Dean Koh

Professor of Radiology, Mayo Clinic College of Medicine and Chair of Clinical Systems Oversight Subcommittee, Mayo Clinic, Dr. Patrick H. Luetmer shared in an email interview with Healthcare IT News some key takeaways behind the success of the Plummer project. The massive EHR rollout project at Mayo Clinic was named in honour of Dr. Henry Plummer who developed a patient-centred health record at Mayo in 1907. Mayo Clinic has achieved a historic milestone with the final Epic implementation in Florida and Arizona in October 2018. With that, all Mayo locations are now on a single, integrated electronic health record and revenue cycle management system. Could you tell us about your involvement in the Epic implementation across Mayo Clinic’s 90 hospitals and clinics, which started in July 2017?  The Mayo Clinic journey to a single, integrated electronic health record and revenue cycle management system, a key component of a long term strategic practice convergence plan, began with an EHR task force in 2009/2010 which focused on interoperability with a two vendor, three EHR system.  The journey accelerated in the Spring of 2013 when we learnt that the EHR vendor supporting our Rochester destination practice was planning to end support of our Rochester legacy EHR.  I was the physician responsible for governance of our Rochester EHR and I played an active role in assessing the readiness of Mayo Clinic to pursue a converged single EHR. In the October 2013, we received Board of Governors endorsement and launched an EHR vendor assessment.  I played an active role in the RFI/RFP process and site visits.  In February 2015, we received Board of Trustees approval confirming selection of Epic as our vendor partner and we launched the Plummer project with a four phase implementation strategy beginning with “big bang” conversions of all of our Wisconsin Mayo Clinic Health System (MCHS) sites followed by our Minnesota MCHS sites, then our Rochester Destination practice and finally our Florida and Arizona destination practices.  During the project, I served on the Plummer project steering group as well as provided governance of the legacy Rochester EHR through the Rochester go live in May 2018. I now serve as chair of our enterprise clinical systems oversight committee which is responsible for the ongoing governance of our converged EHR and well as departmental clinical systems. During the organisation-wide movement to Epic, what do you think were the key factors in the successful implementation of the Epic EHR in a relatively short amount of time? Key project success factors included: Extensive practice convergence in the years prior to project kickoff. Many enterprise practice groups were actively working to converge to a single high value practice and the lack of a single converged EHR was recognized as a barrier to convergence. The Plummer project was viewed as part of a solution to allow convergence, not as the sole driver of convergence. Those areas most actively engaged in practice convergence prior to the project tended to do the best with the project. Utilisation of a formal change management program with comprehensive activity for all levels of staff was critical as every staff member experienced significant workflow changes. A talented core implementation team with limited turnover Appropriate project resourcing, clear strategic priority of organisation, full engagement of leadership at all levels and sites.  It was evident to all in the organisation that this was a top practice priority for three successive years. Strong support and collaboration from Epic.  A formal lessons learned process with rigorously tracked follow-up allowed project improvements which enhanced each successive implementation. Rigorous tracking of co-dependent projects and careful management of a separate team to support legacy systems ensured system stability prior to and during cutover and go lives. What tips or advice would you give to healthcare organisations looking to carry out a system-wide implementation of a new EHR? A new EHR will impact the workflow of every physician, nurse and allied health care provider. The success of the project will depend on the adoption of the system by these providers and their full engagement is critical.  They need to understand and endorse the need for change. They need to be actively involved in system configuration, workflow analysis, training and personalization and ongoing refinement of the system. As a trained radiologist yourself, what were some of the improvements to workflows with the implementation of Epic? Our legacy environment relied on interoperability of interfaced systems with disparate legacy databases. The Epic Radiant module provides a radiology specific view of the single Epic database. This provides a substantial advantage. Radiology order details, exam protocol and technologist note details, provider notes, labs and patient correspondence are just a click away.  Care Everywhere allows the radiologist to quickly review reports from prior exams performed at other health care organizations. The Radiant RIS driven workflow allows prioritization of the reading list by a “reading priority score.” A cumulative weighted score including factors such as ordering priority (stat vs routine), patient class (such as intensive care unit, emergency department, outpatient), exam indication (such as stroke or trauma), patient clinical status (hypotension, other clinical or lab elements) time elapsed since end exam and time to next appointment can be calculated to present the radiologist with the most important case to review next.  Critical test result management is enabled within the RIS workflow simplifying both provider notification and documentation of critical test result communications. As an academic radiologist, feedback to trainees on preliminary reports has been enabled within the RIS workflow improving both quality and timeliness of trainee education. Dr. Luetmer will be at the HIMSS Singapore eHealth & Health 2.0 Summit on April 24 2019 to share about the key lessons learnt from the massive EHR rollout. In particular, he will emphasise the importance of rigorous tracking of co-dependent projects and careful management of a separate team to support legacy systems prior to go lives. Keen to explore more about the lessons learnt from the Plummer Project? Sign up here to enjoy early bird rates for the upcoming HIMSS Singapore eHealth & Health 2.0 Summit held from April 23-24 2019!

