Friday, 10 November 2017

MOH wants to make national patient database mandatory; Legislation set to be introduced in 2018

All health providers, even GPs, will have to upload health details if plans are approved
By Linette Lai, The Straits Times, 9 Nov 2017

The Ministry of Health (MOH) wants to make it compulsory for all healthcare providers to upload data to the National Electronic Health Record (NEHR) system - from large hospitals all the way down to the neighbourhood GP clinic.

This means that every aspect of a person's medical history, including visits to doctors in the private sector, chronic medication, allergies and vaccination details, will be captured in these records.

These plans come on the back of a slow take-up rate from the private healthcare sector in the six years since the NEHR was launched in 2011.

Sharing medical data in a national electronic repository will make for more seamless treatment and save money for patients, said the Government.

Singapore is one of the first countries to have established such a comprehensive system. The records, however, will not include details such as doctors' personal case notes, as they are meant chiefly to provide a summary.

Currently, most NEHR data comes from public sector institutions such as public hospitals and polyclinics.

Only 3 per cent of the more than 4,000 private healthcare providers - including specialist clinics, nursing homes and hospices - contribute to the scheme.

This is despite the fact that a quarter of them have access to it and can view patient records.

"Patients can realise the full potential of the NEHR only if the data is comprehensive," said Health Minister Gan Kim Yong, who made the announcement yesterday at the start of the three-day FutureHealth Conference. The conference was jointly organised by Nanyang Technological University and the Centre for Healthcare Innovation.

"And for NEHR data to be comprehensive, every provider and healthcare professional needs to contribute relevant data to it," he added.

The proposed changes will likely be tabled in Parliament next year. If approved, healthcare groups will be given a grace period of two to three years to make the necessary preparations.

Early adopters who start contributing data by June 2019 will be able to claim a one-off amount from MOH to offset the costs of upgrading their systems.

A $20 million fund has been set aside for this, said Mr Gan.

He added that MOH will be organising workshops for doctors to help them understand the new requirements.

Workshops will also be conducted for IT vendors who help doctors provide such electronic clinical management services.

MOH plans to introduce the changes under the Healthcare Services Act so that all health-care providers will be legally obliged to follow through with its plans. If the changes go through, those who do not comply will likely face penalties.

"This will not be an easy journey," said Mr Bruce Liang, MOH's chief information officer and chief executive of the Integrated Health Information Systems.

"However, it is a journey we must make, as a strong digital backbone is essential in meeting our patients' and healthcare system's needs in the future."

How the electronic records will affect patients
By Linette Lai, The Straits Times, 9 Nov 2017

As all healthcare providers get pushed to adopt the National Electronic Health Record (NEHR) system, here is how the move could affect the average person:


A Only doctors who are caring for you will be able to access your records. Other doctors will not be able to do so.


A The NEHR will have a summary of your diagnoses, medications, allergies and vaccination records from both private and public healthcare providers.

It will also include operating theatre notes and procedures, as well as laboratory and radiology reports. It will not, however, include doctors' personal case notes of each consultation.


A If anyone wants to look up your records for purposes other than your medical care, they will have to get your explicit consent.


A Currently, you can already opt out of the NEHR. When you do so, your medical records will still be uploaded into the system, although doctors or other healthcare professionals will not be able to access them. The authorities have said that this will not change for now, although they are open to feedback on the issue.


A No, data from old records will not be put into the system.


A The authorities have said they will take measures similar to what the Inland Revenue Authority of Singapore uses to protect its tax database from hackers and other cyber-security threats.

GPs among biggest groups affected by MOH’s plans to make health database mandatory
While most see merits of health database, some say data entry may impact waiting time
By Linette Lai, The Straits Times, 9 Nov 2017

General practitioners (GPs) form one of the largest groups to be affected by the Health Ministry's plans to get all healthcare providers on board the National Electronic Health Record (NEHR) system.

They run more than 1,600 clinics in Singapore, including solo practices and chains, and are often the first point of contact for many who fall ill.

While most acknowledged the new system has its merits, some worry the new rules could mean losing the personal touch with patients.

"My patients don't like it when during a consultation, I am facing the computer to look at their medical records and key in data," said Dr Auw Tiang Meng, who runs T M Auw Clinic in Hougang. "They are my regulars, so I know their background."

Dr Yik Keng Yeong, who runs Tan and Yik Clinic and Surgery in Bishan, said: "I realise there are lots of advantages because medical care is so fragmented and everybody needs to be kept in the loop.

"But it is not that difficult to get information from the patient. We would prefer not to be dealing with the computer when we are dealing with the patient."

