SINGAPORE (Mar 19): Nearly 20 years ago, Dr Eugene Loke and a few classmates from medical school began tinkering with a web-based personal health record system that put patients in charge of their information. “We wanted to empower patients,” Loke says of their early efforts. The system was adopted by a local public hospital and later acquired by a medical IT company. Loke spent five years with the company, novaSPRINT, designing electronic medical record systems for hospitals.
Today, Loke has left his IT endeavours behind and is a practising family physician at a private clinic in Serangoon Gardens. But he is not done with electronic health record systems just yet. Under the new Healthcare Services Act, scheduled to be enacted in phases beginning in the second half of this year, all licensed healthcare services providers are required to contribute to the National Electronic Health Record (NEHR). The new regulation will also cover traditional medicine practitioners, nurses and allied health services providers such as physiotherapists, dieticians and medical social workers.
General practitioners that The Edge Singapore spoke to are largely sceptical of the system, particularly on the issue of data privacy. Loke says dialogue sessions at which ministry representatives met doctors to discuss the NEHR were rather heated. Nonetheless, he says he is impressed with the ministry’s efforts to engage with healthcare professionals.
Another issue is how the national record database will integrate with clinics’ existing information management systems. “We are asking for more details,” Loke says. Apart from software compatibility, challenges could arise from different doctors having different ways of referring to a specific condition. Also, some clinics or healthcare establishments would not have digital records at all.
“The creation of a national health record is an ideal state,” says William Chew, founder and managing director of myHealth Sentinel. “[But] harmonising all the data in different repositories is a gargantuan task.” His telehealth company aggregates, filters and integrates patient device data with electronic medical record systems.
Chew reckons it will take a decade or more for the system to be fully implemented. Over time, he says, the amount of health-related data per patient is sure to increase. “The challenge for healthcare systems is how to deal with the large increase in the volume of data [from wearables],” he adds.
Dr Beng Teck Liang, CEO of specialist clinic network Singapore Medical Group, brings up the issue of costs. “How much has the government already spent to establish this? How much more is it going to cost, and who’s going to pay for it? Are we going to pay for it? Is the government going to help us pay for it? These are real questions we have to address” he says. Nevertheless, he is “very supportive” of the initiative and “very curious to see how it pans out over the next few years”
Providing better care
The NEHR was first mooted in 2009. In 2010, Accenture was awarded the tender to develop it with partners that included Oracle It was launched in 2011 and progressively deployed across public and private healthcare institutions. But up until the end of last year, only 3% of private healthcare providers were participating, according to Integrated Health Information Systems, the national agency that manages the NEHR.
The government stresses that NEHR is a secure system and is now mandating its use to collect patient health records across different healthcare providers. This data can then be accessed by the doctors and therapists caring for the patients. The information collected is likely to include laboratory results and diagnoses, surgical history, prescriptions and case notes.
In initiating such a system, the government intends for doctors and other healthcare professionals to take a “holistic and longitudinal view” of an individual’s medical history. The data on the NEHR system is protected according to “industry best practices”, and healthcare professionals authorised to access the data “are bound by law and professional ethics” to keep those records confidential. Access will be logged and audited.
There will be an opt-out provision for patients, although the Singapore Medical Association has raised objections to the way this provision is being implemented. In a letter to the Ministry of Health in March last year, SMA pointed out that a patient’s medical record remains in the database even if they opt out. Doctors and other carers are merely unable to access these records. Also, to opt out, a patient would have to approach staff at a public health institution. According to an MOH brochure, these patients would then be counselled on the implications of doing so.
SMA says patient privacy needs to be distinguished from confidentiality. Confidentiality refers to privileged communication between a patient and his doctor, which cannot be shared with third parties without expressed consent of the patient. And, in SMA’s view, only when patients’ privacy rights are addressed can their confidentiality rights then be accommodated.
There have been cases of unauthorised access to patients’ data by healthcare professionals, SMA points out. In February last year, for instance, a plastic surgeon was fined for unlawfully accessing a patient’s data stored in the Singapore General Hospital system. “Even though a doctor or healthcare professional can be punished for accessing a patient’s records without valid justification, such measures are punitive and retrospective in nature, after the transgression and damage has already been done,” says SMA’s letter, which was signed by SMA president Dr Wong Tien Hua.
Privacy, which is more fundamental than confidentiality, refers to the right of the individual patient to be left alone and to make decisions about how personal information is shared. SMA proposed, in its letter, that patients be given the option to forbid the updating of their information in the NEHR. “In an era of increasing patient awareness, sophistication and empowerment as well as rapid technological advancement, SMA advocates that patients be allowed to decide for themselves what information they wish to reveal to which healthcare provider and that control be imposed prospectively. In such a manner, a patient’s confidentiality rights and needs can be addressed with more finesse and measured control.”
Evolving patient attitudes
In the UK, it was reported that a patient record system for the National Health Service was abandoned after chalking up nearly £10 billion in costs. Among the reasons cited for its failure were changing specifications, technical challenges and disputes with suppliers. Industry watchers expect that Singapore’s small size, coupled with the government’s power to legislate this initiative, makes the NEHR more likely to succeed.
It could also be very useful, given that in Singapore people have the option of seeing different doctors in both the public and private sectors. This means that a new doctor would not be “blind” to what preceded that particular visit, Chew of myHealth Sentinel points out.
Loke, the physician, says that ultimately “challenges are not an excuse for not moving forward” The healthcare sector has been comparatively slow in adopting IT, but that has to change as patient attitudes change.
“The model has shifted. It used to be that the doctor knows better; but in the last 10 years patients [have been] coming in expecting discussion,” he says. Last May, the Court of Appeal in Singapore used a new legal test to determine whether a doctor had been negligent. Previously, all aspects of a doctor’s duty were assessed according to a single legal test known as the Bolam test, which looked to whether there was a body of other doctors who considered the defendant doctor’s course of action to be acceptable
However, the court noted that patients now have access to more information and expect to participate more actively in consultation with a doctor. The court therefore applied a modified version of the Montgomery test to determine if a doctor had properly discharged his duty of providing advice. The test considers whether the patient is getting useful medical information, whether a doctor is negligent in not obtaining information and whether a doctor is justifiable in withholding information.
“The doctor’s responsibility is not to make the decision but to provide all the information so that the patient can make an informed decision,” Loke explains. Whether the NEHR accommodates this shift towards patient autonomy remains to be seen. But the patient-centric health record system Loke and his classmates built at the turn of the millennium now seems particularly timely. “We were far ahead of our time.”
This article first appeared in Issue 822 (Mar 19) of The Edge Singapore which is on sale now
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