Last Wednesday (February 20), President Rodrigo R. Duterte of the Philippines officially signed the Universal Health Care (UHC) Act into law, which guarantees equitable access to quality and affordable healthcare services for all Filipinos. It will also automatically enroll Filipino citizens into the National Health Insurance Program and expand PhilHealth coverage to include free medical consultations and laboratory tests. Aside from the automatic enrollment of all Filipinos to PhilHealth, other significant reforms that will be implemented over time include: designating PhilHealth as the national purchaser for health goods and services for individuals, such as medicines; improvement of health facilities especially in underserved areas; responding to the gap in health workers throughout the country; strategic engagement of the private sector; and creating and expanding new functions in the Department of Health (DOH) to improve the delivery of health services, according to an official statement by the DOH. Presidential Spokesperson Salvador Panelo said the UHC program may be implemented “gradually” since Congress has yet to draft a final bill raising tobacco taxes. Last month, the House Committee on Health in the Philippines House of Representatives chaired by Rep. Angelina Tan approved a substitute bill seeking to establish the National eHealth Systems and Services that shall deliver health services through cost-effective and secure information and communications technology (ICT). The bill seeks to utilise ICT to deliver health services which has the potential to be profitable, improve quality, change the conditions of practice, and improve access to healthcare, especially in rural and other medically underserved areas. With the approval of the National eHealth System and Services Act and UHC being signed into law, the Philippines has a monumental task of delivering accessible, quality healthcare services to all its 105 million citizens. Some have criticised the UHC as a political gimmick but the true challenge for its successful delivery cannot rely on the sole commitment of state authorities: it must also seek the cooperation and collaboration from private healthcare players and even tap on the capabilities on the burgeoning health tech industry.

