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Is Asias Healthcare Sector Ready for the Future?

Planning Ahead

Sponsored by Fuji Xerox

October 2009

 2009. FutureGov Research. All rights reserved. All information in this report is verified to the best of the authors and the publishers ability. However, FutureGov Research does not accept responsibility for any loss arising from reliance on it. Neither this publication nor any part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission of FutureGov Research.

PREFACE
Planning Ahead - Is Asias Healthcare Sector Ready for the Future? is a FutureGov Research whitepaper, sponsored by Fuji Xerox. The views may not necessarily reflect those of the sponsor. This report was researched, written and prepared by the FutureGov team. The principal contributors were James Smith, Jianggan Li, Chris White and Ran Elfassy. The cover was designed by Patrick Schulze. Our sincere thanks go out to all those that contributed their time to the survey and the interviews.

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TABLE OF CONTENTS

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ABSTRACT EXECUTIVE SUMMARY RESEARCH DEMOGRAPHICS Geographical segmentation Segmentation by Organisational Type Organisational size Organisational by Service Type and Location The role of it in asias healthcare Introduction The Importance of Electronic Record Management (ERM) Insights Looking Ahead Where Strategic Plans Are Taking Healthcare Insights The Role of Outsourcing Who Decides on IT Investments? Insights Deciding Whats Important Prioritising IT in Healthcare CURRENT CHALLENGES BREAKING THROUGH THE IT BARRIER Finding the Paper Trail in an Age of Innovation Insights Making the Jump and Getting Connected Getting Networked Connectivity in Healthcare Insights CONCLUSION

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TABLE OF FIGURES

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Figure 1 - Respondent profiles by staff role (%). Figure 2 - Respondents by location (%). Figure 3 - Respondents by geographic location from private/ public sector healthcare organisations. Figure 4 - Respondents by size of organisation (%). Figure 5 - Healthcare services by geographical location. Figure 6 - Medical insurance coverage in China from 2003 to 2008.

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9 10 11 12 14 15 17 20 21 23 25 26 27 28 29 31 32

Figure 7 - Relative importance of ERM for the future (% of respondents by location). Figure 8 - Investment areas over the next 1 to 2 years period by geographical location (% of respondents by location). Figure 9 - Areas of focus for a three-year strategic plan (% of respondents by location). Figure 10 - Organisations outsourcing behaviour (% of respondents by location). Figure 11 - Parties responsible for IT investment (% of respondents by location). Figure 12 - Ranked importance of implementing major IT projects. Figure 13 - Improvement area of interest (% of respondents by location). Figure 14 - Dependence on paper-based processes to manage internal workflow and patient care (% of respondents by location). Figure 15 - Whether or not manual paperwork contributes errors and increases risks to patients (% of respondents by location). Figure 16 - Agreement that organisational dependence on paper-based processes has contributed to errors (% of respondents by location). Figure 17 - Whether or not the organisation implemented, or is it in the process of implementing, Electronic Record Management (% of respondents by location). Figure 18 - Time period legally required to keep patient records, even after being stored digitally (% of respondents by location). Figure 19 - Why multifunction devices have not yet been connected to the network (% of respondents by location).

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Abstract
In this study, responses were sought from public sector IT Executives in The Peoples Republic of China, Hong Kong, Malaysia, The Philippines, Singapore, Thailand, South Korea and Taiwan. Respondents were initially contacted by FutureGov Research via email and telephone in September. They were invited to complete an online questionnaire that was hosted on the FutureGov web site between September and October 2009. In all, 172 responses were received before the study was closed in early October 2009. However, not all questions were answered by all respondents and some were not included. A total of 169 respondents were included in this study. In addition, five hospital executives in the region were contacted after the initial analysis had been completed and asked for their anecdotal comments on some of the survey questions. The responses were spread relatively evenly across the countries, with the greatest number of respondents coming from Singapore (49) and the least coming from Taiwan (6). The survey sought to receive from the respondents their thoughts on the current state and use of IT within their organisations, and the strategic value given to electronic record management (ERM) as they moved into the future. Investigated topics included: What is the importance given to ERM? How advanced are public sector health organisations in the region in scanning and imaging for converting paper forms into digital formats? What role does outsourcing play in Asia Pacifics healthcare sector? What have healthcare organisations adopted within their strategic plans as offices move toward greater automation? In order to improve patient care and workflow, who are the decision makers and which departments are involved in IT initiatives? What are the priorities for deciding how to implement major projects?

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Executive Summary
In Planning Ahead Is Asias Healthcare Sector Ready for the Future?, researchers sought responses from public sector IT Executives in The Peoples Republic of China, Hong Kong, Malaysia, The Philippines, Singapore, Thailand, South Korea and Taiwan. The survey attracted 169 complete responses in total, with representation for respective roles being: 32% from senior management; 53% from middle management; and 15% from patient care staff, department coordinators and administrative staff. Just over one third of respondents were employed by government healthcare organisations located in Singapore, with the remainder being roughly split among the remaining countries. The division of respondents coming from public or private hospital facilities was roughly even, with the remaining 4% coming from other medical facilities and clinics. In terms of organisational size, the majority came from organisations with less than 500 staff, and then organisations that were between 501 and 1000 staff members. The majority of respondents (96%) reported that ERM of patient information over the coming years will be Very Important or Somewhat Important. Hence, both frontline staff and the executive office are taking ERM very seriously. Most respondents agreed on the importance of Quality Management in ERM, especially over data collection and institutional transparency. Where outsourcing of IT processes hasnt been fully adopted, this may bedue to a lack of outsourcing agents; that if there are agents, theyhave had difficulties with integrating into the country system; or, as in the case for Chinas particular context, the survey wasnt able to capture the details of the organisations outsourcing behaviour. In areas like Hong Kong, Malaysia, Singapore and Thailand, outsourcing activity has been used for in-house printing facilities, printer management, and document scanning. Deciding how to identify and then fill the gaps is a challenge that is especially pressing in the healthcare sector, and IT Departments have generally been given autonomy and responsibility to decide how IT budgets will be spent. The only responses where IT Departments were not the most responsible for IT investments were from Singapore, where roughly equal decision power is shared by the IT Department, Department Heads and the CEO.

