Dean Koh

Military health leaders from Australia, Singapore & the UK came together at the inaugural International Military Health IT plenary at HIMSS AsiaPac 18 in Brisbane to discuss the key challenges in their respective military health systems.

The HIMSS AsiaPac 18 Conference in Brisbane officially started today with an opening plenary, Leadership Voices: Healthcare Anytime, Anywhere featuring five healthcare leaders and experts with experience from different parts of the globe. Dr Charles Alessi, Chief Clinical Officer, HIMSS, the moderator of the panel started with an opening question to the panelists – what are the drivers and challenges of healthcare? Dr Manish Kohli, Senior VP and Chief Medical Information Office (CMIO), Aurora Healthcare and Chair, Global Board of Directors, HIMSS said that from his experience in the US and bringing a Cleveland Clinic to Abu Dhabi, healthcare systems around the world are struggling with the same issues – providing quality care, ensuring accessibility to care, reducing costs of care, enhancing the clinician experience as well as the patient experience. “Another challenge in healthcare that is consistent across the globe, specifically in Western countries, India and China with large populations is that of the silver tsunami – an ageing population. They bring with them the wonderful benefit of extended lives but this also means that they are living with diseases longer,” said Hal Wolf, President & CEO, HIMSS, USA. He added that a tremendous amount of healthcare resources is being consumed and about seven to ten percent of the population is consuming 80 percent of the resources, and with it comes funding challenges: “We not have a clear pathway to be able to sustain the encounter-based (healthcare) paradigm that we have grown up with. We will not be able to build enough hospitals fast enough.” There is also the issue of a 7.2 million global workforce gap for the healthcare industry, according to the World Health Organisation (WHO). On a more positive note, Hal said that currently the healthcare industry has access to technological tools like never before but of course the healthcare information must be available first – the information can be used to provide better health outcomes but this needs to be balanced with privacy concerns in place. CEO and CIO of eHealth Queensland, Australia, Dr Richard Ashby, was convinced and optimistic of the objective benefits brought about by rolling out digital health initiatives in Queensland. Seven to eight percent of hospital costs around the world in first world countries are caused by adverse events that are largely predictable and preventable. “We are seeing the reduction of these preventable adverse events through the digitisation of healthcare, streaming data and giving clinicians data about what they have done and what they have not done. For instance, digitisation was reducing the length of hospital stays by six to nine percent. Translate that across Queensland and that is one less 700-bed hospital that we have to build,” said Dr Ashby. However, in the context of Australia, he said that a real challenge is to address and provide for the health of the rural and indigenous communities, which are 600 or 700kms away from the urban areas. This is where mobile health initiatives such apps to help with eating disorders can be useful to address some of these challenges, for instance. Sharing examples of consumer-direct health apps in China, Dr Jenny Shao, Health Information System Director, United Family Healthcare (UFH), Chair, HIMSS Asia Pacific Governing Council said that the whole healthcare industry in China is very much driven by the central government, so every reform and launch of a new platform or technology is usually directed by the government. One of these examples is that a person living in an urban city in China can easily grab his/her phone with Internet access, open up an app and talk to the phone about his/her medical condition. The person will be guided to a list of doctors, he/she can pick one from the list, the physician’s face will appear on the screen and the consultation begins! If a prescription is needed after the consultation, the medication will get delivered to the person’s doorstep within half an hour or an hour, depending on traffic conditions. This is happening right now in China and no longer a dream, truly working towards the conference theme of “Healthcare Anytime, Anywhere”. Another platform that was launched by the government in Shenzhen city, in the Southern part of Guangdong, requires residents to sign up with their GPs online. As long as the resident signs up, he/she will have a dedicated GP who will provide services to him/her, such as medical check-ups and referrals. The GPs will even check for alerts from the wearable devices of the resident. A dedicated physician will provide the resident with education on chronic diseases as well as helping him/her with the self-management of his/her health. This is currently in use in China for both younger tech-savvy consumers and also for older people to help them manage their chronic health conditions. Tim Kelsey, Chief Executive, CEO, Australian Digital Health Agency, shared his perspective on the role of the consumer in healthcare as Dr Alessi mentioned how consumers are ‘pulling’ healthcare to themselves. “Governments in other parts of the world and certainly Australia are tapping into the energy source of the community and the person, in order to meet the sustainability challenge of a paternalistic health service, they need people to take more control of their healthcare and well-being”, Tim said. He sees that in Australia that there is a very determined political commitment to un-tap that asset to get the community engaged in healthcare. Additionally, in terms of healthcare, the different administrations are trying to build on each other’s success with lots of collaboration, which is evident in the recently launched National Digital Health strategy in July this year. As a light-hearted wrap up to the panel, Dr Alessi asked each of the five panelists what they would want to receive in a box for Christmas. Dr Shao wanted powerful clinical decision support tools for all physicians and healthcare providers. Dr Ashby wished for a big hard drive with hyper-advanced artificial intelligence that will aid in the prediction of demise and also help patients in hospital. “In terms of healthcare, what I would really to receive in a package is the ultimate clinical decision support, an analytic platform that really allows for the best possible personalisation per person and circumstance,” Hal shared. Dr Kohli wished for resilience for those in the healthcare industry as it is an exciting time in healthcare and health information technology, in which the current generation has a unique privilege to shape healthcare like it has never been delivered before. Tim wanted to see the evidence of benefits from digital investments in healthcare to encourage those who remain skeptical that it is the right way to go.

