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National electronic health records need a check-up

Private sector's lack of participation in database must be looked at and addressed

Singapore's National Electronic Health Record (NEHR) system became available to all public healthcare institutions, and a few private ones, in 2013.

Since then, all healthcare players have been encouraged to link up to the NEHR so their doctors can access data on patients who may have been treated elsewhere. This could give them information on treatments that their patients are undergoing as well as their test results and medication.

This gives doctors a more complete picture of a patient's health than the patients themselves can provide.

Doctors can also check for past conditions and histories of adverse drug reactions. With such information at their fingertips, doctors can tailor their treatments and avoid pitfalls. The availability of such data also does away with duplicate tests.

Today, more than 760,000 NEHR patient searches are made each month by the 21,000 doctors, nurses and pharmacists who have access.

Unfortunately, the current data in the NEHR is not as comprehensive as Health Minister Gan Kim Yong would like it to be. This is because, while it incorporates all the records from the public sector, there is very little input from the private and charity sectors.

This is a massive gap, given that 80 per cent of primary care takes place at private general practice (GP) clinics. So far, only 40 GP clinics out of more than 1,600 contribute their patient data, although 868 or more than half, can access their patients' information on NEHR.


Should GP clinic patients, who form the majority of the population, have an emergency and be taken to a public hospital in an ambulance, the doctors there would not be able to retrieve their medical history. This could put the patient at a disadvantage in the treatment he gets.

Associate Professor Low Cheng Ooi, chief medical informatics officer at the Ministry of Health (MOH), said: "GPs are patients' primary and most frequent touchpoints for medical consultation.

"The contribution of patient summary records from private care providers would provide important clinical information for the NEHR."

The medical information they provide on their patients "would help other healthcare professionals to make better informed decisions in delivering care to patients", he said.


The same argument holds for private specialist clinics. Someone who is being treated for a heart problem might suffer a heart attack and be sent to a public hospital. Time can be critical in reducing lasting damage, and knowing the patient's history could make a huge difference.

Also, two in three people here have private insurance plans. Most who are covered by their companies are also treated in the private sector. Here's the catch: The medical records of a significant number of such people, treated by private hospitals, would not be available to other doctors treating them.

That is because until today, not a single private hospital or specialist clinic has contributed anything to the NEHR. Of these, only Raffles Hospital, and 65 specialist clinics out of more than 1,000 here, access NEHR.

Many in the private sector still operate in silos, although increasingly, as the population ages, more people are suffering from multiple co-morbidities that require the attention of more than one specialist.

Although Mr Gan has been urging the private sector to digitise their records and to share them on the NEHR, this has yet to happen.

Should the Government legislate the participation of the private sector since the advantages to their patients are clear?

Doing so would provide Singapore with the complete electronic medical record of all citizens which could improve healthcare here.

Aside from immediate benefit to patients, having a comprehensive databank of diseases, treatments and outcomes provides a rich source of information on what works best.

This could lead to better, and sometimes even cheaper, treatments.

Take diabetes, for instance. Some doctors consistently achieve better outcomes. Is it because they are more persuasive in getting patients to change their lifestyles, or is it because of better choice of drugs? Or for some other reason? Finding out and sharing the information could lead to better treatment for all.

The recent drug guidances provided by MOH showed that not all doctors know which drug works best or gives better value for money. In one example, the team found that three different drugs gave the same outcome - but their prices were very different.

Such information can be better culled from a national database of treatments, rather than only what is available in the public sector. So the benefits of a truly comprehensive national database accessible to all healthcare providers are significant.

Nevertheless, making participation compulsory is not something that should be done without first finding out, and addressing, the reasons that the private sector has been holding out so far. And there are valid reasons for their reluctance.


Not all in the private sector are computerised. Even those that are might have different systems, and getting them aligned to the NEHR could be costly. And frankly, while it might benefit the patients, there is little advantage to the hospital or clinic.

The Government has a $2 million fund to help the charity sector, which runs community hospitals and nursing homes, to digitise and get onto the NEHR.

It might want to consider doing the same for the private sector.

Yes, these are for-profit entities, but this is a move that they do not really need to embark on. While big hospitals can afford the cost, it might be painful for some small GP clinics. So some financial assistance, especially for the smaller players, could make a big difference.

Another argument from the private sector is that of patient confidentiality. They say their patients may not agree to share their medical data. Some seek private sector treatment because they want certain ailments kept confidential because of the stigma that attaches to these conditions. These include mental illness, sexually transmitted diseases and abortions by unmarried women.

If they were to share their patient data with NEHR, then, without so much as a by your leave, this "shameful" medical history could be read by more than 20,000 healthcare professionals.

A writer to the Forum pages recently complained that all his cousin's medical information became available to an insurance company, which then excluded cover for all of them, including minor problems like eczema.

Prof Low, who is also the chief clinical informatics officer at Integrated Health Information Systems (IHiS), which manages NEHR, said: "Insurers do not have access to NEHR. In general, NEHR would be accessed only by authorised healthcare professionals providing care to patients."

While that might be so, insurance companies do employ doctors and these doctors would have access.

While one might argue that, except in an emergency, doctors need the patient's consent, the reality is that people are not often given much choice. In the case of the Forum writer's cousin, the insurance company required her permission to access NEHR in order to provide coverage.

Also, how about someone applying for a job which requires a medical check-up, and the company doctor looks up the person's medical history and passes the information on to the employer?

Such concerns are valid, and it is good that the private sector is worried about them.


On the other hand, the advantages of a comprehensive database are too numerous to ignore.

One solution is for selective medical information to be withheld and made accessible only when the patient is being treated for a related or similar condition. But some doctors argue that this is not a good option, since it could affect the current treatment, and in certain instances, could actually put the patient in danger.

The better answer is to perhaps legislate that doctors cannot reveal information made available through NEHR, nor should any party - whether it is the employer, insurer or even family member - be allowed to demand it.

Employers and insurers should be entitled only to the results of the tests they require of the person, and not his entire medical history.

This should be a given, since medical information between doctor and patient is supposed to be sacrosanct. Unfortunately, in practice, this might not always be the case.

The MOH and IHiS need to find out the obstacles to the private sector's participation, and address them. Only after this is done should legislation come in, to ensure there are no laggards.

Having a population-wide medical database can advance the provision of healthcare here. As Prof Low said, it "enables patients to move seamlessly and safely across all healthcare settings. During emergencies, access to critical information in NEHR can also save lives".

There is no country today with a national shared medical record.

Singapore, which is at the forefront of medical care, can also lead the way in this - after making sure that its citizens reap the advantages, without getting inadvertently hurt.

A version of this article appeared in the print edition of The Straits Times on June 15, 2017, with the headline 'National electronic health records need a check-up'. Print Edition | Subscribe