healthcare providers should ensure that IT works in performance with meaningful changes in organisational functions and processes (Rothenberg, 1995).
How IT can be used?
In the healthcare industry, one suite solution is not common because certain user departments will need to have more in-depth functionalities than others. A more common approach in the industry is best of breed where it attempts to give full equal weight in terms of functionalities and features to individual user departments. Some considerations for best of breed approach are:
It deals with more than one vendor
A need to connect or interface the different applications to provide a fully integrated solution
Future upgrades issues.
Therefore, there is a need to strike a balance between having too many application platforms and departmental requirements or functionalities (Online Consultant Software).
IT Infrastructure for the Healthcare Industry
Functional interoperability is needed in order for computers to be able to share clinical data with one another. Computers must have functions to be able to physically communicate, send and receive documents and data files, share data and information.
Therefore, there is a need for integration, standards and interface engines to build the healthcare industry infrastructure.
MediNet forms the backbone of medical system in Singapore (IDA, 2006). It is Singapore’s nationwide computer network for medical and health care community that focuses on five components (Lim, 1990):
Central Claim Processing System(CCPS) – processing of claims in hospital bills
National Patient Master Index (NPMI) – consists of patients’ risk factors, drug allergies and demographic data
Procurement – Electronic procurement of medical and surgical supplies
Notification – Transmission of notifications to government agencies
Information Services – Access to local and foreign databases
MediNet links up computer systems of all participants (MOH, Central Provident Fund Board (CPFB), Government Bodies, restructured hospitals, private hospitals, general practice clinics) in the healthcare delivery system so that they will be able to communicate, exchange data and access common applications on the network (ANNEX C: FACTSHEET: Infocomm Milestones, 2006).
Health Level 7
A group of healthcare computer systems users who founded the Health Level 7 organization in 1987 started developing the HL7 protocol to create that common “language” that allows healthcare applications to share clinical data with each another. Over time the HL7 interoperability protocol became a nationally, internationally and globally accredited standard (HL7 Singapore). Health Level Seven’s domain is clinical and administrative data.
Interface engine is a software program intended to simplify the creation and management of interfaces between separate applications and systems, either within the organization or with other affiliated organisation (McLeod CG, Inc., 2006). It carries out messaging between systems and usually handles any mapping, translation and data modification required to ensure the effective exchange of data. Examples of common interface engines used in the healthcare industry are Cloverleaf, Datagate and Openlink (MDI Solutions, 2009). Imagine in a hospital where there are different departments needing different functionalities and features, different applications might be running. It would be very complex and technically difficult to maintain separate interfaces between them.
Enterprise Resource Planning (ERP)
The public healthcare sector uses SAP industry solution for hospital (IS-H) (SAP, 2008). It supports patient management, medical and nursing documentation, and patient accounting, and integrates these with financial accounting, controlling and materials management. The information system contains evaluations of patient and hospital data that can be used both internally and externally. It also contains a communication component that enables data transfer both within the hospital and to external parties.
The picture below shows the SAP footprint in Singapore Healthcare Industry. Only Parkway Health (Private Sector) and Republic Polytechnic (for educational purpose) are not under the public healthcare sector.
Source: (SAP, 2008)
Case Study: Hospital Information System at St Andrew’s Community Hospital (InfoComm Singapore Portal, 2008)
St Andrew’s Community Hospital was relocated in April 2005 to a larger premise in Simei. The change in hospital and care processes was the drive to upgrade the Hospital Information System (HIS) at St Andrew’s Community Hospital from its manual administrative system and record stock which require tedious work to a more efficient way to process information by technology.
The project team were focused on being user-centric rather than IT-centric in the choice of an HIS. User departments were pro-active and committed during the pre-selection brainstorming and consultancy and during the implementation stages of the new system.
The VESALIUS, a complete HIS provided NovaHealth which covers front-end modules such as Appointments, Registrations, ADT and billing and ancillary support modules such as Pharmacy, Medical Records, back-end Inventory and integration to the Financial System.
The benefits of the system are:
Assisting management to track costs down to the minute details
Increasing efficiency as manual and administrative work are being minimised
Enabling links to the MOH’s Elderly and Continuing Care system for online submission of information to receive government subsidies; and the CCPS for automated submission for Medisave claims
Serving as a check and balance for inventory audit and reducing waste.
As a result, there is no need for Pharmacy staff to spend time physically checking stock levels when transferring items from the various stores in St Andrew’s Community Hospital. Having a lean and efficient team complemented by the HIS, paperwork is also minimised.