In July 2018, IDC Thailand named Khon Kaen as having the most outstanding smart-city project in APAC excluding Japan, alongside Phuket. The winning projects, Khon Kaen Smart Health and Phuket Smart Tourism and Living Communities won under the “Public Health and Social Services” and “Tourism, Arts, Libraries, Culture and Open Spaces” categories respectively at the 2018 IDC Smart City Asia Pacific Awards. Healthcare IT News Asia Pacific had the opportunity to learn about the latest developments of the Khon Kaen Smart Health Project from four key stakeholders involved in this pioneering digital health project. They are: -Associate Professor Cholatip Pongskul, Associate Dean for Information Technology, Faculty of Medicine, Khon Kaen University, -Dr. Apichat Jiravuttipong, Director, Srinagarind Hospital, -Dr. Chavakij Bhoomibunchoo, Associate Dean for Medical Hub, Faculty of Medicine, Khon Kaen University and -Ms. Chaturapron Chokphukhiao, Representative, Digital Economy Promotion Agency, Northeastern branch, Khon Kaen, Thailand The Khon Kaen Smart Health Project originated from the “Manee Project”. Could you tell us more about the “Manee Project”? (Response from Prof Cholatip) Manee Project is the research project funded by The Thailand Research Fund. It is aimed to find the suitable health sensor platform for monitoring health and behaviour of the household residents, mainly the elderly staying at home on their own. The data from their homes will be integrated with their medical records in order to help the doctor better analyse the health data. Its ultimate goal is preventive analytics of the individual for the purpose of changing their lifestyles from corresponding persuasive technology. Webinar: Educating the Next Generation of Physician Informaticians Khon Kaen City recently announced its integrated smart healthcare model with three components – smart ambulance, preventive healthcare service and blockchain & analytics. This Smart Health project is driven by local healthcare service providers and universities. Could you share with us which are the healthcare providers and universities that are involved in this project?   (Response from Prof Cholatip) The healthcare providers involved in the project are: (i) Srinagarind Hospital, Faculty of Medicine, Khon Kaen University (ii) Khon Kaen Provincial hospital (iii) Regional Health Promotion Centre, Khon Kaen (iv) Upper Northeastern Pharmacy Association (v) Khon Kaen Provincial Health Office Could you provide us with an update on the latest developments of each of the three components – smart ambulance, preventive healthcare service and blockchain & analytics? (Response from Ms. Chaturapron) Smart ambulance: This project is initiated by the trauma and critical care centre, Khon Kaen Provincial Hospital. It consists of the Ambulance Operation Centre or AOC, a technology designed and developed to reduce limitations caused by the distance and time taken to travel to the site.  With the AOC system, everything can be connected through the Internet and the barriers for the ambulance to reach the exact position without consuming too much time are greatly reduced. Ambulances can accurately reach the patients in a faster time. GPS will indicate the exact site and the nearest ambulance will be assigned. As such, the patient has a higher rate of survival. All necessary information for doctors to make critical decisions such as vital signs, blood pressure, patient situation are sent to the hospital in real time by snapshot or video stream displayed on the screen. Staff at the hospital can prepare appropriate methods for the patient prior to the arrival of the ambulance. (Response from Prof Cholatip) Preventive healthcare service: This service was initially launched using smart wristband to monitor the steps from the selected population. Regarding the health sensors platform, Manee Project, 30 households that have elderly residents with chronic diseases were selected for the installation of sensors. The installment has begun in October 2018 and will be expected to be completed by the end of November 2018. (Response from Dr. Apichat) Health analytics: Prototypes of the smart ICU have already been completed. Data from the respirators and vital sign monitors were sent to Google Cloud Analytics. The system can display warnings for 10 minutes before the blood oxygen desaturation. The next step is the integration of EHR data and customising it to the UI and alert system. Health information exchange via blockchain is also being developed. CAT Telecom, which is a government-held telecommunication company will provide the infrastructure for information exchange. The first project will be on drug information exchange followed by logistics