Dr NT Cheung has been the Chief Medical Informatics Officer (CMIO) of Hong Kong’s Hospital Authority (HA) for the past 26 years. The HA is a statutory body established under the Hospital Authority Ordinance in 1990 and has been responsible for managing Hong Kong's public hospitals’ services since December 1991. As the CMIO, Dr Cheung has been key in driving the IT transformation of the organisation from one which began with a very rudimentary use of IT in the 1990s to one which is able to continuously roll out new initiatives, very quickly and at a high degree of standardisation not just to improve the work processes of clinicians, but ultimately for the benefit of patients under their care. “Looking forward on healthcare - the pressures on healthcare, which all of us share in any advanced economy now, it's the same, which is that people live longer, you have more chronic disease, you have more demands, and healthcare people expect more and your healthcare manpower is not growing at the same pace.  You can't just keep on doing more and more healthcare in the old way, you have to change the way that you are doing it – you have to change your service models, you have to add significant amounts of automation to this very labour-intensive sector of the industry. And so again, that's what health IT is able to deliver. And there are very few other options to be honest. So it's becoming an increasingly important part of getting us into a more sustainable model for the whole healthcare in the future,” Dr Cheung explained. HA’s Clinical Management System (CMS) – 1990s till present Currently in its fourth generation, the CMS at HA started off modestly in the 1990s with convincing the frontline to start using these tools with a very basic digitalisation of hospital wards. By the year 2000, the second phase of development for CMS began when HA linked together the various hospitals, as well as linking the outpatient and inpatient records together. More tools were also built to support the healthcare process with features such as order entry and rudimentary forms of decision support. Phase three of the CMS was about rebuilding the entire platform to a more modern one which allowed for a much greater integration/standardisation across the board. “So from CMS two, we had this integrated electronic record but in terms of functionality and functional modules, they were all pretty much stovepipes and they would then contribute data into the central repository but they were separate stovepipes. So CMS three was trying to build it as a platform using the then newest technology of putting the applications on the server side rather than the client side of approach, and then build that platform using a more modern Java-based platform,” Dr Cheung said. The fourth phase of development of the CMS has a ring to it – with a slogan called the 5Ps approach: Paperless – Dr Cheung shared that the HA has hit an inflection point where in many cases, the paper workflows are now going to be more cumbersome than the digital workflows that they can now design, Protocol-based – introducing clinical intelligence from people, guidelines, websites, books into the CMS Closed looP - in a very complex workflow like a high volume hospital, things get missed out, the loop does not get closed because nobody can keep track of everything all the time. Communication tools at the clinical side will be strengthened to make sure everything is followed up and the loop is closed. Personalised - to allow for a greater degree of personalisation for every single individual user across different hospitals, depending on their particular situation. Patient-centricity - a reminder that the patient is still the centre of the healthcare universe. A unified patient app One of the five portfolios under HA’s IT 5-Year Strategic Portfolio is Enhanced Patient Experience & Outcome, which focuses on new patient-centric service models with disruptive technology. Dr Cheung said that one of the key deliverables that HA is working on now is a unified patient app. HA has been releasing patient apps since 2011 and a portfolio of apps have been built but there are simply too many apps for patients to keep up with. “We are building a single patient app that we call HA GO - it does several things more than the previous collection of apps. So first of all, it's a one stop shop. So you would download the single app from HA, and then you would register as an app user once and all the apps will know who you are. Secondly, it functions as a conduit - it's not just a collection of little apps, it is a framework for allowing your health care which is delivered in the hospital or clinic to extend out to the rest of your life when you're in the community or at home,” he added. The HA GO single patient app is slated to be launched this year with a modular design consisting of ‘mini apps’. For instance, diabetic care would be a mini app and the app will be pushed to the phones of diabetic patients who need it.

