Just now, we discussed
how we must gear up Singapore for our healthcare needs of 2020.
We discussed the 3 key resources that we will need: financial,
physical and human resources. But having more resources alone
will not necessarily lead to a better healthcare system. Witness
the huge amount of resources some countries are pouring into their
healthcare today and yet they deliver much poorer outcomes than
other countries which spend much less. More of the same will not
do. We need to have the courage and wisdom to transform
healthcare.
Transforming Healthcare
2. Some analysts in the automobile industry compared GM with
Toyota and criticised GM for being too product-focused. They
praised Toyota for focusing on the changing needs of customers
over their lifetime. Parents buy a small car for their child when
he graduates from high school. A young adult buys a Corolla, then
an MPV when his family grows, and when he gets promoted, he buys a
Camry, later a Crown and so on. Toyota made over a hundred models
to meet the needs of different market segments.
3. Healthcare is unfortunately more like GM than Toyota. We focus
on buildings, equipment and skills. This is not wrong but we are
not paying enough attention on the varied needs of our patients.
Let me give some examples:
-
An infant with a
hole in the heart needs a one-off highly specialised care
involving a large team of specialists and other staff to fix the
problem using highly sophisticated equipment. But once fixed,
the infant will be more or less normal and well.
-
Another infant born
with severe brain damage will also require sophisticated care
but the best outcome may still be a lifetime of pain, discomfort
and total dependency.
-
An 80-year old with
advanced cancer may also need highly specialised care involving
experts and sophisticated equipment. But the outcome may be a
prolongation of life for a few weeks with pain and discomfort.
-
Another patient in a
similar condition may well choose a less aggressive treatment
regime focusing mainly on palliative care.
-
A young person with
a broken bone needs a surgery and after a few weeks will be back
to normal. The surgeon plays a key role and the patient plays
only a relatively small role in that treatment episode.
-
On the other hand,
an obese patient with diabetes will need life-long medical
attention. The patient's well-being is almost entirely
dependent on his personal willingness to change his lifestyle
and follow the treatment regime strictly. The healthcare team
can only play a supportive role.
4. As you can see, a
patient's treatment choice is often determined by a complex
interplay of his understanding of likely outcomes, advice from his
doctors and friends, his personal expectations, values and
philosophy, and his ability and willingness to pay for treatment.
Clearly, one size cannot fit all. Even a dozen sizes will still
not fit many. There is a need for us in healthcare to segment
patients more, clearly understand their needs by observing them
closely and consulting them. We have to develop practical
treatment strategies, innovate and continuously fine-tune
approaches to improve outcome and reduce cost.
5. To transform healthcare to better meet the different needs of
our patients, we must innovate. To innovate to meet diverse
needs, we must have diversity in organisations, structures, models
of care and pricing. This requires a change in mindset on the
part of the healthcare providers. For example, hospital
specialists will need to work more closely with Family Physicians
and step-down care facilities as a team, with patients at the
centre. Ideally, they will all share a common medical record for
each patient, consult regularly and function as a team whose sole
purpose is to advance the health of the patient.
6. This is challenging even when all the healthcare providers are
from one single employer and serve patients with the best of
intentions. Complications multiply many-fold as such a team often
comprises members coming from all the 3 sectors: public, private
and charity sectors. Co-ordination and trust take time to build.
That is why true care integration has not yet happened, whether
here in Singapore or in other countries. It will take years, not
months, to achieve such an optimal outcome. Many pieces have to
fall in place. Let me highlight some.
Electronic Medical Record
7. First: an important infrastructure is the Electronic Medical
Record (EMR). I have coined the slogan, "One Singaporean, One EMR"
to catalyse this initiative. Right now, it is one Singaporean,
multiple medical records, stored away in different clinics and
hospitals in different formats, and not connected or
consolidated. As a result, when patients visit different doctors,
they have to have tests repeated and scans redone. This adds to
unnecessary cost.