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Executive Summary

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On the whole, respondents considered Increased quality of patient service as the most important measure of whether an IT project should or should not be implemented. Respondents were also highly focused on improving Quality of Service. Singaporean and Thai respondents reported that Return on Investment (ROI) was a concern, and this was correlated to responses regarding improved cost savings. Hospitals and other such organisations are still heavily dependent on paper-based processes to manage workflow and patient care. Results showed that risk to patients seemed to increase when patient data were paper based. The study also measured the length of time that departments were required to keep patient records, even after they were stored digitally. The majority of respondents reported that they were legally bound to keep the records from 4 to 10 years. In the final part of the study, participants were asked why they thought multifunction devices were not yet connected to the organisations IT network. The greatest factors hampering connectivity in the healthcare organisation relates back to procurement and technical issues. Much as staff may want new technology and see it as a means to reduce inefficiency and mitigate patient risk, there remains the barrier of getting the hardware and software and ensuring that it actually works on the ground. Respondents from Singapore and Malaysia also identified Lack of centralised vision during purchase cycles as a possible source of organisational inertia.

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CONCLUSIONS
Improved ERM is a critically important area of concern, where new technologies and customised solutions to patient information must be adopted. Outsourcing is one way of quickly adopting and launching solutions, but the need to have these solutions customised to the local context is crucial. There remains much room for improvement when it comes to adopting scanning and imaging technology to convert paper forms into digital formats. Quality Management around data collection, institutional transparency and improved ERM processes was the most important strategic concern for the future. IT Departments play the greatest role in deciding how IT budgets will be spent for local decisions within an organisation, yet for greater implementation it is up to the Department Heads and the Executive Office to set the vision. Increased risks to patients are believed to come from errors associated with workflows and processes that remain dependent on manual inputting across paper-based methods.

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Research Demographics
The survey Planning Ahead Is Asias Healthcare Sector Ready for the Future? attracted a total of 169 complete responses, with their respective roles indicated by Figure 1 below. Those from senior management positions in the public sector amounted to one third of the respondents, and half came from middle management. The remainder came from patient care staff, department coordinators and administrative staff. The breakdown of respondents by geographical location and by organisational size (in terms of staff numbers) is outlined in the following sections.

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CEO, Managing Director, President CFO/Controller, COO or Chief Administrative Officer (CAO) CIO - IT General Manager Vice President of Operation, General Manager (GM) Senior Management - Vice-President IT Manager Middle or Line Manager, Director, Manager, Head of Dept. etc. Patient care staff, dept coordinator, Administration

u Figure 1 - Respondent profiles by staff role (%).

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Geographical Segmentation
The location of those who responded to the survey is shown in Figure 3 below. As indicated, just over one third of respondents were employed by government healthcare organisations located in Singapore, with the remainder being roughly split among Mainland China, Hong Kong, Malaysia, The Philippines, Thailand, South Korea and Taiwan.

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China Hong Kong Malaysia The Philippines Singapore South Korea Thailand Taiwan

u Figure 2: Survey respondents by location.

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Segmentation by Organisational Type

The division of respondents coming from public or private hospital facilities was 83 and 80, respectively, with the remaining 6 coming from other medical facilities and clinics. Figure 3 details how China, Hong Kong and Singapore were mostly represented from staff working in public sector healthcare organisations, whereas respondents from the remaining countries were mostly represented by professionals coming from private sector.

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90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

China Hong Kong Malaysia The Singapore South Korea Thailand Philippines Taiwan Total

Private Public Other

u Figure 3 - Respondents by geographic location from private/public sector healthcare organisations.

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Organisational Size
Respondents were asked to nominate the size of their organisation, including satellite hospital locations like clinics and offices. They then chose from 7 different options, running the range from less than 100 staff to over 10,000 staff, to the disclosure of uncertainty around staff count. The results from this survey follow in Figure 4 below.

<500 501 to 1000 1001 to 5000 > 5000 Dont know

u Figure 4 Respondents by organisational size (%).

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Organisational by Service Type and Location

With regard to the scope of healthcare services offered by the respective organisations, Figure 5 below provides a breakdown of each, by geographical location. It is of special interest that respondents from Mainland China, which were similarly represented from staff in Medical Care and Specialty Care departments, will likely see a rapidly and dramatically changing landscape over the coming years. This is especially important, as how Premier Wen Jiabaos major healthcare reform will impact on the Asia Pacific healthcare sector predicted to revolutionise public health in China is bound to change the healthcare landscape. Special attention is also brought to the rise in so-called medical tourism, wherein patients from around the world are choosing to undergo elective surgery in countries like Malaysia, Singapore, and, most famously, Thailand. Regions like Hong Kong and Mainland China have been taking strong steps to develop such medical tourism within their borders, and it is assumed that patient/client expectations will likely pressure both private and then public sector healthcare organisations to keep up to speed in both medical care and patient information.

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20% Medical Care 10% Cosmetic Surgery Medical Tourism 0%

China Hong Kong Malaysia The Philippines Singapore South Korea Thailand Taiwan

Specialty Care

u Figure 5 - Healthcare services by geographical location.