Last week, BC Platforms, an MIT Whitehead project spinoff which specialises in powerful genomic data management and analysis solutions, announced that it will be providing its genomics platform to Bumrungrad International Hospital, a private multiple-specialty medical centre founded 1980 in Bangkok, Thailand. WHY IT MATTERS BC Platforms will be providing its customisable end-to-end Software-as-a-Service (SaaS) platform to enable Bumrungrad to offer personalised healthcare solutions for their patients in the clinic. The core system will be seamlessly integrated in the hospital infrastructure from laboratory to electronic patient records. To support advanced patient care, the ability to handle all types of genetic data from Genotyping and Next Generation Sequencing (NGS) instruments into clinical reporting is essential. Bumrungrad will also participate in providing its extensive Asian data and samples to BCRQUEST, providing additional sample diversity and data resources for researchers. BCRQUEST is a global network of healthcare service providers and biobanks that provide genomic and clinical cohort data for pharmaceutical and medical research and development. THE LARGER TREND Precision medicine, of which genomics is a subset of, was a key topic addressed at the recently concluded HIMSS19 Precision Medicine Summit. At the event, Dr. John Halamka, CIO of Beth Israel Deaconess Medical Centre, said that precision medicine, at its core, is "the right care in the right setting from the right provider at the right time." Data – structured, complete, well-governed and easy to see – will be key to precision medicine becoming more widespread and Dr. Halamka added that on the precision medicine journey, having the data accessible is going to be hugely important. He also pointed out that besides technology, there are also other challenges such as "interesting politics and policy issues that are part of the precision medicine journey.” While precision medicine offers huge promises, policy, technology, clinical processes and patient engagement need to evolve to make it a reality for primary care. ON THE RECORD “We are excited to be partnering with BC Platforms to bring personalized healthcare solutions into our clinical practice and research. We are looking forward to working with BC Platforms to set a new standard for predictive medicine complementing conventional treatment for our patients and clients across the globe,” said Artirat Charukitpipat, Chief Executive Officer at Bumrungrad. Tero Silvola, CEO of BC Platforms, said, “We are pleased that Bumrungrad has chosen to adopt our genomics platform for their clinical practice and to benefit research. We aim to build comprehensive collaboration programs with Bumrungrad to facilitate projects where patients will benefit from the latest innovations and thereafter gain access to clinical trials relevant to their individual disease status. Bumrungrad is one of the largest healthcare providers in South East Asia and by contributing their data mainly focusing on Asian haplotypes to BCRQUEST we can greatly improve the diversity of our offering to research organisations worldwide.”

Due to an error in the software administered by NCS Pte Ltd., about 7,700 individuals received inaccurate healthcare and intermediate and long term subsidies, said the Ministry of Health (MOH) on Feb. 16, 2019. The individuals affected were those who had their Community Health Assist Scheme (CHAS) card applications and renewals processed from Sept. 18 to Oct. 10, 2018. CHAS enables Singapore citizens from lower to middle-income households and all Pioneers* to receive subsidies for medical and dental care at participating GP and dental clinics near their home. Specifically, the error occurred in the computer system when it calculated means test results. MOH said it is working with healthcare service providers and scheme administrators to reach out to the affected individuals. About 1,300 of them who received lower subsidies will have the difference reimbursed to them and another 6,400 individuals received higher subsidies due to the error. However, they do need to return the additional subsidises disbursed. The means-test system calculates the healthcare subsidies which individuals are eligible for, based on their income information. Timeline of key events (as stated by MOH and NCS) Sept. 24, 2018 : First means test discrepancy was detected by CHAS processing team and incident reported to NCS. Oct. 10, 2018 : Software version issue detected was fixed. Oct. 10 to Nov. 29, 2018 : 5 more cases of inaccurate means-test results were detected, NCS applications support team investigated since Sept. 24 but could not pinpoint the root cause. MOH was informed. Nov. 29 - Dec. 5, 2018 : MOH and NCS worked together to assess the impact to individuals and the extent of impact was assessed to be thousands of individuals, and scheme beside CHAS. Jan. 14, 2019 : Correct subsidy tiers for each scheme were generated and provided to MOH. Jan. 18, 2019 : Measures were implemented to contain impact on non-CHAs schemes. Feb. 10, 2019 : Number of unique individuals affected all schemes were determined. Feb. 16, 2019 : Subsidy tiers of affected individuals were fully corrected and affected individuals were to be progressively informed. Reimbursements to commence. MOH expects all the affected individuals to be informed by mid-March 2019. Just last month, MOH announced that the confidential data of 14,200 individuals with HIV were illegally leaked online and the information is in the possession of American Mikhy K Farrera Brochez, who used to reside in Singapore. A police report was made and investigations are still pending. *The ‘Pioneer Generation’ is defined as living Singaporeans who meet 2 criteria: i. Aged 16 and above in 1965 (born on or before 31 Dec 1949, which also means they are aged 65 and above in 2014); and ii. Obtained citizenship on or before 31 Dec 1986.