8. We are moving towards this target of "One Singaporean, One EMR".
Because of legacy systems, we cannot achieve it in one step. But
we have made progress. As pointed out by Dr Lam Pin Min, public
hospitals now have the EMR eXchange (EMRX). We achieved a first
but important psychological step in 2004 when public hospitals
began to electronically exchange their Hospital Inpatient
Discharge Summaries. Since then, we have made the EMRX more
comprehensive, by adding other patient records such as laboratory
tests, radiology reports and medication information. The
electronic volume of laboratory results exchanged has grown 7
times in 2 years. Thousands of patients benefit from EMRX every
month.
9. Our doctors' feedback is that EMRX has made their work easier.
In particular, our Emergency Department doctors have said that the
EMRX gives them greater reliability and confidence in treating
patients, especially those with long and complicated medical
histories. Extending EMRX to private doctors will be a natural
step and is the objective. As Dr Lam pointed out, a National EMRX
will minimise unnecessary medical investigations. More
importantly, I see EMRX playing a critical role in the integrated
delivery of care to patients.
10. However, this is a complex national project - very few if any
countries have successfully implemented a system that links up
public, private and the charity sector. This is because there are
many issues such as data protection, regulation and audit to be
addressed. We need to take a measured approach, to pilot and put
together a comprehensive framework that takes care of these
issues. This will begin with common data standards. We will do
this within the public sector, and extend this to the step-down
institutions. We have started to build the linkages to the
private sector GP clinics by helping them to set up their IT
systems under the Chronic Disease management effort. I am
confident that we will get there.
Care Integration
11. Second: we need to strengthen the collaboration between acute
hospitals and community hospitals to achieve seamless care for
patients when they move between these two types of institutions.
For patients who no longer need medical treatment in acute
hospitals and who should move into community-based care, we must
ensure the continuity of patient care and eliminate barriers and
bureaucracy. The handover must be smooth, as though it is from one
ward to another within the same hospital. For a start, we need to
enhance medical collaboration between the doctors in our acute
hospitals and either their counterparts in the community hospitals
or the Family Physicians who look after the patients over the long
term. Patients must feel confident that they are getting seamless
care.
12. The same approach is needed for patients who require care at
nursing homes. We are working with MCYS on this. We are also
studying the longer-term feasibility of integrating different
residential and community-based healthcare and eldercare
facilities, so as to help the elderly to age-in-place and continue
using familiar facilities even as their care needs change with
time.
Right-Siting
13. Third: we need to have patients treated in the most
appropriate locations by medically-competent teams at the lowest
possible cost. This is referred to as "right-siting" healthcare
services. The logic is obvious. But the outcome is seldom the
case. Today, many patients who choose to be treated at SGH and
NUH need not be there and should not be there. They can be and
should have been treated by their Family Physicians, at less
hassle and at lower cost. But for various reasons, they get
wrongly-sited there. Wrong pricing, as observed by Mdm Halimah,
is one factor. Mdm Halimah's proposal is for us to reduce prices
at step-down care so that patients will have an incentive to leave
the hospital. To achieve this, Mdm Halimah suggested that we
exempt patients to be transferred from hospitals from
means-testing at nursing homes. I am afraid I do not agree. The
correct solution is to extend means-testing at nursing homes to
the hospitals so that we eliminate this policy anomaly. I have
asked MOH to study how we can do so, at least for those patients
who have exceeded the average length of hospital stay.
14. Meanwhile, we will continue our push, through the Medisave for
chronic disease scheme, to shift chronic disease management to the
primary care level, by Family Physicians and in the community. If
patients can be right-sited to Family Physicians and feel
confident that they will be well looked after, we can reduce the
over-crowding at the hospital specialist outpatient clinics.
Exploiting Technology
15. Fourth: we must exploit technology to improve care and lower
cost. Telemedicine is a good example and can potentially bring
benefits to many areas of healthcare. We have started with tele-radiology
in our polyclinics with very good results. Patients save time as
they no longer need to make a return trip for their results.