Doctors said that having to enter such data might lengthen waiting time at their clinics and shorten consultations with patients.

There are more than 4,000 private healthcare operators, including GPs, hospitals, dental clinics and hospices. A recent survey of 1,500 such operators done by the Integrated Health Information Systems - the national technology agency for healthcare - found that two in 10 private GPs and specialist clinics still use written medical records, rather than an electronic system.

And although most private hospitals keep electronic medical records, their systems may not be compatible with the NEHR.

This is the case for the Parkway Pantai group, which runs four private hospitals, a chain of medical clinics, plus laboratory and radiology facilities in Singapore.

Mr Phua Tien Beng, who is acting chief executive of the group's Singapore operations division, said it has been in discussion with the authorities on linking its records with the NEHR since June last year.

"Enhancing our systems to interface with NEHR and maintaining these systems would certainly come at a considerable cost," he added.

A spokesman for Farrer Park Hospital said it has met the authorities on many occasions "to work out technical and administrative issues, including government grants".

Doctors who have used the NEHR say it can be useful, especially in an emergency. "It is important to know what medications they are currently taking, which will affect the way we treat the patient," said Dr Lim Jia Hao, a consultant at the Singapore General Hospital's emergency medicine department. "If the patient has been getting medication from a private GP or hospital, they are essentially a blank slate to us."

One GP who has made the switch to the NEHR system is Dr Low Kee Hwa, who runs Low Medical Clinic in Kallang Bahru. "After 20 years in practice, I was running out of space to store patient record cards," he said. At the start, Dr Low and his clinic assistants took some time getting used to the new system and were "rather slow". But it has proven to be helpful because many of his patients are elderly and may not know the details of their medication.

"The information from NEHR enables me to make a more accurate diagnosis, and ensures my prescription does not interfere with their medical condition or medication they are on," he said.

Additional reporting by Shelina Ajit Assomull

Doctors to have access only to own patients' data
By Linette Lai, The Straits Times, 9 Nov 2017

Doctors will have access to only National Electronic Health Record (NEHR) data of the patients they are treating, say the authorities.

They will not be able to look up the data of other people who are not directly under their care.

In addition, said Associate Professor Low Cheng Ooi, who is chief clinical informatics officer at the Integrated Health Information Systems, anyone who wants to access a person's records for reasons other than his medical care will need the latter's consent.

This includes, for example, doctors who have been hired to review someone's health records as part of a pre-employment check or for insurance purposes.

"As long as it is not for patient care, you would need to have explicit consent from the patient," said Prof Low, who is also chief medical informatics officer at the Health Ministry.

However, Jurong GRC MP Tan Wu Meng, who is a medical doctor, pointed out that safeguards may be needed to prevent insurers from taking a "disproportionate view of past medical history".

He gave the example of how an insurance company told a young man that his foot would not be covered following a stress fracture - even if a future foot condition was unrelated to the fracture.

Cyber-security measures taken to protect patients' data in the NEHR system will be similar to those used by government agencies which deal with confidential information, said Mr Bruce Liang, chief executive of the Integrated Health Information Systems.

"The methods we use are very similar to how the Inland Revenue Authority of Singapore, for example, protects its tax database when it collects information from thousands of companies," he said.

Mr Nick Savvides, who is a security advocate with Symantec Asia-Pacific and Japan, said it has seen many attacks on overseas medical clinics, which may not have dedicated IT staff and rely on external vendors to manage their electronic systems.

"In such scenarios, it is critical that good security hygiene is implemented with strong endpoint security, such as e-mail security and gateway security with multifactor authentication," he said.

National patient database not easy to achieve, but necessary
By Poon Chian Hui, Mind & Body Editor, The Straits Times, 9 Nov 2017

The move to compel the private healthcare sector to join the shared national patient database sends a clear message - the Government is done waiting.

Next year, a Bill is expected to be introduced in Parliament to pass the requirement into law. Private healthcare operators will then have to link their computers to the National Electronic Health Record (NEHR) system, failing which they are likely to face penalties.

The proposed rules will impact more than 4,000 private operators, including general practitioners (GPs) and dentists, specialist clinics and hospitals, as well as community care facilities such as nursing homes.

It will be a massive exercise for all of them to get on board.

Yet, the NEHR is not an alien concept to the medical community here, including the private sector. It has been up and running since 2011.

Today, public healthcare institutions, such as restructured hospitals and polyclinics, are linked to the database, which is a trove of more than six million unique patient records.

