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Challenges in Implementing EMR

The Singapore Story

Dr. Chong Yoke SinCEO, IHiS

About Singapore

about Singaporeand IHiS

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~ 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 providers11,230 hospital beds~450,000 hospital admissionsPublic sector out-patient visits

Specialist Outpatient Clinics ~3.6m A&E ~800k Polyclinics ~4m

Singapore is a small vibrant country

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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 Singapore’s 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.

Integrated Health Information Systems

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

MoreInteroperability

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

SmartHealthcare

Health Informatics

Electronic Medical Record

EMReHealth

The driving force behind the change …

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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

Singapore’s shifting Demographics asSingaporeans are living longer

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Healthcare 2020 Master Plan

Our Strategies …

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Overview of Public Healthcare ITHospitals

Information sensingPaperlessClinical & Business integrationAdvanced Clinical Decision support

RHEMR EMR

NEHR

GP CH

EMRXExchanges of Images, Records

Intra-ClusterIntegrated WorkflowOne EMROne Patient Relationship Management PRMCross-

ClusterOne EHREMR for Details

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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)

Better Quality, More Resiliency, Fewer Interfaces

Shorter time to Deployment

Lower Development & Maintenance Cost

Enterprise ArchitectureGuidance Towards Solution Harmonisation

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Strategy to achieve Non-Disruptive IT shared Services

Federated Enterprise Architecture

PHI Operating Model

EMRs/NEHR/Clinical systems / Master patient index

Patient Relationship ManagementConnect with AIC, NH, CHs, GPs, etc

Interface through QDX Standardize Integrate and Optimize

Architect the Roadmap

Integrate the Systems

Patient Centric Records

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ICD 10 AM SNOMED CT LOINC

Structured notes Clinical analytics

Clinical decision support (EMRs, NEHR)

Tele-health

Integrate Analytics across

Continuum

Intervene at the Right Channels

Back to BasicsData Standard and Right Channel

Common Data

Standardized

About IHiS

EMROur EMR Journey …

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04/28/2023 16©2011 Healthcare Information and Management Systems Society

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Strategies 2001 2003 2005 2007 2009 2011 2013 2015

Achieving High Quality Integrated Care & Advance Clinical Analytics

BuildingClinical Capabilities, Harvest Full Potential & Benefits of EMR

Consolidation Core Systems, Harmonize Clinical Process & Workflow

20052001

20102006

20152011

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

A common EMR platform & EMRX

Results Reporting and Discharge Summary

Perioperative & ED Notes Cluster eRx, Film-less

Clinical & Nurse Documentation Knowledge-Based Medication

Management CLMM Implementation CPOE/CCOE Implementation eLab & eRad interface to EMR

Cluster’s EMR

The ABC of

digital journey

Our EMR Journey …

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Cluster EMR Roadmap• Application Landscape• EMR Building Blocks

Implementation Strategies EMR Capabilities Highlights:

• CLMM• CPOE• Clinical Document• Coding Standardization• Statistics

Benefits Challenges & Lessons Learnt

Our EMR Journey …

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The EMR Architecture

Patient Safety, Our First Priority

Closed Loop Medication Management (CLMM)

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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

WHY Closed Loop Medication Management

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WHAT are the CLMM components

Electronic Prescription System• Patient’s 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 patient’s 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

Clinical Documentation & Standard

Better Communication, Quality Reporting,

More Effective Patient Care

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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

EMRClinical Documentation Implémentation Stratégies

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• Engage all clinical chiefs and administratorson the new clinical documentation

• Conduct roadshow for all doctors to create awareness

• Set up ‘sandbox’ with feedback system forclinicians to trial the new clinical documentation

• Implement clinical documentation in outpatientsettings 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

EMRClinical Documentation Implémentation Stratégies

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Benefit of Clinical Documentation

Appropriate documentation promotes

A high standard of clinical care Improved communication and

dissemination of information betweenand across service providers

An accurate account of treatment, intervention and care planning

Improved goal setting and evaluationof care outcomes

Improved early detection of problemsand 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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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

Challenges in Clinical Documentation

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Improve Clinician EngagementEMR 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.

AccountabilityDemonstrates the clinician’s accountability and records their professional practice.

CommunicationThe basis for communication between health professionals about the (a) Care provided, (b) treatment, (c) Care plan, (d) outcome

QualityShould be clear, concise, correct, contemporaneous, complete, collaborate, patient-focused

ConfidentialityMust maintain confidentiality

Lessons Learnt

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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 Sinchong.yoke.sin@ihis.com.sg