An Integrated Electronic Medical Database
Electronic medical record (EMR) stores patient’s medical information through IT to enable sharing across healthcare institutions (MOH; SingHealth; NHG, 2004). It can be made more secure through appropriate IT access and security safeguards.
The MOH holds the vision of “One Singaporean, One Family Physician, One Medical Record” to improve long term care. EMR provides medical staff involved in patient treatment with quick and accurate access to patient’s essential medical information (Yong, 2007). The integrated patient database system was thus vital in Singapore as there is a need to get the right information to the right people especially in an industry where a second could mean a difference between a life and death situation.
EMR Adoption Model
The EMR Adoption Model is devised by HIMSS Analytics to track the progress of hospitals towards creating a paperless patient record system. It is based on an eight-stage scale which starts at zero (HIMSS Analytics). The EMR Adoption Model Structure ensures all application capabilities must be operational before that stage can be achieved as it sets a foundation for subsequent stages. Refer to Figure 2 in Appendix for the EMR Adoption Model.
Electronic Medical Record Exchange (EMRX)
EMRX is an initiative by MOH and the two public healthcare clusters (SingHealth & NHG) to share electronic medical record across all public hospitals and polyclinics in Singapore.
The EMRX will have the following information (MOH; SingHealth; NHG, 2004):
Discharge summary which summarises recent hospitalization records including the treatment received and clinical course;
Operation reports and laboratory results, including radiology images and scanned medical records
Medicines prescribed with drug allergy history
It was launched in April 2004 to focus on the improvement of patient care outcomes. It is a pragmatic and incremental implementation where SingHealth and NHG first developed the key systems within selected institutions and then replicate in other institution within the cluster and eventually across clusters and where practical with the private sector.
The benefits of EMRX are (MOH; SingHealth; NHG, 2004):
Better coordinated care for patients moving across different providers and improved levels of healthcare delivery.
Better clinical decisions, with access to complete and legible clinical histories, and updated test results at the provider’s fingertips. Reduce the risks of transcription errors and missing records.
Save cost through the avoidance of unnecessary repeat tests and investigations
Better distribution of care
Facilitation and follow up of other IT based applications such electronic prescriptions and clinical decision support systems
Potential for 24 hour access to real-time data for up to date results reporting
Provision for data security and audit features to be built into the system.
Current EMRX Implementation
The aim of the clusters is to implement the EMR in all institutions within each cluster incrementally. SingHealth and NHG manage their clusters EMR independently. SingHealth started using an EMR system in SGH in year 2000. The main application SingHealth has used to develop its EMR system is iSOFT’s iClinical Manager Solution (E-HEALTH-MEDIA LTD, 2004). Similarly, the National Healthcare group has also started using EMR systems in Tan Tock Seng Hospital and National University Hospital. EMRX was developed to enable secure cross-cluster exchange of patient information. This is to ensure that a patient’s record can be retrieved regardless where he or she seeks treatment.
EMRX was later extended to healthcare partners, providing a central capability for effortless movement or records across the public healthcare clusters, community hospitals and Ministry of Defence (MINDEF), facilitating care delivery.
SAF Electronic Medical Records
The SAF healthcare system is centred on the SAF EMR system which is known as Patient Care Enhancement System 2 (PACES 2). It has clinical data repository, administrative function for manpower and logistics and also has the feature for research or analysis (Wong, 2009). The system connects all SAF medical centres across Singapore to allow for online and real time medical info retrieval and simultaneous viewing. Figure 3 in Appendix shows how it is connected.
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Bukit Batok Polyclinic was the first to adopt the electronic medical records system. With paperless medical records, patients’ medical records can now be retrieved while diagnoses are entered into the system (Hoe, 2009). This move is part of MOH vision of integrating services between the healthcare providers.
Benefits to Patients:
Enhanced safety as there is a reduced patient risk through improved legibility of orders.
Reduced waiting times due to the improved process
Better care coordination and disease management through sharing of medical records
Benefits to the polyclinic:
Quality: Continuous improvement of quality care and patient service through error monitoring and elimination of unnecessary procedures
Productivity: Saving time and effort that would otherwise be spent on correcting lost and illegible orders. Furthermore, there is no longer need to go to the records office, retrieve the physical paper records and bring it up to either the doctor’s or nurse’s room which can take up to 20 minutes or half an hour.
Access: More readily available information and data of patients for healthcare professionals to make faster critical decisions
Future Outlook – National Electronic Health Record (NEHR)
The next phase of electronic health record is moving towards creating a health record that is in fact personalised and accessible everywhere to be implemented by April 2011 (ChannelNewsAsia, 2010). With NEHR, all key information such as a patient’s demographics, allergies, clinical diagnoses, medication history, X-rays, laboratory investigations and discharge summaries will be fully exchangeable between various healthcare providers.