In October 2018, Mayo Clinic achieved a historic milestone with the final Epic implementation in Florida and Arizona. The epic (pun intended) implementation of Epic across the Mayo Clinic’s network of 90 hospitals and clinics began in July 2017 when 24 of its sites in Wisconsin went live. Subsequently, campuses in Minnesota went live in November 2017, followed by Mayo’s Rochester facility in May 2018 and finally in Arizona and Florida. The Epic EHR rollout at Mayo Clinic was dubbed the Plummer Project in honour of Henry Plummer, MD, who developed a patient-centred health record at Mayo in 1907. While the movement to a single Epic EHR and revenue cycle management system to replace 3 separate EHR instances, multiple disparate revenue cycle systems and a total of 287 applications was impressive from a technical and execution standpoint, what was more impressive was the training of 51,000 Mayo Clinic employees to be onboard the Epic system. Mayo Clinic has a total of 65,000 employees of which 51,000 had to go through training in Epic as it was essential for their day-to-day duties and operations. Dr. Steve Peters, co-chair of the Plummer Project, shared lessons learnt from the EHR rollout in a Mayo Clinic Radio video in July last year: “We’ve learn a lot from the earlier implementations – we’ve modified the training and made it more focused to the tasks or some of the scenarios that an individual needs. We’ve increased the number and the training of the super-users – those are individuals embedded in the practice whether it’s a physician, nurse or desk staff who help to understand the local workflow rather than just how they navigate the tool. We then fine-tune where more support would be needed and which types of workflows. For example, moving from one setting to another from an outpatient to inpatient or emergency room to an interventional radiology procedure to the operating room, these are opposed kind of special challenges where we can focus some of the training and some of the build-up of Epic so that it is more easily done.” Dr. Patrick H. Luetmer, chair of Clinical Systems Oversight for Mayo Clinic, responsible for governance of the converged Epic electronic health record and of clinical departmental systems will be at the HIMSS Singapore eHealth & Health 2.0 Summit on April 24 2019 to share about the key lessons learnt from the massive EHR rollout. In particular, Dr. Luetmer will emphasise the importance of rigorous tracking of co-dependent projects and careful management of a separate team to support legacy systems prior to go lives. Keen to explore more about the lessons learnt from the Plummer Project? Sign up here to enjoy early bird rates for the upcoming HIMSS Singapore eHealth & Health 2.0 Summit held from April 23-24 2019!

Northland and Auckland district health boards (DHBs) have been given the green light for the long-awaited upgrade to their clinical record portal, according to an official release by healthAlliance, the Northern region’s shared IT service provider. The two DHBs’ current system, Concerto 6, will be replaced with the latest version of Orion Health’s clinical record viewing software Clinical Portal 8 by early 2020. The project follows the successful implementation of Clinical Portal 8 at Counties Manukau and Waitematā DHBs in 2018. WHY IT MATTERS It will result in a single, connected clinical viewing system that will deliver a patient-centric record accessible from any Northern region DHB location, including authenticated health providers. Clinical Portal 8 is a patient-centric dashboard to view health information. It includes medical alerts, radiology and laboratory results, clinical history and patient movements from a variety of clinical applications. Once rolled out at Northland and Auckland DHBs there will be 24,700 users in the region supporting a population of 1.8 million people. For the many clinicians who work across one or more DHBs, the user experience will be consistent regardless of location, and their access to information will improve. Underlying infrastructure upgrades will also provide more resilience, while single sign-on functionality means it will be faster and easier for clinicians to access patient data. The upgrade projects are being managed by healthAlliance in collaboration with the DHBs and technology provider, Orion Health. THE LARGER TREND In December 2018, a national group was formed to start work on linking New Zealand’s four regional clinical portals, with approval from the DHBs chief information officers. The group is being led by Stella Ward, chief digital officer at Canterbury DHB. If successful, the project would allow any clinician involved in a patient’s care to view that person’s computerised health data from anywhere across the country. New Zealand’s 20 DHBs are grouped into four regions that each have a shared view of their region’s patient information via Clinical Portal 8 from Orion Health. Of the 20 DHBs, three are not yet using their regional shared portal, but all have imminent plans to move on to one. ON THE RECORD Project sponsor and Northland DHB General Manager, Medicine, Health of Older People, Emergency & Clinical Support, Neil Beney, says the regionally-connected clinical portal will form the largest patient information ecosystem in New Zealand. “It will facilitate better sharing of patient information within and between the Northern Region DHBs and across care providers. It will also provide a better way for clinicians to follow their patients’ journey across all care settings.” healthAlliance Chief Clinical Information Officer Dr Karl Cole says the upgrades are part of the foundational work of the region’s IS Strategic Plan (ISSP) which aims to join up the DHBs through technology and prepare them for a rapidly advancing digital future. “A modern regional Clinical Portal is a key enabler for improving patient care in our communities so it’s a very exciting time,” Cole says. “Once implemented, it will mark a significant milestone toward a more connected health system in our region.”