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THE ROLE OF IT IN ASIAS HEALTHCARE Introduction
As the worlds largest economy is currently thrown in socio-political turmoil around public healthcare, the US Governments decisions over providing public and/or affordable health coverage for its citizens are bound to have impact on the healthcare sectors in Asia Pacific. An overhaul of how the health insurance and medical sector will cover costs, and the degree to which hospitals will be able to retain staff is expected to dramatically change the medical communities. The carrot and stick approach for care providers to adopt Electronic Medical Records by a certain deadline, as stipulated in the US stimulus legislation, will have its implications felt in the US as well as trickling through to Asia Pacific. Moreover, the massive overhaul of Mainland Chinas healthcare sector, this from what is emerging as the worlds next-largest economy, will only increase the complexity and impact on healthcare delivery around Asia Pacific and beyond. On the one hand, the massive investments spearheaded by Premier Wen Jiabao will likely spur major opportunities throughout Asia Pacific, and on the other hand, these investments may attract medical professionals away from their home countries leading to a dirth of qualifieid professionals in other countries. This may apply to both medical staff as well as health IT specialists required to plan, upgrade and maintain systems. It is generally understood the lack of qualified health IT professionals is a severe problem impeding greater leverage of IT within the care providers across the region. Over the next decade, the countrys much-anticipated reform to fix the ailing medical system is slated to begin, and the task of delivering fair and affordable healthcare to all its 1.3 billion citizens will likely have consequences that will continue for many years to come. Of special note, the divide between the relatively advanced urban healthcare infrastructure, as compared to the very basic healthcare services in rural China, which is often non-existent in certain areas will need to be addressed. Dr Hans Troedsson, the World Health Organizations representative in China, said WHO is pleased to see that the Government of China has made a firm commitment to universal coverage of essential health care. He later added that, however, China has a long way to go in terms of improving equity in financing and provision of essential health care for all.

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1200 1000 800 600 400 200 0

2003 2004 2005 2006 2007 2008

90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Population (millions) Coverage Ratio

u Figure 6 - Medical insurance coverage in China from 2003 to 2008.

*Source: 2003-2007 data from the Chinese Ministry of Human Resources and Social Security; 2008 data from the National Statistics Bureau of China.
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After three years of intense debate, The Central Committee of the Communist Party of China and the Chinese Cabinet issued the Guidelines on Deepening the Reform of Health-care System. The goal was to deliver a basic universal health-care system by 2020. On the roadmap for reaching this goal, a 3-year implementation plan was recently launched. An investment of US$124billion has been secured and healthcare service providers around the world will likely be affected. This impact represents huge opportunities for Chinas rapidly developing healthcare sectors, with massive investments being made in both securing better facilities and qualified staff, but these changes will spark equally massive new challenges, especially around staffing in all the countries surveyed in this study. The challenges likely to unfold will affect how hospitals, service providers and administrative departments use IT to manage the significant waves of patient records that the overhaul will trigger. For IT executives and their staff, these pressures will place even greater expectations by their national programmes to deliver effective and efficient support. Understanding the context and available resources is what was explored in this next part of the study.

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The Importance of Electronic Record Management (ERM)

In a widely cited paper, Richard Hillestad et al argued that adoption of electronic medical records by healthcare providers brings significant economic and efficiency savings, as well as dramatic safety benefits (Health Affairs, September 2009). This was certainly supported by the respondent data in the current report, as the vast majority of respondents (96%) in the study reported that ERM of patient information over the coming years will be Very Important or Somewhat Important (Figure 7). Of the surveyed countries, the research revealed that respondents from The Philippines felt that a solid ERM was most urgently needed.

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100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
China Hong Kong Malaysia The Singapore Philippines South Korea Thailand Taiwan

Very important Somewhat important Neither important nor unimportant Relatively unimportant Very unimportant

u Figure 7 - Relative importance of ERM for the future (% of respondents by location).

In the next section, investment areas that needed more immediate attention were explored. Figure 8 on the next page shows which areas would be addressed over the coming two years, which for an IT project can be considered a very short timeframe. This means that if the hospital or facility hasnt already committed to these new systems, they have likely at least identified and planned to commit to them in the very near future.

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Centralised web-to-print on RESEARCH demand form management Electronic distribution of documents Workflow automation to reduce costs and errors None of the above

Scanning and imaging to convert forms into digital formats

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Hong Kong Malaysia

The Singapore Philippines

South Korea

Thailand

Taiwan

u Figure 8 Investment areas over the next 1 to 2 years period by geographical location (% of respondents by location).

From the respondents, we see that although IT executives and their staff agreed that ERM is a major point of concern, only more than half of respondents from China, Hong Kong and Malaysia could confirm that they were already committed to addressing ERM over the coming 2 years. Surprisingly, these three countries/territories also showed relatively fewer commitments to bringing better scanning and converting to digital formats. The three were also relatively less committed to launching centralised web-to-print ondemand ERM. Where these countries did show significant measures for commitment was in workflow automation to reduce errors. It is also worth noting that the majority of respondents from Hong Kong and China were from the public sector (61% and 81%, respectively), whereas the similar trends coming from Malaysia were shown from respondents mostly coming from private sector facilities (78%). This suggests that Hong Kong and Chinas public sector had already committed to ERM enhancements, whereas the private sector in these countries have either already settled these issues, or have not yet committed to them. Notably, respondents from Thailand and Singapore showed strong interest in scanning and converting documents to digital formats, as well as enhancing workflow automation in order to reduce costs and errors. Furthermore, about a third of respondents from Taiwan saw centralised print-on-demand as needed. It is also worth noting that respondents from The Philippines and China had significant responses as None of the Above, suggesting that although improved ERM may be needed by these respondents, the precise nature of these improvements fell outside the boundaries set by the survey.

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Insights Singapore CIO at a public hospital