and material flow. Data standards such as SNOMED CT, LOINC, GTIN, and ICD code will be used alongside the project. As part of the preventive healthcare service component, preliminary data from 30 elderly subjects indicated the acceptability of a smart wrist band, together with additional devices to monitor blood pressure, sugar levels, movements and even eating patterns/habits. How is the data from these different devices going to be integrated with electronic medical records from the healthcare providers? What are the opportunities and challenges of such an integration? Above photo: An elderly resisdent tries on smart wrist band as part of the preventive healthcare service component of the Khon Kaen Smart Health project. (Response from Prof Cholatip) Data from each device can be integrated with EMR using the Thai unique ID for identification purposes. The most important step is to apply standards for home use/wearable device connectivity such as Continua to all participating devices. The challenges are mapping values from various devices in to a single standard and getting the data from each cloud storage to a single data lake. Working with local and international device companies on behalf of the Digital Economy Promotion Agency (DEPA) and Khon Kaen Smart City will be one of the keys to the success of the project. Working with the local communities is an important part of the Smart Health Project. What are some early lessons learnt from working with the local communities? (Response from Ms. Chaturapron) Local communities such as universities, chamber of commerce, health tech associations, local drug stores and people working with sand boxes have been actively involved in this project. The Digital Economy Promotion Agency or DEPA, is the main organiser for the cooperation. Sharing the vision and knowledge is very important. Communities need ongoing support if change and sustainability are to be achieved. Are there future plans to expand the Smart Health Project to other parts of Thailand? (Response from Dr. Chavakij) Following Thailand’s 20-year-strategic plan and eHealth Thailand, the national health information system, telehealth and big data analysis are major pillars for healthcare. Our Khon Kaen Smart city project can be the spearhead to the goal. Prototypes from the project will be expanded to cover every health region in northeast Thailand in the next couple of years. Working with government organisations such as DEPA, Ministry of Public Health help us to integrate and customise our project to the whole picture of our country. Prof Cholatip is a speaker at HIMSS AsiaPac 18 in Brisbane this November.

At the Mental Health Awareness Singapore Learning Series “Healthy Mind , Better Life” Seminar organised by charity group Brahm Centre held on 25th October, Dr. Amy Khor, Senior Minister of State, Ministry of Health, announced the launch of the Dementia Friends mobile app. The app allows users to easily access information about dementia, receive updates on upcoming events on caregiving, and most importantly, use it to search for loved ones who have lost their way home. Since its soft launch, more than 1,500 mobile users have downloaded the app and signed up as Dementia Friends. The mobile app is co-developed by the Agency for Integrated Care (AIC), Nanyang Polytechnic and IHiS (Integrated Health Information Systems), which is the national technology agency for healthcare in Singapore. “Caregivers can activate this network of Dementia Friends in times of crisis, as the community of Dementia friends can help to keep a lookout for loved ones once they get a notification from the app,” said Dr. Khor. She also said that to date, six Dementia-Friendly Communities (DFC) have been formed. DFCs are support networks that help seniors with dementia live and age well, as well as provide much needed support to caregivers. Under the DFC initiative, residents, grassroots leaders, business owners and frontline government agencies are trained to help persons with dementia and their families. The six DFCs are at Yishun, Hong Kah North, MacPherson, Queenstown, Fengshan and Bedok. The Dementia Friends mobile app is available for download on the Apple App Store and Google Play Store. In August, the National Institute on Aging in the US awarded a US$4.5 million grant to the University of California Berkeley and People Power, an IoT software provider, to support research on smart home solutions for caregivers of dementia patients. People Power is creating customised systems through behavioral research on targeting everyday stressors for caregivers and dementia patients. The new technology gives caregivers proactive alerts that identify abnormal qualities in patient activities.