In May 2018, Health Minister Dr Dzulkefly Ahmad said that the Health Ministry will be setting up an independent Health Advisory Council within 100 days to advise the ministry on strengthening healthcare delivery. The Health Advisory Council was finally established in January 2019 and “several private hospitals have expressed their wish to cooperate (with the Health Ministry)”, according to Dr Dzulkefly when he visited Ampang Hospital, a government hospital yesterday. He also added that the public-private healthcare collaboration would help public hospitals, in particular, to tackle various issues like shortage of specialists and facilities as well as heavy workload and rising cost of treatment. The Health Advisory Council’s role is to generate ideas towards empowering the nation’s healthcare system as well as assisting the government in formulating a new direction that will steer the Health Ministry to provide world-class services. Dr Dzulkefly also urged the public to undergo early screening and detection tests for cancer as the disease had become the second highest cause of death among the people in Malaysia. He said in an article by The Sun Daily that an estimated 60% of cancer cases in the country are detected at late stages, either at Stage III or IV. Last November, Dr Dzulkefly announced that the Ministry of Health is committed to ensuring that the electronic medical record system (EMR) can be realised within three years at 145 hospitals nationwide, as a way to improve the country's health service to a better level.

Yesterday, Orion Health announced a commercial agreement with Abu Dhabi Health Data Services, a new project company established as part of the Public Private Partnership (PPP) between the Department of Health-Abu Dhabi (DoH) and Injazat Data Systems, a subsidiary of the Abu Dhabi government-owned Mubadala Investment Company, to deliver a Health Information Exchange (HIE) platform. The HIE will be known as "Malaffi" and is the first of its kind in the Middle East. "Malaffi" will provide a platform that will centrally store and enable the meaningful exchange of patient health information between healthcare professionals and will ultimately connect 2,000 public and private healthcare providers in Abu Dhabi. Officially launched last week on 23 January, “Malaffi” is initially joined by six Abu Dhabi healthcare organizations, including SEHA (Abu Dhabi Health Services Company), Cleveland Clinic Abu Dhabi, Imperial College Diabetes Centre, Healthpoint, United Eastern Medical Services (UEMedical) group and Oasis Hospital, Al Ain. The access to the centralised patient records will provide physicians with a tool to make well informed, fast decisions, enhance patient safety, reduce the duplication of diagnostic procedures and ultimately improve the quality of care and outcomes. “The Department of Health-Abu Dhabi has recognised the need to centrally and efficiently, store, exchange, and analyse the enormous amount of data that is being created in healthcare every day, and by using advanced technologies, such as Artificial Intelligence (AI) and machine learning, to drive the digital transformation of the healthcare system, for a happier and healthier Abu Dhabi. The partnership with Orion Health, will enable us to deliver a best-in-class HIE platform, that will guarantee the success of connecting all Abu Dhabi healthcare providers, and place Abu Dhabi on the top of the global map of successful HIE implementations," said Atif Al Braiki, CEO of Abu Dhabi Health Data Services. “Orion Health is delighted to be selected as the partner of choice, to deliver UAE’s first HIE platform,” said Ian McCrae, CEO of Orion Health.