Increased competition has resulted in cheaper X-rays and improved
turnaround times from local radiologists. Almost 60,000
patients benefit from this per year.
16. We are moving beyond simple X-rays to CT scans and MRIs. I
have no doubt this will bring further benefits, and those cost
savings will be even more significant. We will continue to study
other applications of telemedicine and get it to work for our
patients here. I have also encouraged our radiologists, where
there is spare capacity, to sell their services to buyers in
developed countries. We can sell tele-radiology services, as well
as buy it.
Clinical Research
17. Fifth: medical science here will continue to progress, and
we have reached a stage where Singapore should be part of the
global search for faster diagnoses, better and more
cost-sustainable care for patients. Our public sector doctors
have always been bogged down with heavy patient loads. If we are
able to recruit more doctors to improve our doctor-patient ratio,
we can ease their burden somewhat.
18. Through this process, we hope some doctors with special
interest in clinical research will find more opportunities to do
so. Every generation of doctors has always yielded a few
outstanding researchers, for example Professors Wong Hock Boon, SS
Ratnam and more recently, Ng Soon Chye, Yap Hui Kim and Donald
Tan.
19. With our latest emphasis on life sciences development, public
hospitals will now be better supported with research funds to
pursue this interest. Over the next 5 years, MOH, National
Research Foundation and A*STAR will jointly contribute $1.55
billion to support translational and clinical research. It is a
major boost to our researchers, although in the scheme of things
it is not a huge pool of funds. So we will have to prioritise and
focus on specific areas where Singapore-based researchers already
are strong or in diseases where strong capabilities can best
benefit Singaporeans. Because the greatest potential impact will
come from areas where we are strong along the value chain from
basic sciences to clinical treatments, we will encourage our
doctors in the hospitals and the scientists in the laboratories to
work very closely together.
20. We will not be able to allocate research funds equally to each
hospital. Hospitals and researchers will have to compete for
them. Those who are able to better manage unnecessary
overcrowding and free up manpower resources will have an
advantage. That is why it is so important for hospital
specialists to learn to work with the GPs, to co-manage the
chronic patients and make right-siting of care a reality.
Organisational Changes
21. Sixth: we should not shy away from organisational changes that
can help us achieve our mission more effectively. That is why we
restructured hospitals more than 20 years ago. We moved from
central planning by MOH HQ, almost communist-style, to a
decentralised competitive model allowing individual hospitals
greater room to innovate. How else can we nurture experimentation
and bring out improvements?
22. Mr Sam Tan asked if our restructured hospitals are wasting
resources on rich patients and foreign patients, at the expense of
subsidised patients. All patients, poor or rich, receive
competent clinical care. Thus all patients requiring urgent
medical attention are promptly seen: 3 minutes for the
critically-ill; 30 minutes for other true emergency cases. For
non-emergency cases, service standards vary and we publish such
data so that patients can choose the less busy hospitals. All
doctors who practice in the public sector will treat subsidized
patients. This is part of the ethos of public service which our
doctors feel strongly about.
23. As for physical provisions, the Ministry decides on the
distribution of beds among classes. The fact is that 80% of beds
in Singapore are in public hospitals and over 70% of public
hospital beds are heavily-subsidised B2 or C beds. In other
words, more than half of the patients treated in Singapore are
subsidised by the Government, to more than 65% of the cost. We
also have guidelines in place to ensure that public hospitals do
not spend on lavish fittings and renovations. But some renovation
is inevitable to enhance efficiency and to meet public
expectations. Nobody wants to be admitted to a run-down hospital.