In 1995, the Singapore Armed Forces (SAF) Medical Corps introduced a large scale Electronic Medical Records (EMR) system, the first of its kind in Singapore. In less than a decade, the improved second generation of the EMR was implemented and most recently, the latest generation of its EMR system was rolled out in April 2016. In an interview with Healthcare IT News Asia Pacific, RADM (Dr) Tang Kong Choong, Chief of the SAF Medical Corps, gave an update on the recent developments at the organisation as well as some of the lessons learnt behind the implementation of the third generation EMR system. Could you share with us briefly about your role as Chief of Medical Corps (CMC)? How has it been thus far since your appointment in May 2015? As the Chief of the SAF Medical Corps (CMC), I am overall responsible for the provision of quality healthcare services to all SAF servicemen and women and robust medical support to enable the SAF to conduct safe and realistic training. Since assuming the appointment of CMC in May 2015, I have had the privilege of setting the vision and driving the implementation of projects and initiatives to improve the quality of care and medical support provided to our servicemen and women. In April 2016, the 3rd generation of the SAF’s Electronic Medical Records System, known as the PAtient Care Enhancement System 3 or PACES 3, was rolled out. PACES 3 is an entirely new EMR system that connects seamlessly with Singapore’s National Electronic Health Records (NEHR) system. PACES 3 contains clinical decision support features and enhances patient safety by allowing the SAF to share allergy information and other key medical information with Singapore’s healthcare providers through the NEHR. Its user-friendly mobile eHealth portal has allowed our soldiers to conveniently book their own medical review appointments, retrieve information about their health visits and investigations, and enabled greater health ownership amongst our soldiers. In 2017, the SAF Medical Corps reviewed the SAF’s approach to the promotion of health. We collaborated with external partners such as the Health Promotion Board on useful national-level health initiatives such as the National Steps Challenge (Corporate) and introduction of healthier dietary choices for the SAF. The SAF Medical Corps also hosted the 3rd Asia Pacific Military Health Exchange, which saw more than 500 participants from the military medical services of Asia-Pacific nations gather in Singapore to share and learn from one another in the field of military medicine. We also enhanced our cooperation with the Singapore Civil Defence Force (SCDF), with the SAF Medical Corps embarking on a pilot partnership with the SCDF; 12 SAF medics were deployed to work alongside SCDF personnel on their ambulances for three months from October to December 2017. The SAF’s new Electronic Medical Records (EMR) System – PAtient Care Enhancement System (PACES) 3 was launched in April 2016 and was the winner of the “Digitalised Care to Support One Healthcare System” category at the National Health IT Excellence Awards 2017. Unlike its predecessors which was hosted internally on the SAF intranet, PACES 3 is now also connected to national healthcare systems such as the National Electronic Health Record (NEHR) and Critical Medical Information System (CMIS). What were some the considerations and challenges behind implementing an EMR that could easily integrate with other health systems/infrastructures? The key impetus for hosting PACES 3 on an Internet-facing platform was to integrate our medical care records with that of the national healthcare system. Introduced in 1995, PACES was upgraded to PACES 2 in 2005 to have networked capabilities over a secured intranet system. The Ministry of Health’s articulation of the national vision of “One Patient, One Record” and the introduction of the National Electronic Health Record (NEHR) in 2011 was a strong impetus for us to develop PACES 3 onto an Internet-facing platform that is integrated with the national healthcare system. This provided a seamless and safe transition of medical care between healthcare providers. The choice of the health IT solution and the partner agencies was a key consideration in the SAF’s EMR System. After an open tender and robust evaluation process, the SAF Medical Corps awarded the contract jointly to Allscripts and National Computer Systems (NCS). Prior to this partnership with the SAF, Allscripts had partnered Singhealth for their electronic medical records system and had a strong presence in Singapore, while NCS had worked with the SAF Medical Corps for both earlier versions of PACES. With PACES 3 on an Internet-facing platform, we had to ensure the security of the medical data. To address this challenge, the project team built in multiple layers of protection and defences to ensure the robustness of the system against cyber threats. A second challenge was the migration of 20 years’ worth of electronic medical records stored over the lifespan of PACES and PACES 2, to PACES 3. The project team worked closely with our vendors to ensure the fidelity of data transfer as this was important in patient care and safety. Looking to the future, even as PACES 3 was rolled out in April 2016, it is necessary to start thinking about PACES 4 and the next generation of EMR systems for the SAF. I am cognisant that PACES 3 will need to be upgraded or refreshed to meet the health needs of the SAF in the next decade. The SAF Medical Corps will keep abreast of the developments in medical IT through participation in relevant medical IT events and conferences, development of our people in medical IT literacy, and also putting in place a system of continual review and improvements. Are there any collaborations /projects between SAF and other medical organisations with regards to health IT? The SAF Medical Corps is currently in dialogue with the Singapore Ministry of Health to better understand the development and implementation of Smart Healthcare initiatives for Singapore. We want to ensure that the SAF’s future developments in medical IT continue to be aligned with the nation’s push towards Smart Healthcare. RADM (Dr) Tang Kong Choong is a speaker at the inaugural International Military Health IT (IMHIT) track at HIMSS AsiaPac 18 in Brisbane this November.