A polyclinic doctor treating a chest pain, for example, can check if the patient has been hospitalised before for heart issues. He can also check for drug allergies and test results, such as X-ray scans.

The system holds much promise in promoting seamless healthcare and helping patients save money by cutting down on repeat tests.

In 2012, it was reported that the NEHR was expected to be fully up by 2015 and involve the private sector and step-down facilities.

But till today, the vision of "one patient, one health record" has yet to materialise.

While private operators were urged to join on a voluntary basis, few did. Only a few dozen GP clinics signed up, out of the more than 1,600 here. No inputs came from all nine private hospitals.

The barriers, it seems, are pragmatic. Upgrading computer systems or buying new software to synchronise with the NEHR can be costly.

About 30 IT vendors provide such a service, and even among them, the software specifications may differ.

Linking up to the database is also not something that would boost the clinic's or hospital's revenue.

In fact, it has been suggested that private medical practices may fear losing their patients to rivals, as doctor-hopping would be easier.

The financial impact could hit small clinics hard, too.

That is why a $20 million kitty has been set up by the Health Ministry to fund the transition. Each private operator can get a one-time payout, ranging from $2,400 to $200,000.

This would be helpful for many practices. But the money tides them over only temporarily. Eventually, for instance, they will have to pay the IT vendor monthly fees for the upkeep of the software.

It will be good to explore support measures after this initial period to help doctors make meaningful use of the NEHR. For example, some GPs who are linked to the NEHR said that they do not use it actively as it can be tedious to digitise their records. The authorities may want to look more deeply into this.

Health Minister Gan Kim Yong said yesterday that workshops on the new requirements will be offered to doctors and IT vendors.

This is a positive move and could be made even better if these sessions include a strong ethical element of using the data responsibly.

Patient privacy and confidentiality are a valid concern that has been raised by doctors and patients. The authorities have said there are safeguards, such as tracking and stratified access among healthcare staff.

With so many more doctors able to call up a patient's record, it must be impressed upon all users that one cannot search for data willy-nilly.

As with every man-made system, there is a chance that someone will find a way to misuse it undetected.

It is important for providers to have strict rules on how they use the information, on top of the in-built stringent access to the system.

Some patients may still baulk at the thought of their healthcare data being more accessible, but even so, the benefits cannot be denied.

Doctors cannot rely on a patient's memory of his drug allergies or vaccines. Worse still, if that patient is in no state to talk in times of emergency, it might be a matter of life and death.

Things are even more complex now with the greying society - people are seeing more doctors and have multiple health ailments.

A national shared patient database is not just a noble vision, but also a necessary one.

Such a move will fall in line with technology initiatives in the healthcare sector. One example is a national telemedicine plan launched this year that allows more patients to have e-consultations with doctors.

As Singapore marches to the Smart Nation beat, the database must keep pace - with sufficient safeguards to maintain its integrity.

Why some GPs still go with paper records
Those in industry say some still unsure that electronic record systems will truly help
By Linette Lai, The Sunday Times, 12 Nov 2017

At Dr Lee Yik Voon's clinic along Circuit Road, patient records are still scribbled on paper and filed away in bulky cabinets.

But at Lakeside Family Medicine Clinic, where the general practitioner (GP) also works, all this is typed into the computer and stored in a virtual cabinet.

Keeping such virtual records will become standard for healthcare professionals in Singapore, once the Ministry of Health's (MOH's) new rules to get them using the National Electronic Health Record (NEHR) system are fully implemented and become law.

GPs will be one of the largest groups affected by these plans.

Dr Lee has been running his clinic for 20 years, and more than 10 groaning drawers - each the size of a microwave oven - hold his weighty paper records.

"Every year, our drawers get heavier and every few years, we have to upgrade them because of wear and tear," he said.

He finds retrieval of records much easier with the electronic system, and does not know why he has not switched over sooner. "Maybe it's comfort, or maybe it's inertia."

But not all doctors share his positive attitude. Those in the industry said some doctors are holding back because they are not yet convinced that such electronic medical record-keeping systems will truly help.

Mr Tseng Ching-Tse, founder of medical information technology company Vault Dragon, said that if such systems make it more of a chore to input information, doctors may not see the advantages.

Some systems may also be entirely dependent on having a connection to the Internet, he added. This means that work grinds to a halt if the connection is disrupted.

Dr Siaw Tung Yeng, a practising GP who is also the founder of medical IT firm Mobile Health, said: "They see no incentive... instead of making their life more efficient, such systems make their life more miserable." His company's software tries to alleviate these problems by allowing doctors to write on tablets and ensuring that the system will still work even if the Internet is down.