Earlier this week, the Ministry of Health (MOH) in Singapore made an announcement that confidential information regarding 14,200 individuals diagnosed with HIV up to January 2013, and 2,400 of their contacts, has been illegally disclosed online and is in the possession of an unauthorised person. This was yet another serious case of data breach in the healthcare system following the SingHealth cyberattack which happened in June to July last year with 1.5 million patient records being illegally accessed. A Committee of Inquiry (COI) was quickly formed and its findings were published earlier this month. For the case of the HIV data leak, MOH was alerted by the police on 22 January and the Ministry made a police report on 23 January. On 24 January, MOH ascertained that the information matched the HIV Registry’s records up to January 2013.From 24 to 25 January, MOH worked with the relevant parties to disable access to the information. The records were those of 5,400 Singaporeans diagnosed with HIV up to January 2013 and 8,800 foreigners (including work and visit pass applicants/ holders) diagnosed with HIV up to December 2011. The information included their name, identification number, contact details (phone number and address), HIV test results and related medical information. The name, identification number, phone number and address of 2,400 individuals identified through contact tracing up to May 2007 were also included. Background The confidential information is in the illegal possession of Mikhy K Farrera Brochez, a male US citizen who was residing in Singapore, on an employment pass, between January 2008 and June 2016. Brochez was remanded in prison in June 2016. He was convicted of numerous fraud and drug-related offences in March 2017, and sentenced to 28 months’ imprisonment. The fraud offences were in relation to Brochez lying about his HIV status to the Ministry of Manpower, in order to obtain and maintain his employment pass, furnishing false information to Police officers during a criminal investigation, and using forged degree certificates in job applications. Upon completing his sentence, Brochez was deported from Singapore. He currently remains outside Singapore. Brochez was a partner of Ler Teck Siang, a male Singaporean doctor. As the Head of MOH’s National Public Health Unit (NPHU) from March 2012 to May 2013, Ler had authority to access information in the HIV Registry as required for his work. Ler resigned in January 2014. He was charged in Court in June 2016 for offences under the Penal Code and the Official Secrets Act (OSA). In September 2018, Ler was convicted of abetting Brochez to commit cheating, and also of providing false information to the Police and MOH. He was sentenced to 24 months’ imprisonment. Ler has appealed, and his appeal is scheduled to be heard in March 2019. In addition, Ler has been charged under the OSA for failing to take reasonable care of confidential information regarding HIV-positive patients. Ler’s charge under the OSA is pending before the Courts. According to an article by The Straits Times, it is understood that Ler no longer has a certificate to practise medicine in Singapore and no longer has access to the confidential information of patients in the National Electronic Health Records (NEHR), which includes all public-sector patients. Timeline of events leading up to the leak May 2016 - MOH had lodged a police report after receiving information that Brochez was in possession of confidential information that appeared to be from the HIV Registry. Their properties were searched, and all relevant material found were seized and secured by the Police. May 2018 - After Brochez had been deported from Singapore, MOH received information that Brochez still had part of the records he had in 2016. The information did not appear to have been disclosed in any public manner. MOH lodged a police report, and contacted the affected individuals to notify them. 22 January 2019 - MOH was notified that more information from the HIV Registry could still be in the illegal possession of Brochez. On this occasion, he had disclosed the information online. What could have happened This incident is believed to have arisen from the mishandling of information by Ler, who is suspected of not having complied with the policies and guidelines on the handling of confidential information. Additional safeguards in disease registries Since 2016, additional safeguards against mishandling of information by authorised staff have been put in place. For example, a two-person approval process to download and decrypt Registry information was implemented in September 2016, to ensure that the information cannot be accessed by a single person. A workstation specifically configured and locked down to prevent unauthorised information removal was designated for processing of sensitive information from the HIV Registry. The use of unauthorised portable storage devices on official computers was disabled in MOH in 2017, as part of a government-wide policy.