Spanning a long and varied three decade career in military medicine with the Royal Australian Air Force (RAAF) and Australian Defence Force (ADF), Air Vice-Marshal (AVM) Tracy Smart demonstrated her versatility and capabilities in both local and overseas appointments in places such as the United States, Timor Leste and the Middle East. Ahead of the HIMSS Asia Pacific conference in November, AVM Smart talks about her role as Surgeon General ADF and Commander Joint Health, the ongoing digital health developments at the organisation and some of the most rewarding moments in her distinguished military career. Could you share with us briefly about your role as Commander Joint Health and Surgeon General ADF? Essentially, my Surgeon General ADF and Commander Joint Health roles are quite distinct, with different responsibilities. As the Commander Joint Health, I am responsible for health support to the Australian Defence Force in the National Support environment to ensure the health preparedness of our members. This means that all military members not deployed on operations are receiving their health support health centres around the country under my command, and are accessing specialist civilian services through our ADF Health Services Contract. It’s my aim to ensure that our people are fit to deploy and that those who become wounded, ill or injured receive timely, high quality health care, when required. As Surgeon General ADF I am the senior doctor, and the authoritative source of strategic health advice to Defence and the Government. I also exercise technical authority across all Defence health services, where ever they are delivered. This includes those health services delivered by our single Services - Navy, Army and Air Force – in the operational space. Some of the key functions that are executed through Joint Health Command headquarters in Canberra in support of both these roles are: •             The provision of health advice to Commanders at all levels •             Developing health policy and programs •             Delivery of health services to the ADF through a network of facilities in Australia and overseas •             Coordination of the joint health capability domain •             Coordination of health research •             Capability coordination of health material The roll out of ADF’s own e-Health information system throughout Australia was completed in December 2014. Could you give us some key updates/developments on the e-Health information system since its launch almost 4 years ago? Defence electronic Health System (DeHS) is the first and only nation-wide digitally connected primary healthcare system in Australia. Since its roll out in December 2014, there have been significant improvements in patient episode data entry and reporting to enable the comprehensive health care system delivered by the ADF within Australia, on exercises and on operations. We have seen major improvements in patient care, due to the availability of a holistic eHealth record that is accessible by all clinical craft groups, when they need it, regardless of geographic location. Patient privacy and confidentiality have also improved due to role based access. Clinical governance has been improved due to the implementation of patient recall and follow-up workflows and system diary entries. Additionally, we now have superior health intelligence and reporting, supporting both clinical decision making and health administration as well as driving workplace efficiencies and rates of effort. Over the past 12-18 months, DeHS functionality has enabled Joint Health Command to pursue a number of initiatives such as enhanced mental health screening via the Patient Portal, and inter-agency information sharing agreements with Department of Veterans’ Affairs and the Commonwealth Superannuation Corporation to enable prompt processing of member claims for compensation and entitlements when they are transitioning from service. As well as being implemented across our Australian-based health centres, DeHS is now in use on overseas deployments at some of our fixed based locations. What do you think are the key challenges and opportunities in the Digital Health Strategy of the ADF? Digital health systems will enhance the ADF’s capability through a prevention focused, and rehabilitation oriented approach to Defence health care. As with the implementation of any major strategy, the ADF Digital Health Strategy will present some challenges along the way. Some of the challenges include financial constraints on health care delivery and adoption of technologies, and the rising demand for health care services within the ADF and in the Australian community. Despite the challenges, I see some fantastic opportunities in the ADF Digital Health Strategy including enabling patients and providers to make informed treatment decisions, whilst also improving clinical outcomes, health business efficiencies, and human performance through disease prevention and injury rehabilitation. Overall, these opportunities contribute directly to ADF capability through health readiness, and ensure members are receiving care that is command responsive and member centric. How is the ADF working with the Australian Digital Health Agency with regards to the recently launched National Digital Health Strategy & Framework for Action? Defence has been working very closely with the Australian Digital Health Agency for many years, and particularly as we plan for the implementation of our future system. Our recently developed ADF Digital Health Strategy complements the National agenda led by the Australian Digital Health Agency and is consistent with both the Agency’s Strategy and Framework. It also builds upon Joint Health Command’s existing leadership in digital healthcare, recognising the Defence electronic Health System (DeHS) as the first and only nation-wide digitally connected primary healthcare system. The Strategy has been developed in alignment with the My Health Record initiative and will assist in the development of digital health systems that enable improved and more transparent access to and personal control of Defence health information and records. It will inform our future system to ensure that it provides secure, instant access to a patient’s information – whether it is within our health care centres, on board our ships and aircraft, or on exercises and deployments. For our health care providers, digital health systems will provide the necessary technology to reduce their administrative burden so that they can spend more time with patients. You have a vast experience and long service record both within