Asian IT Case Centre

Case No: ES-002

Date: May 7, 2008

Say Yen Teoh, Shan-Ling Pan, Paul Wang

The Alexandra Hospital: Implementing Healthcare Information Systems

“We are a relatively small hospital with a big vision. We aim to improve health and
reduce illness via providing a patient-centered quality healthcare system that is
accessible, seamless, comprehensive, appropriate and cost-effective to everyone”
- Director of Projects

Alexandra Hospital (AH) was restructured on 1 Oct 2000 and became part of the National Health
Group (NHG). In Jan 2004, the Minster for Health challenged the hospital’s management to create a
hassle-free, patient-centric hospital to be located in the Northern Singapore in 2009. The process
restructure includes introducing new ways of working as well as redesigning healthcare services
around the patient’s needs. Ensuing a paradigmatic shift in the hassle-free healthcare delivery, the
Director of Projects noted:

“The Health Minister actually challenged AH, citing us as the pilot prototyping centre,
to put patients at the center, and to see how we can evolve a model of care that could
continuously focus on patients. The change of service paradigm would need lots of
creative work and thinking…”

However, being one of the smallest hospitals in Singapore with limited resources, Alexandra Hospital
had to strategically arrange for the change. Leading the challenge of this transformation is the CEO,
Mr. Liak Teng Lit. Setting a phenomenal standard for the healthcare industry in Singapore, Mr. Liak
told the AH team, “Patients are our priority and we will go out of our way to improve our
environment and to ensure quality and safer medical service. Best practices from other organizations
are also adopted to deliver effective and efficient quality service.”

Since then, AH has undertaken many initiatives to upgrade its major facilities to serve the patients
better, focusing on creating a pleasant environment and providing a “Wow” level of service. As a
result of AH’s constant push to improve the overall patient experience, it has consistently rank the 1st
in the Ministry of Health Patient Satisfaction Surveys from 2004 to 2007. Such encouraging outcomes
have built AH confidence to become the Mayo Clinic of Asia, with the aim to build a patient-centric,
hassle-free hospital. In achieving the aim, the CEO of AH explained:

“A new drive to construct healthcare and information systems that could radiate the
perspective of the patient, whereby the integration and coordination on the wealth of
information assets possessed by the hospital is crucial.”

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Alexandra Hospital ES-002

With a clear vision in mind, AH began to scrutinize their work processes to identify bottlenecks,
review the existing patient care processes, and also rethink how to enhance patient services via the
exploitation of technology. Reducing waiting time and other administrative processing time also
become the main targets in the transformation plan. AH worked closely with the IT industry partners
to embed these hassle-free concepts into the new IT systems: Healthcare.NET was initiated on 18
November 2004 with collaborative participation from AH, Infocomm Development Authority of
Singapore (IDA) and Microsoft Singapore. On a separate track, AH also collaborated with Cisco
Systems on 14 February 2006 to exploit its smart-phone solution for the Bed Management System
(BMS).

The main objective of the above mentioned Healthcare.NET is to deliver patient-centric, seamless,
safe and cost-effective medical services at the Department of Emergency Medicine (DEM). To
ensure the seamless flow of patients to the in-patient wards, the BMS coordinates the just-in-time
(JIT) resource allocation in the hospital bed management. The systematic approach thus frees up
critical resources so that the end-to-end flow is not held up due to process inefficiency. This case
study will focus on these two implementations to examine how AH can transform itself into a hassle-
free hospital by tracing back to the development of the:
- Clinical Digital Dashboard (CDD) and workflow changes within the DEM, and
- Bed Management System (BMS) and workflow coordination between the Bed Management
Unit (BMU) and Ward 13.

This paper presents the issues and activities of resource management taken place in the AH during the
implementation of two healthcare information systems.