24. Mr Low Thia Khiang asked if our hospital cluster system has
led to wasteful duplication and if integration has led to better
service level. One key objective of clustering is in fact to
facilitate better integration of care between hospitals and
polyclinics. This remains an important objective as I have
outlined earlier. We have made some progress integrating public
hospitals and polyclinics, but full integration requires us to
bring in the private GPs and the rest of step-down care
providers. So our journey to restructure and bring about
organisational change continues. Certainly, our hospital clusters
will make a big push on this front this year, but it will always
be work-in-progress. We must never be fossilised into a concrete
structure and become unresponsive to external changes and
expectations. Mr Low made an additional point for certain
specialities to be centralised. My view is that both
centralisation and de-centralisation are viable, but the solution
would depend on the nature of the particular speciality. Both
methods have their advantages and disadvantages.
25. At the end of the day, organisational structures are the means
to an end. Our mission is to serve patients, particularly those
in the lower half of the population. When a person falls sick,
what does he want out of our healthcare system? Two simple
questions: what is wrong with me? And what can you do to help me
recover?
26. Our job is to provide answers to these questions and do so in
a way which makes the total care experience for patients as smooth
as possible and does not bankrupt him or our society. But as I
stressed just now, patients too have a big part to play.
27. Mr Sam Tan spoke about Health Maintenance Organisations (HMOs)
which organised the GPs and then market their services to some
company employees. It is an idea imported from the US. I do not
how wide is their coverage but while we do not regulate HMOs, we
do regulate the doctors working for them. I am sure any attempt
by HMOs to cut corners will be resisted by our GPs as they have
high ethical standards. Companies should also chip in to ensure
that their employees do not get short-changed.
Market Transparency
28. Seventh: we will release even more information to
Singaporeans. We will measure and publish outcomes and
performance indicators, to increase market transparency and help
patients make better choices. NUH, KKH and SGH have recently,
through their own initiative, begun to publish clinical outcome
data on their respective websites. This is a first for any
hospital in Singapore, and I applaud their public commitment to
quality improvement and greater transparency. I will encourage
all our hospitals, both public and private, to publish outcomes
and benchmark themselves with international outcomes.
29. This will similarly apply to step-down care providers. My
Ministry is working with them to develop indicators to measure
their performance in service development, utilisation and clinical
quality. We will ensure that minimum care standards and patient
safety are met. For those who do not perform well, we will help
them improve their standards.
Empowering Patients
30. Eighth: we need to further empower our patients by engaging
them in their care and their care choices. Patient empowerment
led me to introduce the Medisave scheme for chronic diseases last
year. We know that chronic diseases account for the bulk of the
workload in public hospitals and the polyclinics. These diseases
will not go away and, if left unmanaged, will only get worse, not
suddenly but gradually over time.
31. Fortunately, medical science is now clearer on how to manage
these chronic diseases to minimise future complications. The
correct approach comprises 3 elements: (a) early detection; (b)
regular ongoing low-tech low-intensity treatment by Family
Physicians; and (c) good compliance by patients in changing their
lifestyle and habits. The wrong approach is to ignore these
diseases, persist with an unhealthy lifestyle, then when
complications emerge, rush into hospitals for high-tech,
high-intensity attention by multiple specialists, hoping for a
cure and a quick return to the same lifestyle. But there is no
such cure. It is wishful thinking. When a chronic illness is
still mild, that is the time to change your lifestyle and begin
treatment. If you wait, the complications are a lot harder and
much more costly to manage.
32. With the Medisave scheme for chronic disease management, I
hope to bring about a mindset change among our chronically ill.
Through Medisave, we have eased the financial burden. It is now
up to the patients to come forward and help themselves, to work
with their doctors to actively manage their chronic diseases. If
they do so, their health will improve. It can be done. In
small-scale pilots, we have seen such improvements among
participating patients. Through Medisave, we are scaling this
across the nation. Mr Low Thia Kiang asked about the cost of
treatment at the polyclinics. With early treatment for their
conditions, patient will incur lower costs in the long run. The
actual cost of their treatment is also dependent on their
conditions. With this structured programme, we hope to encourage
patients to avoid doctor hopping and for each Singaporean to have
one Family Physician.