Due to the costly implementation, only a number of primary and step-down care providers, including GPs, polyclinics and a community hospital will be linked up first (ChannelNewsAsia, 2010). The full implementation of NEHR will take many years as it has to cover the entire healthcare ecosystem and not just the public sector. The decision on whether to implement each phase will have to be justified on cost-benefit analysis.
Refer to Appendix for an attached article on “What could healthcare in Singapore look like in 2020?” (Ministry of Health, 2008).
Medical Information Services
IT is also widely used as an information tool by both medical professional and the public. Several government and privately initiated websites provide information for health care services and databases for medical related issues. Web portals provide the following services:
Searching for medical professionals within Singapore – The MOH has a list of online resources to search for healthcare professionals in Singapore (MOH, 2007)
Online pharmacies – For example, Changi General Hospital myPharmacy is the first online hospital pharmacy in Singapore (Changi General Hospital, 2004).
Medical publications – One example of medical publications is PubMed (PubMed).
Health related publications – Some examples of health related publications from SingHealth (SingHealth Academy ).
Health service reports – Queue watch provide patients with timely information to arrange their visit. The number of patients waiting for registration and consultation, live webcam images showing the waiting areas for registration, consultation and pharmacy/payment and peak & non-peak periods are displayed online (Government of Singapore, 2007).
Medical schemes such as Medifund, Medisave & MediShield – Information regarding these schemes can be found in CPF Board website (Central Provident Fund Board, 2009).
The growth and survival in the healthcare industry depends on how well Singapore is able to compete in this highly and competitive market. With the integration of the healthcare infrastructure, the advanced medical technology and the highly skilled professionals, Singapore has managed to establish a reputation of being a world class healthcare hub, the ability to deliver innovative healthcare solutions, a complete range of services and quality healthcare providers (EDB, 2009). There will be a strong demand from the population for quality healthcare and value added services with rising economic affluence and longer lifespan. Thus, there is a need to ensure that healthcare research and development continues to be supported so that Singapore healthcare services sector can excel and be a source of competitive advantage.
To sustain the competitive advantages, Singapore should be aware of their strengths and weaknesses and also of their competitors’. The approach for the future must be one that focuses on possible improvements, supporting innovations and facilitating changes. The focus will have increasingly to be on openness to new influences, a willingness to recognize different schools of thought and methods of training and a search for the best available expertise from around the world (Desker, 1991). Innovation is needed to overcome the future challenges ahead to maximise Singapore’s competitive advantage. Healthcare providers should enhance their medical and service offerings, develop new healthcare products, and promote a pioneering spirit that will help in dealing with evolving patients’ needs, and in creating holistic and flawless experiences for patients (Tan, 2009).
Thomson Medical Centre
The Business Times reported that Thomson Medical is leading the healthcare sector (Ramchandani, 2010). Focusing on three core areas – patient expectations, perceived quality and perceived value to improve patient satisfaction, Thomson Medical Centre has been continuously innovating to provide greater value-added services to its patients. Their redesigned patient-centric workflow had helped them gain a competitive advantage over their rivals:
Use of technology and raise in service and product standards has improved patient care and satisfaction
Improve in-patient , out-patient and administrative processes by using touch screen billing in place of a key-in method, which has halved the time spent on billing and has resulted in cost savings of $2000 a month.
Reduce waiting time for admission and discharges with express check outs, direct admissions and courtesy and in-room discharges.
Act on service recovery. When there is an unhappy patient with service, they move fast to resolve the problem.
Train front line staff to raise service standards which resulted in an increase in the number of compliments as compared to complaints (4.9:1 to 9.2:1).
Create a positive patient experience by having a resort style ambience, offering concierge service, a welcome drink and, in the case of premier rooms, luxurious décor and relaxing spa music.
Introduce value added services such as the interactive website ThomsonBaby.com to help new mothers prepare for the parenthood journey and save them time and money.
The hospital’s efforts in cultivating lasting relationships have also led to an increase in patient loyalty. 32.2% of its patients were repeat patients in 2009, compared to 26.8% in 2008. Besides that, there was an increase in the number of babies born.
Thomson Medical Centre’s dedication in understanding patient needs and receiving feedback on their stay and their expectations at key hospital touch points has thus improved patient satisfaction level.
The vision for an integrated and continued patient- centric healthcare system requires interoperable IT systems, active engagement of patients and suitably aligned financial framework. In the development of the Singapore healthcare system, there are some issues that hinder the implementation of healthcare integration due to unique specificities.