Background
Alexandra Hospital, a small public hospital serving mid-western Singapore, was established back in
1938 as the British Military Hospital. After 33 years of British administration, it was handed over to
the Singapore Government at a nominal cost of S$1 and renamed as Alexandra Hospital1. In
comparison to other newly developed hospitals, AH lost its competitiveness and was previously
downgraded to the extent of a One-Star hospital status.

A new hope was given to the hospital since its transformation in 2000, after being taken over by the
National Health Group (NHG). With the assignment of a new management team, this hospital was
tasked with the challenge of restructuring its processes and relocating to a new site to the northern
Singapore. Triggered by the changes, AH seized the opportunity to transform its new-found image to
upgrade its healthcare services. AH focused its initiative to adopt a benchmark using the best practices
of US-Japanese Medicine/Healthcare systems (the Mayo Clinics (United States of America) and the
Kameda Medical Centre hospitals (Japan)) to realize this vision. The CEO explained:

“To advance Singapore’s health system, we need to develop a new model of care to
enhance and reformulate old ones so as to provide the care a patient needs while
decreasing waiting time and improving the patient experience. Information technology
can make this vision a reality.”

Using the lessons learned from internationally reputed hospitals, AH has undertaken many initiatives
to upgrade its major facilities to serve patients better, focusing on creating conducive environment and
providing a high-level patient service. To begin with the change, AH examined the hassles in
conventional hospitals by focusing on the BMU and DEM. AH realized that improvement in hassle
management can achieve its vision of a “hassle-free” hospital but changes may or may not include
sophisticated IT components. The Director of Projects explained:

1
Source: Alexandra Hospital, (2006), Our History, viewed 7 May 2008,
<http://www.alexhosp.com.sg/history.asp>.
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Alexandra Hospital ES-002

“We do not dispute that technology is a great enabler in creating a hassle-free hospital,
but we must make sure that the application is able to streamline our processes and
enhance patient services, while at the same time keeping costs affordable.”

Initiating Transformation
In a traditional hospital setting, upon patient registration at the DEM, patients are assessed by a triage
nurse prior to the seeking of junior doctor’s consultation before determining the next course of action.
The attending doctor may require patients to go for the laboratory tests or X-rays, where they would
bring along the order forms issued by the doctor to the designated stations and subsequently returning
with relevant records for further medical reviews. Under normal circumstances, patients who are
discharged would then proceed to the pharmacy to collect the prescribed medications. Otherwise, they
will have to be warded. Then they will have to undergo necessary admission procedures while waiting
for the staff to allocate a bed in the ward.

The AH’s bed allocation system is similar to many other conventional hospitals where the BMU is not
able to provide prompt updates of the bed availability, resulting in poor bed turnover rate for patients
in need of beds. In the past, the BMU had tried various methods to propagate the latest updates of
planned discharges and bed availability information through various means like a LAN system, cards,
pneumatic tubes, fax machines, SMS and telephone calls. However, the efficiency and practicality of
these methods were in doubt. For instance, with the conventional card system, Patient Service
Associates (PSAs) would have to pass the cards around so that they could allocate time to manually
prepare the faxes for planned discharges. Furthermore, this had to be released to the BMU twice daily.
Along with other administrative roles such as financial counseling and billing, PSAs could not fully
engage with the BMU, thus resulting in poor patient service due to unanticipated delays.

Innovation and Motivation for Improvement

In view of the shortcomings, AH contemplated the implementation of “paperless” administration
which allowed the storing and sharing of patients’ information across the hospital with real-time
access to their historical and current data. More importantly, it gave DEM doctors full access to
patients’ medical history that facilitated faster and more accurate diagnosis. This may lead to faster
discharges especially for the non-critical emergency cases.

In addition, improvements were needed to reduce patient waiting time and total time spent at DEM.
To examine the need for change, an operation team was set-up to consider all possible options such as
examining if the physical layout could be redesigned to minimize hassles of moving to and from
various contact points and explore the potential in trimming the overall DEM consultation process.