the ADF and also in international peacekeeping duties such as in Timor Leste. What would you say are the most rewarding experiences in your distinguished career with the military? I have had many rewarding experiences during my career. It is an honour and a privilege to serve my country and I reflect on this every day when I put on my uniform. It is particularly satisfying to be in the top job and drive strategic and cultural change across our health system and the broader ADF. A particular highlight for me was serving as part of the United Nations Assistance Mission in Rwanda. My role was Officer Commanding Clinical Services and Aeromedical Evacuation Operations Officer, and as a Squadron Leader I was also the senior RAAF Officer in what was primarily an Army mission. Although our main job was to provide health care to the UN troops, most of our work was humanitarian – caring for the local population. This included people who we rescued from around the country by aeromedical evacuation or by road, and those we chose to treat who had presented to the Kigali General Hospital but who were too sick to be managed there. This was an incredibly difficult deployment. We saw many clinical problems that were beyond our previous experience – from the effects of war, such as machete wounds, grenade and mine injuries, to all number of tropical diseases. We also saw lots of kids, many of them orphaned and suffering from malnutrition and diseases, and some of whom died on our watch. We sometimes had to “play God” – allowing people including children to die due to our limited capacity, many of whom would have lived in a first world country. This was very hard on our people, particularly those with kids back home. The toll this mission has taken has been extreme. A 2014 Department of Veterans’ Affairs study found that over 32% of those who served now had an accepted claim for a mental health condition. However, there were many positive aspects and it was an incredibly rich experience for me. A personal highlight was caring for the children of Rwanda, including those from the Mother Teresa orphanage in Kigali. As I saw it, each child we saved or left a positive imprint upon had the potential to grow up and make a positive difference in their country, and so represented a small victory. I feel very proud of the work myself and others did over there, how we contributed to stabilising what has become a successful nation, and of how courageous our people were. I don't think I'd be where I am now, Surgeon General ADF and Commander Joint Health, without my experience in Rwanda. I may not even still be in the ADF. I learned a lot about myself, about leadership, and about resilience, embracing the view that “whatever doesn't kill you makes you stronger”. In other words, while some tragically have developed PTSD, I believe that I have experienced “post traumatic growth”. It has given me confidence that I can challenge myself in extreme situations and survive. Air Vice-Marshal Tracy Smart is a speaker at the inaugural International Military Health IT (IMHIT) track on Day 2 of HIMSS AsiaPac 18 in Brisbane this November.

HealthHub, a one-stop portal and mobile application for Singaporeans to access a wide range of health content, rewards and e-services, which was launched in 2015, had experienced a series of unauthorised log-ins, according to the Health Promotion Board’s (HPB) recent statement. The portal is an initiative by the Ministry of Health, and Health Promotion Board, supported by Integrated Health Information Systems (IHiS), the national technology agency for healthcare in Singapore. HPB and IHiS had detected the unauthorised log-ins during investigations into unusual activities on the portal. The agencies had found “higher than usual attempted log-ins” to the HealthHub portal on four days – Sept 28, Oct 3, Oct 8 and Oct 9 – using more than 27,000 unique IDs or email addresses. Although 98 per cent of the email addresses used were not related to existing HealthHub accounts and the log-in attempts were unsuccessful, 72 accounts were successfully logged in during those time periods. These accounts were subsequently locked and HPB had contacted the account holders to inform them of the suspicious activity, and to check if they had made the attempts themselves. HPB was first alerted when a user suspected her email account had been used without her permission to log in to the portal, and informed HPB. The agency also added that no evidence of a breach in the HealthHub system has been found. Healthcare cybersecurity in Singapore has been in the limelight since the SingHealth cyberattack, which occurred in June 2018. Described as one of the worst cyberattacks in the country, the incident saw the personal information of 1.5 million SingHealth patients being stolen by sophisticated hackers over the period between June 27 and July 4. Singapore Health Services or SingHealth is Singapore’s largest group of healthcare institutions, which consists of 4 public hospitals island wide, 5 national specialty centres and a network of 9 polyclinics. An ongoing Committee of Inquiry (COI) for the SingHealth cyberattack which was convened on July 24, held a series of public and private court hearings since last month and is expected to submit a report of its findings by the end of 2018.  

The IT journey in clinical systems in Singapore dates back to the 1980s and by the early 2000s, two distinct electronic medical record (EMR) systems emerged from the two integrated clusters. However, this meant that sharing of patient information, especially those moving from different clusters, was a big challenge. In 2008, the National Electronic Healthcare Record (NEHR) was conceived out of a “one patient, one record” vision based on a concept paper. Critically, NEHR differs from previous EMR systems as it is a repository of visit summaries specific to an individual. While EMR systems contain detailed information of a patient in their respective institutions, NEHR collects key subsets of health information from these multiple healthcare encounters. NEHR went live in 2011, with the successful uploading of healthcare information from public hospitals in the same year. By the first year, all restructured hospitals, specialist centres and polyclinics, six community hospitals, eight nursing homes, and an increase from an initial 50 to 250 GP clinics had access to NEHR. HealthHub, a one-stop portal and mobile application for Singaporeans to access a wide range of health content, rewards and e-services was launched in 2015. Users can also log-in to HealthHub through their SingPass to view their health records