From our conversation with a Chief Information Officer at a Singaporean private hospital, he asserted that the most important area he saw was in getting the right information at the right time. Getting relevant, timely information throughout the organisation was crucial, something he felt was the most important contribution that IT brought to healthcare. In older, paper-based systems, a person had to be on site in order to view a patient record. The innovation of IT across the enterprise, however, now let staff view information from multiple areas, and not only where those records were physically stored. If access is the greatest benefit, then the greatest challenge is how to digitise and capture all records electronically, and make it useful and relevant. Capturing and scanning is relatively straightforward, but effective and targeted retrieval is very difficult. Questions he has faced are what documents get scanned and how will they be archived? And would records be duplicated? Hence, he would like to see improvements around scanning technology. Active scanning is very easy to do, but to scan an old document, even if its only one year old with a different record format, means that making sense of an irregular, older format becomes a challenge. With scanning, he has found that it is much easier to go from the present forward, than to go back in time and use older formats. For this reason, his ERM could be improved by addressing user-interface. As there are multiple departments that must be catered to, a well designed user-interface is crucial. Poorly designed interfaces will make doctors unhappy, as their day is stressful enough without having to get bogged down by an interface that complicates the process. At his hospital, they hadnt yet faced the ERM challenge in documents. Designing documents, either into structured or unstructured formats for full user acceptance, remains a big challenge. This calls for a paradigm shift for many people. Although efficiency is very important, it is equally important that the documentation interface and utility handles issues in hand-writing, typing and other similarly changing dynamics. At his hospital, theyve been struggling with some of the designs they have adopted. The greatest problems have been in defining what data points, and hence, data type, to use to help standardise the information intake. If forms werent well thought out and carefully designed, one department may find itself using one form while another department creates information noise because of small differences in use. And this only creates big headaches down the line. As he put it, if you have a user problem, you have a design problem; if you have an interface problem, you have IT and business process problem. Hence, he said balancing needs versus resources is the most critical issue that needs to be addressed. Prioritising resources to help everyone across the board was the most pressing concern, and the next issue for hospitals was that there are many platforms available, and the pressure to buy different system to meet specific needs always crops up. Again, standardisation has become an issue. New modules and new applications must have seamless integration, which is not what he has seen. And finally, there remained the issue of hardware. As hospitals increasingly depend on IT, having so many independent hardware components at different locations makes the availability of a shared network all the more important.

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Looking Ahead Where Strategic Plans Are Taking Healthcare

Whereas the previous section asked what organisations had committed to over the next two years, this part of the study explored what healthcare organisations were aiming to achieve over the coming three years. In the former, investment areas were a measure of the tools or systems that were currently needed, and in this latter part the aim was to get a sense of what a target for the future may look like. From Figure 9 below, the areas respondents had to gauge included enhanced quality management, improving workflow efficiency, building strategic partnerships, improving access to information, improved elder-care services, compliance, preparing for pandemics, staff retention, and more.

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Quality Management (data collection, transparency, ERM processes, etc.) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
China Hong Kong Malaysia The Singapore Philippines South Korea Thailand Taiwan

Efficiency of document/Forms/ paper processes and workflow Strategic partnerships Acquisition of high-quality care patients Achieving cost reduction New Elder care services Improve Access to Clinical information Outcome Quality & Safety, Compliance Review and Audits Building operation efficiency and readiness for Pandemic Increase quality of patient related services Retain and attract the best nursing staff and physicians Other

u Figure 9 Areas of focus for a three-year strategic plan (% of respondents by location).

A review of the responses shows multiple trends, but the most significant one revealed a general consensus around Quality Management. This one area was felt as the most important strategic concern for the future. For all countries, except for South Korea and Taiwan, which ranked Acquisition of High-Quality Care Patients and Achieving Cost Reduction, respectively, higher, Improved Quality Management was ranked highest, with the Singaporean respondents showing the least pronounced concern. For the other countries, quality management around data collection, institutional transparency, improved ERM processes and the like were at least twice more important than any of the other areas. This is likely when one considers how the future promises to be even more data-dependant.
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www.futuregov.net The countries that listed Quality Management as most important were China, Hong Kong, Malaysia and Thailand. As we saw earlier, the majority of responses from China and Hong Kong came from the public sector hospitals, whereas Malaysia and Thailand (80%) were from the private sector. This may be the case because the former countries have more public hospitals than private ones, but it can also be because across both private and public sector hospitals in these countries have yet to fully address shortcomings in these areas. Clearly, effective management of information is expected to occupy a significant portion of the respondents future. Of these, respondents from China showed the greatest concern, with nearly 40% of respondents noting that quality management must be addressed. Looking at the other end of the scale, folding new elder care into the strategic plan registered among the lowest among the respondents. This is quite surprising, given the predicted rise in the elder population in most of Asia Pacifics countries. One explanation of this finding could be that as an IT-related issue, improved elder care may simply not have yet registered on respondents awareness. Much as elder care may be a growing concern in the geriatrics ward, among sociologists, economists and the like, this may not have registered yet as a growing concern among the IT professionals and administrative staff. Another area of high interest is around increased quality of patientrelated services. This may be due to the increased presence of competing organisations in the patient market, and the rising awareness that patients are increasingly deciding where they seek their healthcare services. Improving the patient experience is an important part of practiced medicine, and improving the admission, stay and overall patient experience seems to be something that healthcare practitioners are paying more attention to. This seems to suggest that although respondents felt that improving how patient information is recorded and managed needs attention, respondents didnt feel that improving how this information is accessed is as important. This may also suggest that at this stage of the hospitals development, they just havent yet begun to address the complex issue of timely information access and its direct impact to patient safety and care quality improvement.

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Insights China CIO at a private hospital