At the BMU and Ward 13, manual communication by means of phone calls and static displays had to
be minimized with regards to patient information, checking bed availability as well as the booking of
beds. Reducing the waiting times for beds and increasing the efficiency in bed utilization were
prioritized. Changes had to be made to enforce real-time updating of the bed status at all times,
whereby the information is automatically fed to the BMU. This meant that the process of updating had
to be reviewed to accelerate the process of allocating beds to the patients who were waiting at the
DEM for ward admission. Hence, an improved integrated communication system was needed to link
the BMU and Ward 13 to expedite bed utilization. Naturally, changes were made to the existing
workflow in order to complement the new system. Such a change of workflow was essential as they
were capable of transforming AH from a “decision-centric” or “service provider-centric” (terms
described by the DP) to a “patient-centric” hospital. Furthermore, the event for the relocation of the
hospital in 2009 and the implementation of a “hassle-free hospital” have to start from the existing
premises as explained by the Project Specialist 3:

“We are testing things here. So ultimately we will not want to bring things there and
start afresh. Because you see, once the whole hospital is set up, it is very difficult to

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implement changes. Like infrastructure, if your ward layout is like that, it will be
difficult to change.”

Solution for Improvement

The operation team was tasked to map out a typical patient workflow, to physically trace how patients
moved from one “station” to the next at the DEM. The rationale of such an initiative was to identify
processes that could be streamlined as well as other possible areas for improvement. The results
revealed three potential areas for improvement. Firstly, the need to redesign the physical layout of the
DEM station to smoothen the patient’s movement from station to station. Secondly, the need to
improve the consultation process by assigning a senior doctor (rather than a junior) to assess a
patient’s condition at the triage quickly and professionally, under an initiative’s name, “Project
Phoenix”. Thirdly, a system is needed to facilitate and share the electronic recordings and the storage
of patients’ medical records across the departments.

Over at the BMU and Ward 13, a “just-in-time” Bed Management System (BMS) that allows wards to
“pull” patients to the empty beds as required is being worked on. The “just-in-time” concept differs
from the traditional “push system”, where in the latter, the DEM pushes patients to the wards after
calling the wards to check if beds are available. The need for such a system would certainly help to
minimize the communication between the parties involved in the bed allocation, such as in the case of
the BMU and Ward 13.

To begin with the BMS trial, Ward 13 was chosen for its technology readiness and the complexity of
the patients’ profile. This ward with wireless LAN installed, allowing it to support the BMS system.
More importantly, Ward 13 is a multi-disciplinary surgical ward with high daily bed turnovers. Thus,
it was identified as a good place to test the effects of the BMS and its ability to increase efficiency of
bed turnarounds.

Support and participation from the Top Management

Based on the overall informants’ feedback, a common understanding was that the top management
had been actively involved in trying to identify areas for improvements, encouraging the staff to
contribute ideas that may help to improve the patients’ experiences at the hospital, as well as
supporting the implementation of their ideas. According to the Assistant Director of Projects:

“It is common to find members of the management walking the ground to get the first-
hand insights of the problems and sentiments.”

Generally, all informants felt that the CEO was indeed very supportive of any patient-centric initiative
which had the potential to enhance the patient experience, as verified by the Nursing Officer 1:

“He will support you if you have any visionary thoughts and ideas that can really help
patient care; he will really go all the way to help you.”

Contribution from the Staff

According to the Project Specialist 1, doctors and nurses do participate and contribute to the
implementation of the Clinical Digital Dashboard (CDD) at the DEM. In this case, they shared their
knowledge and experience by providing ideas on how the CDD could be better designed as well as the
type of workflow changes required to complement the CDD. Project Specialist 1 commented:

“We worked together, and the doctors have a lot of knowledge to share, which has
greatly contributed to the planning and designing. The Head of DEM is also IT-savvy.
So when we talk to him, he knows what you are talking and we know what he is talking.
Straight away we look at the same thing.”

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The Director of Projects commented that active participation and involvement with the staff were
essential for the management to contribute positively and effectively.

