Associate Professor Wong Teck Yee
Assistant Dean, Family Medicine
Consultant, Department of Continuing & Community Care, Tan Tock Seng Hospital
Dr Ravinder Singh Sachdev
Deputy Chief Medical Informatics Officer, Associate Consultant, Department of Continuing & Community Care, Tan Tock Seng Hospital
A patient was admitted to Tan Tock Seng Hospital in the middle of the night and all we had access to was a blank set of clerking notes and inpatient medication record form because the patient’s medical records and medication lists were not available until the following morning. That was the reality we faced when we started out as newly minted doctors some 20 years ago. We were at the mercy of the patient’s memory – what was the reason for the operation last year? Which medication was the patient on? To which the typical answer was “Three white tablets and one green capsule”.
Once the patient’s previous notes arrived the following day, we would have to sift through the multitude of folders containing sheets of information in various shapes, sizes and stages of oxidation.
Similarly at the polyclinics, the workflow consisted of ‘tracing’ a patient’s often-hard-to-find outpatient notes from the Medical Records Office, consulting the patient, and then manually writing a Medical Certificate (MC) or prescription.
Nowadays, patients’ notes are available at the click of a button. We can find out a patient’s full medical history, including past and current medications (issued at any public institution in Singapore) and any specific drug allergies. To this we add the latest information from our consultation. We write MCs and prescriptions electronically too. By the time the patient walks to the pharmacy, the prescription has likely been processed and packed.
Many of our work processes have been streamlined with the introduction of technology, but this is only the tip of the iceberg.
A possible future – what will it look like?
“Prediction is very difficult, especially if it's about the future."
Attributed to Niels Bohr, Nobel Prize
winning twentieth century physicist
‘Smart’ Electronic Medical Records (EMRs)
Current health information systems, while improving efficiency and enabling safer practices, are fundamentally ‘flawed’. While each performs its task effectively off its own database, information cannot be shared or merged.
However, the next generation of EMRs will likely run off a single database and integrate all the information available within its database (and others that it interfaces with), analyse the information, and provide personalised clinical decision support.
For example, a patient comes in to the clinic with a cough. The EMR of the future will be able to access (with the patient’s consent) information not just from his medical, social and medication history, but also from many other sources, including social media, wearable technology, and remote monitoring devices, presenting a much richer profile to the clinician.
It may, for example, be able to alert the physician that the patient recently travelled to the Middle East and needs screening for MERS-CoV. The system could also recommend the most appropriate medication based on up-to-date statistics of the likely bacteria’s resistance pattern. While some clinicians do not wish to embrace this type of ‘cookbook’ medicine, it cannot be argued that these processes will not improve patient care, reduce errors, and increase productivity.
Wearable Technology – enriching doctor-patient relationships
The ability to walk around with a Heads-up Display (HUD) used to be confined to Science Fiction novels and video-games. But imagine how technology like Google Glass could personalise the doctor-patient relationship. As soon as a patient enters the room, the clinician looks at the patient – not down at his notes – seeing the patient’s basic demographic details, allergies, diagnosis, and, possibly, the reason for his visit, if the patient has completed an electronic form beforehand. Linked to a smart EMR, the clinician will be able to manage the patient effectively and efficiently within perhaps even as little as three minutes.
Other wearable devices shaking up the healthcare world include devices such as FitBit, Nike FuelBand, and Jawbone Up. These currently track a variety of parameters, including distance walked per day, duration and quality of sleep and even location, for those with GPS.
Now imagine devices that track true physiological parameters, like blood pressure, pulse and respiratory rate, and possibly even blood sugar levels (scientists are currently exploring non-invasive methods of detecting blood sugar using Near-Infrared (NIR) spectroscopy). All of these devices, through the Internet of Things (the point in time when more "things or objects" are connected to the internet than people), could feed data back to the smart EMR (Vasseur & Dunkels, 2010). However, “rather than just reporting raw data, these connected devices will send higher-level information back to machines, computers, and people for further evaluation and decision making” (Evans, 2012).
It is through the analysis of this stream of “big data” that this information resource will come into its own as a powerful, truly personal, health portal. Minor fluctuations could trigger appropriate responses from healthcare providers, preventing major incidents, keeping people healthy and outside the hospital.
“Some of the current measures of success today, like bed occupancy percentages, will become measures of failure in tomorrow’s reality. There will be more attention to care outside of the hospital, such as links to the home environment. Consolidating electronic health records in inpatient and outpatient settings is a huge initiative for us."
Mark Laney, President & CEO, Heartland Medical Center,
USA (CEO Forum Report Review Board, 2012)
With the introduction of Web 2.0, the internet is no longer a read-only source of information, but a highly interactive portal where people share experiences, learn from each other, and express themselves in a multitude of ways. According to Carleen Hawn, author of “Take two aspirin and tweet me in the morning” (Health Affairs, 2009), using social media in healthcare is about “changing the locus of control to the patient and altering the relationships between care givers and care receivers.” While Web 2.0 tools cannot substitute for a face-to-face encounter with a healthcare provider, they “allow for richer engagement and deeper doctor-patient relationships.”