In our conversation with a CIO from Mainland China, it became immediately apparent that the greatest hurdle facing his organisation was simply transferring knowledge and data in a timely manner. As admissions, diagnostics and treatment feel the pressure of an increasingly stressed healthcare system, the need for effective and networked internal communications is increasingly seen as a means to alleviate those pressures. That said, there remained a gap in terms of what information was even available in the first place. As to what would be the most useful and effective solution to this executives current needs, he too felt that current scanning technologies werent adequate for solving the issues in document management, even if hospitals found it the most practical way to get things onto a digital platform. An automatic means to capture scanned forms and documents and transpose them into electronic formats into the database would be perfect, he explained, although he doubted that there was a system out there that could decipher the physicians writing.His organisation was very much oriented around capturing information through manual input than through automated systems. When discussing how he would like to improve the automated systems that dealt with patient records, he said his preference was for commercial, off-the-shelf software, which he would like to use as much as possible. However, these had to come at a reasonable cost and be easy to implement. Having very limited manpower to deal with new system setup and rollout, he didnt want his staff bogged down with maintaining new systems. As he saw it, ongoing maintenance was the vendors responsibility. Moreover, any new system was chosen depending on whether it could be integrated within the hospitals current ERM or not. Doctors simply would not use the new system if they could access some information on the ERM but had to pull documents from another application. At his organisation, how they decided upon budgetary limits and systems to finance was by inviting various vendors to come present their ERM solutions. Based on these options, the hospital would make its investment; the hospital did not specifically budget for new systems adoption. For this reason, the financial downturn did not affect the hospitals IT strategic plans, even when many other factors did. His hospital conducted a four year plan for their IT upgrades, including the ERM, and that was not affected by the financial downturn, acute though it may have been. At the heart of the change into new ERM systems at his hospital was the fact that the country legalities prevented electronic documents in a court of law. That was clearly a hurdle that needed to be addressed. Moreover, how to make sense of the data within a scanned document is problematic, a point common to almost all respondents in the survey. Ultimately, the heart of the issue of a systems success and usability, or so he believed, transcended the healthcare-specific context. User acceptance remained the critical and deciding factor. He felt that despite the socalled healthcare boom in Asia, most hospitals remained pen and paper institutions; what he called paper-ful and not paper-less. Breaking through the barrier, he continued, may require the talents of a visionary leader, which really boils down to luck. Change management is the other, more systematic approach. He believed that how to get users into the habit of capturing the information or document whenever it is generated is the point, and the challenge. Hence, user interface played a big role in letting this change happen. Currently, there has been much talk around implementing electronic health records by taking the approach of a central repository. However, whether all the information can be meaningfully captured and stored or not, and making sense of the information captured in those files, is an issue that remains unsolved. On the next level it remained the same challenges that have been seen across Asia Pacific and beyond: ensuring a secure platform where the right professionals and staff get access at the right time. Doing so just from within the hospital has been problematic, and it remains to be seen if a system that works across organisations can be developed and implemented.

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The Role of Outsourcing

For many hospitals and other healthcare organisations struggling to keep up with the waves of information, outsourcing to an outside vendor is often seen as the right solution, at least while the hospital finds its bearing. The financial advantages and incentives can be significant and critical, especially when the outsource agent can deliver or respond with timely, customised solutions. Figure 10 below details replies to the question of outsourcing in todays healthcare facilities.
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
China Hong Kong Malaysia The Singapore Philippines South Korea Thailand Taiwan

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u Figure 10 - Organisations outsourcing behaviour (% of respondents by location).

The results reveal an interesting correlation between the need for solutions and the degree to which an organisation will outsource to solve the challenges being faced by the organisation. For example, in locations like China, which communicated the need for improved ERM within the organisation, there hasnt been much in the way of getting help from an outsourced party. This may be due to the fact that there is a lack of outsourcing agents; that if there are agents, they have had difficulties with integrating into the country system; or that the survey simply didnt capture the route that China has taken in its outsourcing. In areas like Hong Kong, Malaysia, Singapore and Thailand, there are a few areas that have seen relatively strong outsourcing activity, such as in-house printing facilities, printer management, and document scanning, respectively. Respondents have clearly indicated the need for enhanced ERM, even the need for outsourcing in order to solve the problems they are facing in their daily workload, and yet the move towards outsourcing hasnt caught up. The demand may be strong but there is a lag in securing delivery.
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Who Decides on IT Investments?

Deciding how to identify and then fill the gaps is a challenge that is especially pressing in the healthcare sector. If outsourcing is an untapped resource since it can provide the quickest path to efficient implementation and reduced waste there may be organisational inertia from the decision makers themselves, delaying the push to outsourcing due to anticipated investment potential. Hence, the report paid special notice to the decision makers in both private and public sector healthcare organisations, in order to identify who on staff has the power and capacity to bring about the muchneeded change. In Figure 11 below, the management office and staff responsible for identifying and investing in the needed change are listed by geographical location.

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100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Procurement IT department CFO or Hospital controller Logistics Department Board of directors Government Officer or Representative Head of department CEO Clinicians Other
China Hong Kong Malaysia The Singapore Philippines South Korea Thailand Taiwan

u Figure 11 Parties responsible for IT investment (% of respondents by location).

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www.futuregov.net Generally speaking, IT Departments are given enough autonomy and responsibility to decide how IT budgets will be spent. This makes sense, as these professionals are generally well suited for knowing what is out on the market, what will fit the needs of the organisation, and they will have the contacts for purchasing and installing the new systems. The only responses that indicated that IT Departments were not the most responsible for IT investment were from Singapore and Taiwan. In these two countries, roughly equal decision-making power is shared by the IT Department, Department Heads and the CEO. A telling result is seen in respondents from China, where the secondmost powerful deciding power came from a Government Officer or Representative. In all these other countries, such a Government Officer ranked among the lowest in the hierarchy of IT spending decision making. It is also interesting to note that clinicians play a relatively minor or completely removed role in terms of the IT decision-making process. Although clinicians are likely involved in some of the operations that involve scanning, capture and other ERM processes, and they may have good input in terms of fulfilling their needs on the operational level, the results suggest that what hardware and software is at their disposal is decided by more technical professionals.

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Insights Hong Kong IT Manager at a public hospital

From one of our one-to-one interviews, it became clear how the Hong Kong Hospital Authority (HA) created a unique reality in the citys healthcare landscape. The HAs top-down decision-making process with regard to new IT systems meant that IT managers at his hospital were exclusively focused on installing or updating new systems that were defined by the HA, leaving the strategic issues for IT essentially outside of the hospitals mandate. He said this is common in Hong Kongs healthcare organisations. Hence, the greatest challenge for Hong Kongs IT executive is with working within this framework of implementing new IT systems from a coordinators perspective, and not from the users. Frontline and administrative staff that use the systems are the users, and as far as his duties were concerned, their needs were beyond his areas of control. He then added that he did not decide which new technology to implement be it an updated or improved ERM system but to ensure that once defined or designed by the HA, the updated systems rolled out on schedule and on budget. He then commented that although Hong Kongs healthcare system effectively took him out of directly serving users needs, he believed the remaining concern from users remains whether or not ERM systems were user-friendly. He said that once patient information was been stored, a key concern he regularly faced was how this data gets aggregated for use. There remained the need to define and store the data so it is useful and accessible. He concluded by pointing out that the HA was currently pushing public and private hospitals towards shared patient records across platforms and institutions. Having data so easily available will be a great benefit to clinicians, staff and patients, but there were privacy issues that needed attention. He anticipated a roll out to occur over the next 2 to 3 years.