“The contribution is from everyone, because process flow, process change, has to
happen on the ground, where the service providers do some experimentation work etc.,
we [management] help to “systematize” the social components or the requirements
from the system etc. Then we go down to the ground to take a look to see how we can
improve and support.”

Identification of Resource Constraints

AH was well-aware of its constraints and limitations as well as its potentials and capabilities in
achieving its objectives. This explained why the Director of Projects suggested that scarce resources
should be exploited more carefully for value-adding activities. For a start, AH just had limited IT staff
to deploy in full-time technical development of the CDD at the DEM. Therefore, the solution laid in
engaging external professionals to work in tandem with the Operations team. Space was another
factor constraining the transformation process at the DEM. Being one of the smallest hospitals
undergoing restructure exercises in Singapore, AH also had the limitation of relatively small floor-
space. Therefore, space limitations were taken into consideration when redesigning the physical
layout of the DEM. In short, the aim was to maximize the available floor-space, ensuring the floor-
design “synchronized” with the natural flow of patients under the supervision of external expertise.

Request for New Resources

At the DEM, Nanyang Polytechnic (NYP) was brought in under a Memorandum of Intent signed in
October 2004 to support the development of CDD as well as to bring in new ideas and solutions.
Later, Frontline Solutions was roped to play the role of System Integrator in March 2005. This project
aimed to integrate patients’ medical records and other related information into a single, connected
system. The implementation of the CDD at the DEM also required other deployments such as high-
end servers, wireless infrastructure (from Cisco Systems and Fujitsu Asia), databases to capture and
store patients’ information, and large LCD screens where real-time patient queues can be displayed
and monitored by staff.

AH obtained the services and supports from Fujitsu Asia to implement the Cisco Clinical Connection
Suite (CCS) for its bed management unit, using GlobeStar System’s ConnexALL software as the
integrative solution to Cisco IP Telephony system. Fujitsu Asia, which was the system integrator,
customized the solution using the ConnexALL software and Cisco IP Telephone to coordinate
housekeepers, the ward nurses and the bed management unit to prepare the beds for the admitted
patient.

Deploying Healthcare Information Systems: Strategic Partnership

Implementation of the CDD at the DEM

The CDD is a portal and all-in-one database implemented as part of the transformation plan at the
DEM and was piloted in October 2005. CDD allows doctors to see patients and prescribe medication
at one go. According to the Project Specialist 1:

“Now, with the new system, it’s easy for doctors to know the patient medical history. In
the old days, cards were used. So doctors might not know the patient history if nurses
fail to locate the relevant cards. Now, doctors just key in the information into the CDD
to track the patient history instantly.”

With the customized CDD, doctors at the DEM are given the opportunity to record patient’s data into
the system. In addition, doctors may be able to refer to the patient’s repository to retrieve whatever

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information on their patients’ previous treatment records. Such information is critical to determine the
next course of action. As explained by a senior doctor:

“The basic medical information stays the same. But it is the way the data is stored and
organized. So now I can call upon my written notes in the past, and I can see what I
have written.”

In addition, doctors can directly execute laboratory tests (such as blood tests and X-rays) through the
system rather than filling all the necessary forms, which are sometimes duplicative, always tedious,
and time-consuming. Finally, doctors can prescribe medication and record patient discharge notes via
the system. As explained by a Nursing Officer 1:

“You know how tedious it is to fill in the X-ray form? But now, the doctors can just click
on these red dots. Drop down just like that…”

In summary, this CDD was designed to serve the following functions:

- To enable the registration, consultation, treatment and prescription of mediation for the
patients through the using of relevant modules within a single system
- To provide real-time, integrated and comprehensive view of any patient status from his point
of registration to the point of discharge or admission
- To allow seamless flow of patients’ medical records across all departments, or within the
department during his visit
- To serve as a repository of patient information, including patients full medical history, current
and past treatment plans, prescriptions and follow-up appointments.