“Just imagine if every care home was wifi [sic] enabled and used the power and potential of digital technology and social networks to develop new models of care for older people!” (Ayres, 2013)
The Future – why will it be different? Why must it change?
When Gary Kaplan, CEO of Virginia Mason Medical Centre, first decided that it was time to standardise work processes to improve care delivery, he faced strong opposition from clinical leaders, who felt that standardisation “robbed a clinician of freedom and creativity” (Kenney, 2010).
However, twenty-first century medicine has gone from a “doctor-knows-best” approach to a patient-centred, collaborative, team-based model of care. Patients expect the same efficiency and value from the healthcare system as any other service.
Healthcare practice has to change to accommodate the customer. In an age where time is measured in download rates, access to health-related resources must be (almost) immediate – and technology will have to be leveraged to accomplish this.
Of course, there are other challenges that need to be overcome for clinical informatics to flourish. Confidentiality of information (or the lack thereof) is still a hotly debated topic.
For many people, declaring a medical illness to their doctor is different from liking the support group page of that illness on Facebook. Twitter is full of highly personal, health-related information, yet we would be outraged if an insurance company declined a claim because of such posts.
The recently introduced Personal Data Protection Act will guard against personal information being shared without the individual's consent. But how will it affect the reverse, harvesting information from publicly available sources like Facebook, Twitter and others by healthcare institutions?
LKCMedicine – preparing our students for the future
“The illiterate of the twenty-first century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn.”
Alvin Toffler, American writer and futurist
Our students are exposed to and use technology early during their time at LKCMedicine to learn and interact with each other and their teachers. Feedback on their work is also enabled by IT and while face-to-face interaction with patients remains key, they are also able to reach out to patients remotely via video-linkage.
When they start their clinical training at Tan Tock Seng Hospital, they will be exposed to a wide-range of technology-enabled healthcare processes like the use of tablet PCs to administer medication, RFID sensors to monitor patients’ physiological parameters and use of analytics in predictive scoring for patients’ health status.
We are very conscious that as teachers of future doctors, we have to equip them with the skills and knowledge to ethically manage issues such as the increased use of technology and data stewardship. For example, would advice given during a video conference, constitute a medical consultation or just advice? How should this information be added to medical records? Will it be legally admissible? At LKCMedicine, professionalism and ethics are taught from Year One to ensure that our students understand that these are not separate skills but inextricably intertwined in a good doctor.
On a more personal note, as Family Physicians, the concept of personalised and continuing care is important to us. We foresee that the primary care consultation of the future will be different. It could be based on social media collating health information, doctors and patients interacting via an algorithm and, possibly even, supported by an automated system of care.
As future doctors, LKCMedicine students must learn to cultivate lasting and trusting relationships with their patients. Technology may help us to be more efficient and effective from a system’s point of view, but we still believe that the patients of the future will insist on being treated as individuals, instead of an NRIC number connected to related packets of health data.
We can’t predict the future exactly, but we can make sure that as future medical professionals, our students can adapt to and lead future changes to our system.
On a cautionary note, we would like to end of with this thought from George Orwell’s “1984”:
“For citizens of this future world, there is no hiding, no such thing as privacy. Big Brother is always watching you.”
About the authors
Assoc Prof Wong Teck Yee is Assistant Dean for Family Medicine and oversees the students’ polyclinic attachments and the long-term patient project among other activities.
Dr Ravinder Singh Sachdev provides home care to post-acute geriatric patients. He also teaches anatomy at LKCMedicine. As deputy Chief Medical Informatics Officer, he is helping to drive NHG's Care Transformation Project.
Ayres, S (2013, October 15). How digital technology is supporting people living with dementia. Nominettrust.Org.Uk.
CEO Forum Report Review Board. (2012). Leading Through Transformation: Top Healthcare CEOs’ Perspectives on the Future of Healthcare (pp. 1-41). Chicago.
Evans, D (2012). The Internet of Everything: How More Relevant and Valuable Connections Will Change the World. Cisco IBSG (pp. 1-9). San Jose: Cisco IBSG.
Hawn, Carleen (2009). Take Two Aspirin And Tweet Me in the Morning: How Twitter, Facebook and Other Social Media Are Reshaping Health Care. Health Affairs, 28(2):361-368
Kenney, Charles (2010). Transforming Health Care. Virginia Mason Medical Center. (New York). CRC Press
Vasseur, J., & Dunkels, A (2010). Interconnecting Smart Objects with IP: The Next Internet. Interconnecting Smart Objects with IP: The Next Internet. San Francisco, CA: Morgan Kaufmann Publishers Inc.