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Deciding Whats Important Prioritising IT in Healthcare

Respondents clearly communicated that IT departments are among the leading voices for choosing how and on what to invest on when it comes to IT-related spending, followed by the executive office and the CEO. Yet how do they decide what to invest in, and more importantly, what benchmarks or other measures are used to decide whether or not the investment was sound? In the following part of the study, as detailed in Figure 12 below, respondents were asked to rank and prioritise the importance of 7 measures against the backdrop of an implemented IT project.

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Thailand Taiwan
Ranked as Relatively Unimportant (50%) Ranked as Most Important (50%)

China Return on Investment within 2 years Matches focus and mission of the hospital/ organisation Increase efficiency of the Human Resources We have endof-the-year budget to spend Increased quality of patient service Differentiate ourselves from other hospitals Matches strategic initiatives to insure a proper "balanced scorecard"
Ranked as Least Important (86%)

Hong Kong
Ranked as Least important (61%) Ranked as Relatively important (61%)

Malaysia

The Philippines
No significant trend

Singapore
Ranked as Relatively Unimportant (52%) Ranked as Relatively Important (91%)

South Korea
No significant trend

No significant trend

No significant trend

No significant trend

Ranked as Relatively Important (73%)

Ranked as Relatively Important (57%) Ranked as Relatively Important (67%)

No significant trend

Ranked as Relatively Important (50%) Ranked as Relatively Important (18%) Ranked as Least Important (33%) Ranked as Most Important (67%) Ranked as Relatively Important (56%)

Ranked as Relatively Important (95%) Ranked as Least Important (95%) Ranked as Most Important (86%)

No significant trend

No significant trend

No significant trend

No significant trend

No significant trend

No significant trend

No significant trend

No significant trend

Ranked as Least Important (48%) Ranked as Most Important (39%) Ranked as Most Important (23%)

No significant trend

No significant trend

Ranked as Most Important (83%)

Ranked as Most Important (59%)

Ranked as Relatively Unimportant (86%) Ranked as Most Important (48%)

No significant trend

No significant trend)

No significant trend

No significant trend

No significant trend

No significant trend

No significant trend

Ranked as Relatively Important (95%)

No significant trend

Ranked as Least Important (40%)

Ranked as Least Important (48%)

Ranked as Relatively Important (68%)

Ranked as Relatively Important (37%)

Ranked as Relatively Important (89%)

Ranked as Least Important (67%)

Most important

Relatively important

Relatively unimportant

Least important

u Figure 12 Ranked importance of implementing major IT projects.

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www.futuregov.net For each item, respondents needed to rank it on a scale of 1 to 7, corresponding to a scale of Most Important to Least Important. When responses varied and the data points were scattered across the scale, this is indicated in the Table as No significant trend. Where there was a significant trend in the data, the percentage of respondents that had chosen that particular ranking is provided. The Table reveals how most respondents considered Increased quality of patient service as the Most Important measure of whether an IT project should be implemented. This is sensible enough, as a healthcare organisations mission is, after all, to serve patients. A very surprising result was that 86% of respondents from The Philippines measured improved patient service as Relatively Unimportant. Nearly half of the respondents from The Philippines ranked Differentiate ourselves from other hospitals as Most Important. Although there was general consensus on what was Most Important, there was no such trend in what was considered Least Important. From the Chinese respondents, nearly 90% considered an ROI of 2 years as Least Important. The Hong Kong respondents were similar, with two-thirds giving the same rank. Matches strategic initiatives to insure a proper balanced scorecard was something the Malaysian and the Philippines respondents felt was Least Important. Half of the respondents from Singapore and a third of respondents from Thailand felt that We have end-of-the-year budget to spend was Least Important.

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CURRENT CHALLENGES BREAKING THROUGH THE IT BARRIER

In the previous section, seven areas for discerning between IT projects were ranked with regard to the organisation, yet these were not necessarily indicative of what respondents personally felt needed specific improvement. In the following section, respondents were sampled to find out which areas they were more interested in. Again grouped by country, results in Figure 13 show respondent interest in terms of patient or physician satisfaction; cost savings and ROI; public image; quality and efficiency of care; and more. As in the previous section, respondents were highly focused on improving the Quality of Service, with Malaysian respondents rating patient satisfaction higher. This is a surprising finding, as one could assume that reaching high patient satisfaction is the priority. However, taken from the service providers perspective, improving the service quality could be a technical or operational improvement that may be more tangible than focusing on patient satisfaction, much as that was considered very important.
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
China Hong Kong Malaysia The Singapore Philippines South Korea Thailand Taiwan

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Patient satisfaction Physician satisfaction Cost savings Public image Quality of service Efficiency of care Return on investment Other

u Figure 13 - Improvement area of interest (% of respondents by location).

Singaporean and Thai respondents felt the ROI was a concern, and this was correlated to responses regarding improved cost savings. This may have been a result from a higher skew in the respondents coming from the executive office, people whose professional concerns are likely tied to such financial performance measures.

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www.futuregov.net The highest-ranked score was seen in the group from China, where two-thirds felt that improvements in quality of service was needed most, compared to a score of less than 10% for patient satisfaction. This result may have come from the pragmatic desire to deliver adequate or satisfactory care, given Mainland Chinas current challenges that were discussed above.

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Finding the Paper Trail in an Age of Innovation

Whereas past technological innovations delivered better and faster means of paper and image reproduction, the current trend is leading towards paperless or digital technologies. In the previous sections, the study attempted to describe who decided what IT projects would be implemented, and what were the aims and the medium-term objectives. In the following section, illustrated in Figure 14, responses were taken to better understand what the current environment is in the healthcare organisations, especially in light of paper-based record keeping.