--------------------- Insert Figure 1----------------------

Redesigning the Physical Layout at the DEM

A total of eight weeks were spent on renovating and redesigning the DEM to improve the physical
layout of the various stations (i.e. position of the triage, registration counter, etc.), with the aim to
provide better facilities, a conducive ambience and comfort to patients. The layout of the DEM was
actually being redesigned a few times over a short period for test runs and to make sure that the
stations were built to support the normal path taken by patients when they move around the DEM. To
provide better patient experience and service in the DEM, a “triangle concept” was introduced, where
the patients are surrounded by doctors, nurses, and clerical staff.

Reducing Patients’ Waiting Time at the DEM

To further transform a hassle-free patient experience at the DEM, an initiative name “Project
Phoenix”, where AH attempted to radically transform doctors and nurses operation at the triage. In
essence, two main issues are always encountered in A&E departments:
1. Time-consuming patient registration process before consultation
2. Longer consultation time, as junior doctors may be less efficient compared to experienced and
senior doctors.

To tackle the first problem, AH reengineers the administrative process of patient registration.
Contrary to traditional practice, AH now allows patients to be diagnosed, and sometimes even treated
before registration depending on the patients’ conditions. This means that patients are attended to by
doctors, while the patients are being registered by relatives or friends.

To handle the second problem, AH initiates a bold and historical move to revamp the triage system.
Instead of deploying a junior doctor (trainee medical officer) to serve as the first point of contact for
the patients in the consultation process, a senior doctor or an experienced medical office now takes
over that role. The rationale for this repositioning is explained by the Project Specialist 1:

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Alexandra Hospital ES-002

“You might think that by putting the senior doctor right in front is a waste. But from the
exercise carried out, we find that by doing so we gain valuable time. Because these
senior doctors know how to assess very fast, so patients are treated and discharged
even before being sent to the triage. By doing so, we save a lot of time.”

Furthermore, senior doctors have the expertise and experience to diagnose patients effectively and
efficiently more so for the lower priority cases such as out-patient cases. They have the confidence to
discharge patients with minor conditions which may be easily treated with medication rather than
being warded in the hospital. This was suggested by the Nursing Officer 1:

“Why we put the senior doctor in front is we need their vast experience to see that you
are fine and you will be okay. They have the experience and knowledge to discharge you
with appropriate medication.”

The change of workflow has trimmed the average waiting time at the DEM from 40 to 20 minutes.
According to the Project Specialist 1, this achievement has attained the patients’ wish-list.

Implementation of the CCS at the BMU and Ward 13: Bridging Communication Gap
The Bed Management Systems (BMS) refers to a comprehensive solution for bed management that
comprises of the Clinical Connection Suite (CCS) from Cisco, the wired and wireless LAN
infrastructure, a medical-grade network solution, ConnexALL, software from GlobeStar, together
with built-in bed awareness. Essentially, the BMS serves the following three primary functions:
1. Provide a real-time visual display of the most current bed census (instantaneous ward
occupancy) to facilitate the process of allocating beds to patients
2. Eliminate the need for multiple phone calls between BMU and Ward 13 just for checking bed
availability and the booking of beds for patients from the DEM
3. Provide a means to inform housekeepers of the beds to be prepared for the next patient

The system offers a variety of color codes to represent the actual status of a bed, such as “booked”,
“ready” and “discharge”. Based on the colored status, anyone accessing the BMS would be able to tell
instantly the status and availability of beds. An advantage of this is that the PSAs can now forecast the
planned discharges more easily, as pointed out by Project Specialist 3:

“By having an interface, I can forecast the patients who are marked and ready for
discharge. I can know the number of available beds that I can assign to A&E.”

--------------------- Insert Figure 2 ----------------------

In total, this system has bridged the communication gap between BMU and Ward 13 as all relevant
information is now accessible through the BMS system. The Nursing Officer 2 explained:

“Now no need to call, right away they look at the system, they (the staff) would know
this bed is ready to accept. So my task is to quickly plant the patient in accordingly. All
information is ready in the system, so I wouldn’t need to call. Also, A&E never calls us
(Ward 13). Straight away we know this case is coming, so we need to prepare a drip for
the patient, all the things that are required, oxygen, no need to inform. Unlike in the
past where we have to run around to answer the phone calls and prepare for the
patient.”