33. Now that we have got over the implementation phase, we will
use this whole year to collect and analyse the outcomes. By next
year, we should be better able to answer some questions as posed
by Mdm Halimah and others: how do the various clinics perform in
terms of managing their patients' chronic diseases? How much do
they charge their patients and for what treatments? Are their
patients showing signs of improvement? I will be publishing these
outcomes so that patients can make better choices on which family
physician to visit.
34. Every patient should be given a personal health information
folder by his doctor on his chronic disease and what he should do
to improve his health. His health status should be regularly
tracked and charted, and explained to him by his doctor. If your
doctor does not do this for you, ask him why not. Suitably
empowered, I hope many patients will take their health more
seriously and work to improve on it. If we do it well, the
long-term impact will be significant. If it cuts down unnecessary
hospital care, it means major savings in dollars and human
suffering. Let us work to make it succeed.
SingaporeMedicine
35. Finally, let me touch on SingaporeMedicine, the strategy to
attract foreign patients to Singapore. This is an economic
objective, not a strictly healthcare mission. My advice to the
public hospitals is that SingaporeMedicine is not our primary
objective but a secondary and consequential outcome. Our primary
objective is to serve Singaporean patients, rendering good medical
care at competitive prices. That is our mission. But if our
standard is high and our prices are reasonable, Singapore is bound
to attract many foreign patients, as we always do.
36. Our regional neighbours have raised their medical standards
over the years. But we remain ahead of them, and should always
strive to stay ahead. If we do our job well in serving
Singaporean patients, we will always attract foreign patients. It
is a validation of the quality of our healthcare. We should
therefore factor in this reality when we make projections of
hospital beds, doctors, nurses and so on. If we do not do so, and
since we cannot prevent foreigners from coming here for treatment,
public hospitals and subsidised patients will get crowded out. If
nothing else, costs will go up because private hospitals poach
public sector doctors and nurses, pushing up wages. This is the
reason why we are stepping up foreign recruitment of foreign
doctors and nurses, even as we ramp up local training.
37. While we may see some visiting foreign patients in public
hospitals, the fact is that the majority of foreign patients go to
the private hospitals and clinics. 80% of foreign inpatients stay
in the private hospitals. Foreign patients make up less than 2%
of public hospital admissions. Ultimately, I agree fully with Mdm
Halimah that SingaporeMedicine must benefit Singaporeans, and must
not come at the expense of care for Singaporeans.
38. Mr Chairman, I believe I have addressed all the queries by
Members. I know Mr Low Thia Khiang spoke on HOTA. He was not in
this House when we had a full discussion on the SGH incident
brought up by Dr Lim Wee Kiak. In the interest of time, I do not
wish to repeat the points already made here last week, except to
say that we will learn from the SGH incident and try to do a
better job. We will certainly step up public education on organ
donation and brain death and help Singaporeans think about the
plight of those fellow Singaporeans on the waiting list. As I
said in this House, it is often the luck of the draw. We can
never be sure whether we may end up on the waiting list. Before
HOTA, we could only save 5 lives a year. After HOTA, we now save
a life a week. This is the reality of HOTA. HOTA is good both
for the dead and the living. But we respect the wishes of those
who want to opt out of HOTA. We will facilitate it. Every year,
about 2,500 opt out of HOTA. The number went up soon after the
SGH incident but has since come down to 80 a day. I respect the
wishes of those who opted out but I worry for the poor patients on
the organ waiting list.
From Good to Great
39. In conclusion, I acknowledge that our healthcare system is not
perfect. But it is actually not bad. My foreign counterparts
told me so. They would happily trade off their systems for ours.
40. But it can be better. Over the next few years, we will get
the pieces together and be better ready for the challenges ahead.
I thank Members for their continuing support and advice.
One Singaporean, one electronic
medical record (EMR)
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