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100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
China Hong Kong Malaysia The Singapore Philippines South Korea Thailand Taiwan

Yes, were still dependant No, we arent

u Figure 14 Indication of an organisations dependence on paper-based processes to manage internal workflow and patient care (% of respondents by location).

Clearly, hospitals and other such organisations are still heavily dependent on paper-based processes to manage workflow and patient care. Surprisingly, respondents from technologically advanced cultures like Hong Kong and Singapore were outperformed by respondents from The Philippines and Mainland China. That respondents from Mainland China, South Korea and Taiwan were about evenly split, as opposed to the other respondents, seems inconsistent with perceptions of lacking infrastructure (e.g. in Mainland China) or advanced healthcare (e.g. South Korea) and may deserve further investigation.
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www.futuregov.net The follow-up question in the study was whether or not paper-based patient records were responsible for added errors or increasing risks to patients. Naturally, human error could also be involved when digital processes are used instead of paper-based ones, but many such IT innovations have been designed to reduce or remove the human-error factor. Figure 15 below illustrates responses to this question, recording the perceptions that human error plays in record keeping and the relation it may have to increasing the risk to patients.

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100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
China Hong Kong Malaysia The Singapore Philippines South Korea Thailand Taiwan

Yes No

u Figure 15 Whether or not manual paperwork contributes errors and increases risks to patients (% of respondents by location).

Again, it is interesting to note that respondents from China, The Philippines and South Korea had similarly matched results, and were somewhat evenly split on the question. Respondents from Malaysia and Singapore were closely matched in that risk to patients did increase when patient data were paper based, and these results were closely matched by Hong Kong respondents. That all the respondents from Thailand felt the risk was real indicates the strong favour towards moving to a more digital platform, as since nearly 90% of Thai respondents had indicated that their healthcare facilities were essentially dominated by paper-based processes.

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www.futuregov.net By comparing the findings of the previous sections, an even stronger correlation emerges. Figure 16 below reveals the relationship between the dependence on paper-based processes to manage internal workflow and patient care, and whether or not manual paperwork contributes errors and increases risks to patients. This is especially telling, as it shows what IT executives and staff feel is missing, if at all, and what may be needed to fill that gap.

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120 100 80 60 40 20 0
China Hong Kong Malaysia The Singapore Philippines South Korea Thailand Taiwan

u Figure 16 Agreement that organisational dependence on paper-based processes has contributed to errors (% of respondents by location).

All respondents from China, Hong Kong, Malaysia and Taiwan that had a dependence on paper-based processes indicated that this was what contributed to errors and increased risks to patients. In other words, for these respondents, this outdated dependence invariably led to error. Similarly strong but not absolute agreement was seen in respondents from The Philippines, Singapore and Thailand and South Korea, with the relatively lowest fraction of three-quarters of respondents from The Philippines were in agreement that that organisational dependence on paper-based processes has contributed to errors.

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www.futuregov.net Next, as shown in Figure 17, results were gathered regarding paper versus digital-format record keeping. From the Chinese respondents, for example, where roughly half said their processes were paper based, it was observed that about half of the respondents reported that their organisation had or was in the process of implementing an ERM. Similarly, nearly 40% of respondents from The Philippines and 62% from South Korea reported that their organisation had completed the roll-out of an ERM system. As well, around 80% of respondents from Hong Kong, Malaysia and Singapore reported that their organisation was in the process of introducing an ERM. It is of interest as well that a small but significant fraction of respondents from China, Singapore, South Korea and Taiwan were unaware of any plans to implement an ERM in their organisation.

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100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
China Hong Kong Malaysia The Singapore Philippines South Korea Thailand Taiwan

Yes, completed Yes, in progress No, but we plan to implement No, and we have no plans to implement

u Figure 17 Whether or not the organisation implemented, or is in the process of implementing, Electronic Record Management (% of respondents by location).

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Insights Hong Kong CIO at a private hospital

From our conversation with a Chief InformationOfficer in Hong Kongs healthcare sector, the greatest impact to date has been seen in customer service. One example is with queue display, letting people at admissions know how long they are going to wait. This relatively straightforward utility has reduced intake stresses simply by letting people know wherethey are in the queue. Surprisingly, this CIO did not feel that current scanning technologies offered enough within the healthcare context. As things stand, documents are essentially captured as image files, leaving much of the recordsincomplete and impossible to make sense of in an automatic manner, thus needing further data entry. Many Hong Kong hospitals, like Hong Kong Sanatorium and Hospital, Hong Kong Baptist Hospital and others, do include scanning in their processes, however they are limited in terms of how deeply the technology can capture and classify the information. At his hospital, for example, there remains a need to help staff capture and classify the information within patient records. Physicians typically shy away from excessive data entry, and yet to segregate and aggregate information with current technologies requires an excessive amount of such manual data entry. Part of this has come from the difficulties in managing patient records, especiallywith regard to storage. This has also engendered issueswith integration will information be freely shared within different departments? From his experience, Hong Kong has clear guidelines on how to process paper-based information,both for keeping paper records and how manyyears to keep it. For electronic files, however, the guidelines arent as clear. If electronic copies are kept, he said it was fine as long as they cant bemodified. Electronic files can be changed rather easily, so from a legal standpoint, informationaccess and protection needed to be addressed. As far as he is concerned, the greatest area in need of improvement for ERM solutions was in the area of accurately and automatically capturing information stored on documents. For now, as part of the legal requirement, the organisation was still warehousing the older patient records in paper offsite. Moreover, his hospital tries as much as possible to input the data into a structured database without the need to scan the documents. Thus, the top-three most important factors deciding the hospitals future plans for ITinvestments were to get clear identificationat the admissions level. Hong Kong has theelectronic HKID , but, for example, as manywomen are now coming over from MainlandChina as visitors and changing their visa permitsevery three months, their identification documents keeps changing. Getting a clear means of identifyingand tracking patients is a major issue. Another critical factor was around sharingpatient information across the hospital an integration issue that created errors and redundancies he wished werent there. The thirdfactor regarded security access. The hospital has patients who need or want increased security or protected access, and this was an area hedefinitely wanted to be enhanced. Nevertheless, the overarching challenge remains to create a workflow wherein patient information gets affectively logged and parcelled for later use.

