Looking at Singapore, which is expecting its senior citizen population to double over the next two decades, it is encouraging to see the country taking huge strides in not just tackling its healthcare challenges, but also delivering better value in care.
According to research from Philips’ 2018 Future Health Index, Singapore recorded the highest value score of the 16 countries researched for the FHI report. Using connected care technologies like telehealth, HCPs in the country are increasing patients’ access to care. They’re also confident about this approach to drive change; 82% of HCPs in Singapore think that the healthcare available to patients meets their needs and 88% trust the country’s healthcare system.
What’s the secret to Singapore’s success? We spoke to Dr Joanne Ngeow, a Senior Consultant and Head of Cancer Genetics Services at the National Cancer Centre Singapore (NCCS), to get behind the stats and find out the inside story on Singapore’s healthcare system.
How far do you feel the health system in Singapore gives patients access to what they need?
The beauty of Singapore’s healthcare system is that it’s innovative on many fronts, particularly in terms of its payment model. Since patients are responsible for a portion of their healthcare, they have ownership over their care, and that in itself is very different from other countries. We are, however, very much focused on a reactive care model. When patients get sick, they have access to various diagnostic care and medications, but we are behind on the preventive care side.
There is a single electronic health record (EHR) in use across the whole country, which makes everything very well-tuned. One of the problems of the US healthcare system, for example, is that there are lots of different EHRs in use and they don’t necessarily talk to each other. In Singapore, any new program that a hospital wants to bring on board needs to be able to interface with a layer called Integrated Health Information Systems (IHiS), which allows EHRs across different hospitals to talk to each other.
How has that made a difference in how doctors handle patients – what’s easier now?
I belong to SingHealth, which is the largest public healthcare cluster but there are three others such as the National University Health System (NUHS) and the National Healthcare Group (NHG). Because of the universal EHR, I can look up the patient results and what has been done across all these clusters. In the past, I would have had to trace the notes from there, but today I can just click on it and I can see everything. It’s remarkable!
What’s the patient perspective on EHRs?
I think patients do like it as they don’t have to repeat what medications they are and other information as they go from one provider to the next. So I think in terms of the patient experience, there is a certain level of trust regarding their data on EMRs. There’s a recent article in the New York Times that talks about how doctors are so bogged down with the number of clicks and texts that they have to write that it’s affecting patient relationships – that I think is true in Singapore, too.
We haven’t studied the qualitative cost of implementing EHRs on doctor welfare, doctor engagement and how patients feel about doctor-patient time. My suspicion is that if we were to do those studies, they would show something similar to the experiences in the US, where there is some dissatisfaction amongst both doctors and patients that physicians are spending more time working on computers than with the people that need care.
Do you think this is a perception issue and the public in general needs to re-imagine what it expects of healthcare?
No, I’m a strong believer that as a physician the patients come first and our attention should be on the patients and not the computer. There has been an evolution in terms of the technology; the first generation EHRs were not designed with the patient-doctor interaction in mind – they were designed to help with information management.
In Singapore, we are tweaking the EHR continuously to make it easier for doctors to use and allowing them to spend more quality time with the patients. Neither patients nor physicians should accept anything less than a system which aids the patient-physician encounter rather than distracts from it.
What’s the state of connected care technologies in Singapore?
In Singapore, there are examples of home-based chemotherapy and patient monitoring, which mean patients don’t have to come to the hospital as often. At the moment, most of these projects are being piloted and proving successful so far. Where there needs to be parallel innovation is how healthcare professionals and the healthcare system get paid when there are more of these home-based services in use.
Other than that, these technologies are welcomed by doctors and patients, and it’s the right thing to do – I think there’s a lot of momentum behind it.
As a country, we are very tech-savvy – our smartphone use is extremely high – so it’s an ideal environment to adopt more mobile health programs.
Associate Professor Joanne Ngeow
Senior Consultant in Division of Medical Oncology, National Cancer Centre Singapore
What are the challenges of delivering healthcare in a country that is almost entirely urban?
Since we are an urban society where many of us work very long hours, we have an issue with people taking time off to come and see doctors. If we can perform more healthcare-related tasks remotely, especially if it’s a simple check like remote blood pressure monitoring, it’ll be really welcomed by patients.
As a country, we are very tech-savvy – our smartphone use is extremely high – so it’s an ideal environment to adopt more mobile health programs. There are lots of pilots and studies going on to see how this can help issues such as pain management, diabetes control and arthritis monitoring. Like all urban cities, chronic diseases such as diabetes and cancer remain big challenges. The public will need to be better educated about how to prevent and keep “well” in contrast to current practice of “reacting” to symptoms.
Are there any common challenges when it comes to implementing a new app or method of care delivery into the system?
Not every clinical leader understands that in order to get these things off the ground you need to present the data that will convince policymakers to implement new technologies. Everyone is interested in coming up with a product or a service, but no one is really championing how we can get these things implemented and used. That’s the biggest gap – and I think this is something Singapore has realized in the last five years.
Singapore has a Medical Technology Advisory Council that assesses which technology has significant impact and should be implemented. But until we have more people available to assess the utility and economics of each project, implementation will always be slow.
We also need to do a better job of educating medical students and medical residents on how to adapt to an era of technology-enabled healthcare. This is something not traditionally covered by medical schools globally but a critical need. We want a system of ‘high tech, high touch’ where patient care and comfort is not a casualty of technology and emphasized. We will need to teach our students and medical doctors how to do that.
Where do you think elements of the Singapore system could improve healthcare in other countries?
Having the IHiS is vital as it ensures that all the EHR systems speak to each other. In that sense, communication is generally easier amongst the different clinics, which is much more fragmented in other countries. For instance, in the US you might be at the best clinical centre, but if they needed to get a pathology report from across the road it’s quite a laborious process. However, IHiS will need to remain nimble, innovative and responsive to the needs of the health system or it risks becoming the problem rather than the solution it was designed to be.
In Singapore, we do connections very well and we have very strong partnerships between the industry and the academic and research institutions. We are much more integrated from a national perspective. Where we can learn and improve, however, is in preventative healthcare. I think we need to work hard in that area because not everyone is at the same level of risk from a preventative perspective, and different people require different levels of investigations depending on their genetic and/or lifestyle risk factors.