and medical appointments across different polyclinics, public hospitals and other public health institutions. The information from HealthHub is drawn from a few IT systems, which include the NEHR, the School Health System, School Dental System and National Immunisation Registry. As of November 2017, only three percent of the more than 4,000 private healthcare providers – including specialist clinics, nursing homes and hospices – contribute to the NEHR scheme. Additionally, a study of private healthcare institutions done by the Integrated Health Information Systems (IHiS), the national technology agency for healthcare, found that two in 10 private GPs and specialist clinics still use written medical record systems, rather than an electronic one. At the time of writing, the Ministry of Health (MOH) website has a list of 1230 healthcare institutions/organisations (public and private) who are participating in NEHR. Due to the slow uptake by private healthcare sector in the NEHR, MOH wants to make it compulsory for all healthcare providers to upload data to the NEHR. Early adopters who start contributing data by June 2019 will be able to claim a one-off from MOH to offset their costs of upgrading their systems and a S$20 million fund has been set aside by the ministry for this purpose. One of the unique developments is that the latest generation of the Singapore Armed Forces (SAF)’s EMR system, Patient Care Enhancement System (PACES) 3, which was launched in April 2016, connects to healthcare infrastructure outside of Ministry of Defence (MINDEF)/SAF via the internet, such as the NEHR. This helps to provide more holistic care for SAF servicemen. Traditionally, the first two generations of PACES operated independently on their own with no ability to connect to external healthcare infrastructures. While there has been a progressive development in health IT in Singapore in terms of the NEHR and HealthHub, the nation-state suffered a setback in its goal to becoming a Smart Nation when a cyberattack occurred to SingHealth, Singapore’s largest group of healthcare institutions, which consists of 4 public hospitals island wide, 5 national specialty centres and a network of 9 polyclinics in July 2018. Described as one of the worst cyberattacks in the country, the incident saw the personal information of 1.5 million SingHealth patients being copied and stolen. Plans for compulsory contribution to NEHR has been suspended temporarily after the SingHealth incident and a four-member Committee of Inquiry (COI) was set up promptly to look into the events and factors that led to the attack. In response to the incident, Prime Minister Lee Hsien Loong shared, “If we discover a breach, we must promptly put it right, improve our systems, and inform the people affected. This is what we are doing in this case. We cannot go back to paper records and files. We have to go forward, to build a secure and smart nation.” PM Lee’s response reflects Singapore’s ongoing journey in continually advancing healthcare IT infrastructure – in fact, there are already plans to develop and implement the Next Generation Electronic Medical Record (NGEMR) by 2020.

Silvia Pfeiffer, CEO and co-founder of Coviu spoke with Healthcare IT News Asia-Pacific about her team's experience developing technology at the Women in Tech (Asia) conference in Singapore.

As healthcare providers worldwide strive to provide a more seamless experience to their patients through the better integration of information systems and shift from paper-based medical records to electronic medical records, the successful implementation of Health Information Exchange (HIE) projects becomes a critical part of this process. However, this is a daunting task at both local/regional and national levels, requiring collaboration from various stakeholders from a technical and policy standpoint. Jürgen Brandstätter spoke to Healthcare IT News about his experiences and insights in HIE implementation in Europe and the Middle East. "Integrating the Healthcare Enterprise" (IHE) is a global not-for-profit initiative with regional and national branches. It provides a pragmatic methodology ensuring interoperability between healthcare IT systems resulting in a body of technical and semantic specifications, which are published by IHE as Technical Framework(s). IHE Europe engages clinicians, health authorities, industry and users to improve healthcare interoperability. This is done through helping national and European stakeholders and policy-makers in adopting, promoting and implementing IHE specifications, as well as developing tools and services in support of interoperability testing. Could you tell us more about your role as vendor co-chair at IHE Europe? How has the journey been like for the past 2 years? As co-chair of IHE Europe, together with the user co-chair and the other members of the executive board, we are responsible for the management of the organization on behalf of the IHE Europe Steering Committee. The executive board is supported by chairs and directors of the different sub-committees, such as IHE Services, EU Affairs or MarCom. The IHE-Europe Connectathon provides a unique opportunity for vendors to test the interoperability of their products in a structured environment with peer vendors. Credit: IHE Europe IHE Europe is a fabulous organization and it was a pleasurable ride the past 2 years. We have conducted two Connectathons, which are growing in size by every year and we see our operative arm IHE Services getting involved in more and more national programs, consulting in architecture and strategy and covering the interoperability task by its vast experience out of the development of our testing tool Gazelle. Our relationship to the European Commission is excellent and we are involved into several European projects. All in all, I am happy to have been recently re-elected for a second term to continue my engagement to further advance IHE Europe and the IHE mission. You have been a consultant on various e-health exchange projects in Europe and the Middle East. What are some of the common challenges experienced by healthcare providers that you work with in these projects? Do you have any memorable examples or case studies? During my engagements in various Health Information Exchange projects globally it was not much surprising to see that eHealth interoperability use-cases are pretty much similar everywhere. If you examine closer Patient Identification, Clinical Document Sharing, e-Prescription, e-Immunization or other use-cases, you realize that they are similar in its core, no matter where you want to implement it - even if you