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Making the Jump and Getting Connected

The study then measured the length of time that departments were required to keep patient records, even after they were stored digitally. As many organisations from around the world are faced with decreasing storage space for their patient records, the move towards digitisation of records clears physical space, which in many organisations is at a premium. Figure 18 below illustrates the responses, with only a very few reporting that the organisation was required to store the information for less than two years. A small fraction of Singaporean respondents reported that they were duty bound to keep the records for less than 1 year. The great majority of respondents reported that they were legally bound to keep the records from 4 to 10 years, and it is supposed that some may even need to keep them for longer periods of time.

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
China Hong Kong Malaysia The Singapore Philippines South Korea Thailand Taiwan

Less than 1 year 1-2 years 2-4 years 4-10 years We are not legally required to keep a hard copy of patient records

u Figure 18 Time period legally required to keep patient records, even after being stored digitally (% of respondents by location).

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Getting Networked Connectivity in Healthcare

In the final part of the study, participants were asked why they thought multifunction devices (MFDs) were not yet connected to the organisations IT network. By MFDs, researchers meant copiers, printers, scanners, email utilities, all linked to archives, data repositories and all-in-one information/IT solutions. Figure 19 below provides a percentage breakdown by location, showing which 4 or more reasons could be used to explain the lack of an MFD platform.

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180 160 140 120 100 80 60 40 20 0 Procurement issues IT issues Lack of centralised vision during purchase cycles Organisational issues All of the above Other
China Hong Kong Malaysia The Singapore Philippines South Korea Thailand Taiwan

u Figure 19 - Why multifunction devices have not yet been connected to the network (respondents by location, multiple selections allowed).

When it comes to leveraging on the power of new IT devices and the benefits that they deliver to a department, having access to network functions is among the top benefits. Part of what makes todays capture-and-storage devices so appealing is that once the information has been stored in a central repository, it can later be accessed and cross-accessed by multiple users and for multiple uses. Hence, identifying resistance points or reasons why these devices havent been fully exploited is helpful for reducing waste, streamlining patient-data retrieval processes, and more. From the respondent data, it would seem that the greatest factors hampering connectivity in the healthcare organisation relates back to procurement and technical issues. In many cases, simply getting the technology in house is the main barrier, and in many other cases departments must find solutions that will specifically help the organisation within its context. A review of the data suggests that much as staff may want new technology and see it as a means to reduce inefficiency and mitigate patient risk, there remains the barrier of getting the hardware and software and ensuring that it actually works on the ground.
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Of note, respondents from Malaysia, Singapore and South Korea identified Lack of centralised vision during purchase cycles as a possible source of organisational inertia on the matter. This is especially interesting when matched to the responses of who was most responsible for decision making around IT acquisitions. Given that IT Departments, which generally have the technical knowledge needed to decide what is needed and how to use it, arent charged with the task of leading the organisation, it would seem that it is up to the CEO and the Executive Office to rise and lead in a more concerted effort.

Insights IT Director at a private hospital in the Philippines

When we spoke with an IT Director at a private hospital in Manila, he identified the issue of how to reduce errors in record keeping as the greatest area of concern. On the one hand, the facility was introducing new technologies very aggressively, yet there was still an excess occurrence of problems in information gathering. This has led to compounding issues down the line. Having come from the commercial sector, he found it surprising to see how hard it was to get a clean bill of health with regard to the hospitals ERM. On this point, he was happy to report that the hospital will be implementing an updated programme in the coming year, one that would unify multiple departments and that aimed at acquiring both new systems and deliver better training. At the heart of the IT effort were the technologies to replace the mounds of paper that were physically piling up. Record keeping has been especially challenging as diagnostic tools have progressed, and making the transition from paper-based processes to the latest IT is what he will be focussing on in the coming two years. Even just getting the obvious advantages, let alone the full potential from their new ERM, has been an issue. He believes that now that the hospital has a clearer path with targets for both IT and HR, they will see significant improvements in the near future.

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CONCLUSION
Planning Ahead Is Asias Healthcare Sector Ready for the Future? aimed at describing and capturing the fractured image of IT in healthcare in Asia, especially under the major changes that are anticipated to follow in the coming medium to long term. As healthcare costs and needs from a bigger, older and more discriminating population rise, so too will the challenges bloom for public and private healthcare organisations. Not only will physicians, nurses and support staff need to have the technical skills to serve their patients, but so too will the administrative and operational systems also need to work smoothly and efficiently. From the results, the following conclusions were found: Healthcare professionals across the region and organisational hierarchy see ERM as a critically important area of concern, where new technologies and customised solutions to patient information must be adopted. Where some countries have adopted more comprehensive IT platforms, they are being used and valued. In countries where these networked ERM solutions have not yet been adopted, the need remains. Healthcare professionals from across the organisation in both private and public sectors recognise that outsourcing is one way of quickly adopting and launching solutions, but the need to have these solutions customised to the local context is crucial. There remains much room for improvement when it comes to adopting scanning and imaging technology to convert paper forms into digital formats. In both the public and private sectors, although there are many cases where paperless systems are in place, they hardly work across the organisation or on the national level. Quality Management around data collection, institutional transparency and improved ERM processes was the most important strategic concern for the future. Increased risks to patients are believed to come from errors associated with workflows and processes that remain dependent on manual inputting across paper-based methods. IT Departments play the greatest role in deciding how IT budgets will be spent for local decisions within an organisation, yet for greater implementation it is up to the Department Heads and the Executive office to set the vision. If organisations havent yet scaled up to meet the challenge, it may be due to a lack of effective leadership or resistance to change, even if the benefits are clearly perceived.

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