Some doctors fear that such systems could mean losing the personal touch and add to waiting times at their clinics. Dr Low Kee Hwa, who runs Low Medical Clinic in Kallang Bahru and uses the NEHR, said he finds it much easier to retrieve information although he agrees that the convenience comes with a "slight loss" of personal touch.

"It is impersonal when I look only at the computer throughout the consultation. As long as we take the time to communicate with a patient before or after computer input, it helps," he said.

Others raised the issue of patient confidentiality under the NEHR, which could arise when any doctor involved in caring for a patient can access all his medical records, including visits to different doctors.

According to MOH, the idea is to give doctors a fuller picture of their patients' medical history, especially in emergency situations.

Even so, doctors said that people may prefer certain parts of their medical history to be known to one physician alone.

"For example, you might be a senior banker with thoughts of suicide and major depression, and you trust me enough to share them with me," said Dr Goh Tze Chien, who practises at a Northeast Medical Group clinic in Simei.

"I have treated you, and you are well now. Would you want all the other doctors to see these details?"

Mobile Health's Dr Siaw suggested that a "break glass" feature - where most information is disclosed only with a patient's consent but exceptions are made during emergencies - could be useful.

GPs said the NEHR system can be very useful in providing an overview of a person's health over time.

Dr Leong Choon Kit, who runs Mission Medical Clinic, said: "The majority of my patients are chronic patients, and many of them see multiple doctors."

Dr Yik Keng Yeong, who runs Tan & Yik Clinic and Surgery, said having everyone's records in one place may even help doctors sift out addicts who doctor-hop in order to get a constant supply of cough medicine or sleeping pills.

Dr Lee Yik Voon, although still using pen and paper in his own clinic, said: "Actually, I prefer electronic records because I think I can type better - my scribbling can get horrendous."

* Healthcare Services Bill: Draft Bill eases privacy fears over electronic health records
Employers, insurers barred from databank; doctors can access data only to treat patients
By Salma Khalik, Senior Health Correspondent, The Straits Times, 6 Jan 2018

Many Singaporeans have been worrying that employers and insurers can obtain their medical history without their consent when it becomes compulsory for such information to be stored in a national health databank.

Yesterday, their fears were allayed when a proposed piece of legislation was unveiled.

The draft Healthcare Services Bill made it plain that employers and insurers will be barred from accessing the information. Also, people can choose between two options should they want to shield their medical history even from doctors.

They can agree to store their data in the National Electronic Health Records (NEHR), but it will not be uploaded for doctors to access until they give their permission. Alternatively, they can choose not to have their medical history in the system.

These measures for the NEHR are part of the draft Bill, which sets out changes in store for the healthcare sector as the Health Ministry prepares to update the law. These include regulations to cover mobile and online care as well as protection for the frail elderly, areas not covered in the Private Hospitals and Medical Clinics Act, which last underwent major changes in 1999.

The centralised databank was set up in 2013, but public-sector medical institutions were inputting patient information, with only a few private clinics contributing.

Last year, Health Minister Gan Kim Yong announced it will be made compulsory for everyone.

The move is to enable all Singapore doctors and other medical practitioners to have the relevant medical information for the diagnosis and treatment of patients. This is especially critical in an emergency.

Dr Charmaine Manauis of Tan Tock Seng Hospital cited the case of an unconscious patient whose medical history in the NEHR showed he was on dabigatran, an anti-coagulant that prevents blood clots. This was critical information as doctors were able to give the antidote to prevent him from bleeding profusely.

Even in a normal clinic setting, past data is particularly useful in treating elderly patients who may not remember, or even know, the medicines they are taking.

Despite the benefits, many Singaporeans were concerned that potential employers may turn them away or insurers may use their past medical conditions to refuse them a policy or impose hefty premiums.

But the proposed law states explicitly the data can be obtained only to treat patients. And doctors can access only basic information such as diagnosis, medication, laboratory reports, allergies, immunisations and the discharge report of patients who had been hospitalised.

Those who flout the rules face harsh penalties.

Ms Tin Pei Ling, a member of the Government Parliamentary Committee for Health, was all for prohibiting employers and insurers from accessing the NEHR. "The data collected should be to enhance patients' care," she said.

But the Life Insurance Association Singapore said insurers should be given access on "receiving explicit and appropriate consent from the patient when the need arises''.

Its spokesman said: "Ultimately, we believe there will be benefits from this approach for consumers in improving claims servicing."

The association will give the ministry feedback on this, she added.


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