consider all national specialties of the respective countries. This is actually the added-value the IHE standards initiative contributes to society, namely to cover this “common core” once-for-all on a global scale to safe costs and increase sustainability. So from a technical perspective the most common e-Health use-cases are very well worked out already and best practice and successful case-studies are available – just take a look at them here. But apart from that, also the challenges are usually overlapping, foremost the need of good and stable political governance and policy, the building of local capacity and the need of strict alignment to international standards, which can become a serious risk to the project if not considered sufficiently. One memorable example was as I engaged into the specification of the e-Prescription track of the Saudi eHealth Exchange (SeHE) project right after I accomplished the specification of e-Medication in Austria. Both countries differ so much in location, culture and the way how medications are prescribed, but in the end the course of the workshops with the doctors as well as the final specifications were so much similar. It was amazing. In terms of experience with Health Information Exchange (HIE) systems, you have been a vendor, created profiles and oversaw organizational development, which is certainly invaluable as you understand the different roles and requirements at different levels of HIE systems implementation. How do you think stakeholders at the different levels can work together towards implementing an effective HIE system? From my perspective, the success of a HIE project is mostly depending on its degree of acceptance in the short term and sustainability in the long term. So it is essential that the stakeholders of a HIE system do proper local capacity building and then seek out for international case-studies and standards to see if their intended eHealth use-case is already covered by the standardization community. Look around what works and communicate with others, before you make up your own plans. There are plenty of global initiatives out there, which could serve as a platform for such communication, as for example the recently founded “Global Digital Health Partnership” to foster this for example on government level. Also, the stakeholders should get in contact and engage with the standards community. Sustainability requires leveraging international standards and the standards community is open and ready to collaborate. Most likely the standards and even standard-compliant software ready-to-buy for the use-case is already in place, but even if not, it’s cheaper to invest into creating the required standard at this occasion rather than inventing on your own. Interoperability is one of the key priorities in the implementation of HIE systems. What are your thoughts on achieving true interoperability across different HIE systems? From my perspective, it’s important that interoperability is challenged on a global scale and in the form of actually tested systems rather than standards on paper. The IHE standards initiative, with its profiling and attached testing activities (Connectathon, Conformity Assessment), is filling exactly this gap and is covering the last mile from the base standards (HL7 CDA, FHIR, DICOM, SNOMED, …) to “real” interoperable systems, which are ready to be bought off the shelf. Today’s question is not “how” you can do it, today’s question is how you can do it in the “most sustainable and cost effective” way! What are some current notable trends or technologies that you observe in the development of HIE systems? Due to the speed and energy the FHIR development has brought to the standards and developer community, FHIR has clearly become a notable trend and there is clearly to see the attempt to leverage this standard for all kinds of HIE interoperability problems. From IHE perspective, FHIR is a great new standard, which is very suitable to a variety of interoperability use-cases, especially in the area of mHealth and we our current profiling work is strongly considering this new technology. However it shall not be forgotten that other existing standards are still in place perfectly working for the use-cases they have been created for, so we recommend to look to the future but be careful to not let any trend overcome meaningful usage of what’s already existing (this also applies to “blockchain”, another current trend). Also, the FHIR standard is still under development and requires profiling work on global scale to be fully optimal useable. This refers back to question 3, where it needs collaboration between stakeholders and the standards-community on global scale to level up the usage of FHIR from “locally created FHIR Implementation Guides” to globally used “FHIR based IHE profiles”. To tackle this profiling work, the “Gemini” project, a Joint Venture of IHE and HL7 to Advance Use of FHIR for Interoperability, has been formed to enable and foster the “joint” development of such FHIR based IHE profiles. I am honored to serve on the Gemini Steering Committee to drive forward this initiative. What do you think are some key lessons that healthcare providers in Asia Pacific can learn from based on Europe’s experience and journey in HIE systems implementation? Europe has done some substantial ground work in exploring the possibilities of national eHealth Information Exchange projects, especially when it comes to cross-border exchange of information between member states. But there are also very interesting case-studies in certain countries which are worth being looked at from an architectural/technical point of view, but also from a strategic/governance perspective. One key lesson is certainly that a standards-based and collaborative approach is always more sustainable in the end as doing an own development, which seems to be cheaper on the first view. In the meanwhile European member states are very much used to collaborate with their neighbors and know about this importance. Another key lesson is that vendor-independence is crucial for success, if the size of the project exceeds certain boundaries. That again points to the importance of international standards, which need to be profiled to lead into interoperable, standards-based, exchangeable products on the market which ideally you can buy off-the-shelf. This profiling is the part IHE is taking care of. Jürgen Brandstätter is a keynote speaker (Connect Track) at HIMSS AsiaPac 18 in Brisbane this November. To learn more about this event, click here. He will also be speaking at the IHE AsiaPac Summit happening on 5 November 2018.