In general, the problems faced by the players involved can be classified into five categories:
Clinical and medical practices: Often built around specialization but could be better oriented towards integrated care
Financing framework: GPs, Specialist Outpatient Clinics (SOCs) and patients does not see the incentive for integration of care
Establishment of a new idea & mindset towards integration of care for players involved
Organizational processes: Enhanced by bridging communication and IT gaps, coordinating across sectors and defining workflows for the smooth move of patients between caregivers
IT systems: Better connected across sectors and allow for the transferability of patient records.
As shown in Figure 4 in the Appendix, these challenges have over the years led to ingrained mindsets and behavioural practices of parties at multiple levels of the system, further hindering the integration of care (Ministry of Health, 2008). The various challenges and loophole that currently exist are the result of institution-centric and tertiary-centric system of healthcare.
As EMRX becomes widely accessible, there are concerns over patient confidentiality and privacy. For instance, legal implications of providing EMRs beyond cluster boundaries were considerable and attaining consent from individual patients would have been burdensome and stalled widespread accessibility of EMRs (MOH; SingHealth; NHG, 2004). This shows that there are vital ethical concerns over the privacy of personal medical records.
Furthermore, the infrastructure for data standardisation needed to achieve this integrated healthcare system is getting more intricate and costly due to the vast amount of data involved from different independent systems. Despite SingHealth and NHG adoption of the HL7 v2.3, data exchange could not be easily achieved in spite of HL7 v2.3. This is because the standard was open to variations that hampered direct interoperability. Moreover, modification of systems to enable data interoperability would have been costly, without direct benefits to the clusters (Lee, Lim, & Tan).
Previously, healthcare sector has lagged behind other sectors in the adoption of IT for its key process. Healthcare providers need to review the way businesses are conducted. IT can be a powerful enabler for an information intensive industry like healthcare through automation, knowledge management, business process reengineering, and even artificial intelligence. A pragmatic approach should be adopted to consider the current status and to focus on implementing immediate goals that would bring about meaningful changes in organisational functions and processes within a reasonable time frame.
The use of IT to create value in a patient-centric approach to care is likely to contribute significantly to the overall level of care that patients can benefit from. Innovation can help healthcare providers to gain a competitive advantage. The success of some healthcare provider as mention above has shown that IT can help in the healthcare sector to improve healthcare quality, reduce costs and to meet some of today’s trends in demographics and disease burden.
This quote which is published in NHG annual review 2007-2008 shows the importance of IT,
“Technology is our enabler. We use technology to record and disseminate information with higher precision, accuracy and safety. More importantly, it allows healthcare to be delivered safer, faster and better.”
(National Healthcare Group Polyclinics, 2008)
In the enthusiasm to adopt and invest in IT, it is important to note that there are some barriers in the move toward an integrated healthcare system as stated in the abovementioned section. Addressing and overcoming these challenges will involve the collaboration and cooperation of players at all levels of the system, across both the public and private sectors.
Learning points / Opinions
Technology should be used as a supporting tool not to steer health care reform. To transform Singapore’s health care system into a modern and responsive 21st-century health care system, a practical IT strategy which is consumer-focused is needed. In particular, it needs to be competitive in terms of price and quality because that is what consumers look for. A tripartite model of health care regulation, involving the active participation of empowered consumers, is Singapore’s best hope for containing costs and ensuring quality of care.
What is done well?
A committee to plan for the future development in healthcare
iN2015 Healthcare and Sub-Committee came out with strategies and programmes to help address today’s challenge and support the developmental opportunities. It aims to achieve high quality clinical care, service excellence, cost-effectiveness and strong clinical research.
Improve business process with IT
IT has played an important role in the delivery and development of healthcare services in this information age with applications ranging from finance and personnel administration to medical equipment operations. Healthcare service administrations have become more efficient and responsive, reducing patient waiting time and paper work. Medical equipments have become more accurate, laboratory results can be processed more quickly and effective communication among medical staff in Singapore and those overseas has become easier.
What more can be done
IT investment decisions must serve the best interests of the key players involved. It is important to understand the users and their work flow and requirements as a one size or solution may not fit all. Flexibility is needed as each department requires different functionalities.
Express clearly the benefits and value for the change
Users involved need to understand the strategic goals of the organization and understand how IT, from technical and managerial perspectives, can help to achieve them. The success of IT investments is to ensure users see the benefit and value of IT so that they will be motivated to make the change.
Limitations of IT
Healthcare providers should be mindful of the limitations of technology and have a deep understanding of the information search behaviours of their target audience. Health care is still a hi
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