Responding to such system, the Nursing Officer 1 claimed that:

“It takes away the nurse’s frustration of having to answer a lot of calls on bed
availability, which disrupt her work. Rather than managing beds, nurses now have more
time for their patients”
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This “just-in-time” approach in bed management has reduced the patient waiting times for
beds by 30%2, thus effectively increasing the efficiency in the utilization of beds.

Getting the Most out of Partnerships

As part of the Memorandum of Intent signed with IDA, Microsoft and later Frontline Solutions and
NYP, AH sought to work with these partners to pilot and test the use of various advanced
technologies in its process of transforming into a hassle-free hospital. Leveraging on their
technologies and expertise becomes part and parcel of the ES implementations throughout AH.

Collaborating with NYP for the development of the CCD prototype in 90 days was an achievement, in
which NYP contributed to the design, development and deployment of innovative IT solutions at AH.
Additionally, the Assistant Director of Projects hinted that AH considered working with NYP as a
lower-cost option in view of their resource constraints:

“We are a very small hospital, so [when implementing] changes cost is an important
factor, because we don’t have the financial arm to bring the big software players. So we
invited NYP…”

However, both sides stand to gain from such collaboration, as explained by him:

“It was a win-win situation for NYP as well. I’m sure they wanted their students to
develop real-life industrial applications. This is a win-win situation. But in the long
term, you can never ask NYP to maintain the system.”

Frontline Solutions came into the scene and took over the system from NYP at a later stage. Playing
the role of a System Integrator (SI), it was tasked with the main responsibility of merging the existing
systems such as the Lab Information System (LIS) as well as the iPharm System for the pharmacy
into a single, integrated system. While AH benefited from the technical expertise provided by
Frontline Solutions, the latter had its own set of agenda to pursue, which includes the
commercialization of the “locally developed patient care system (at AH) to the rest of Asia”.

Similarly, Cisco would like pilot their Cisco Connection Suite (CCS) together with GlobeStar
ConnexALL software for the purpose of bed management. AH can serve as the place for them to
conduct the trials. In addition, Fujitsu Asia, the System Integrator for the project at the BMU and
Ward 13, was brought in to implement Cisco’s CSS over the IP telephony and wireless network.

The Director of Projects also clarified how vendors benefited from these collaborations. Vendors may
secure the IP rights from the solutions they provided to AH. In addition, they could improve future
versions of their systems based on the feedback provided by AH:

“The whole logic [of strategic partnerships] makes sense, because of the IP
[Intellectual Property] creation that the vendor or SI needs to think about. That is their
strategic investment. So that is what we have been doing. We explore, get feedback, and
people who are interested to build the IP, then they contribute, enhance the next
version. That is our collaboration model.”

Enabling Transformation
With the completion of the redesigned physical layout, the successful deployment of the senior
doctors at the triage and the roll-out of CDD, the staff at the DEM gradually became more
accustomed to the new workflow as well as the putting of the CDD into good use for the benefit of

2
Source: Getting patients to beds faster, viewed on 24 June 2008,
<http://www.ps21.gov.sg/Challenge/2006_06/innovation/faster.html>
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the patients. A similar pleasant outcome was achieved in the BMU and Ward 13 after the
implementation of CCS.

The clinical and hospital administration departments also seem to work more closely together now.
According to the Director of Projects, sharing the common AH vision of fostering a hassle-free
hospital experience for patients could have helped to strengthen the ties between the departments:

“I think everybody here has a common interest…. I observed that it’s true that
comparatively, the collaboration between these two groups [clinical and administration
departments] is very strong, simply because everybody here thinks, “I am here to serve
our patients.”

This synergizes everybody to work together and that is actually one of the drivers.

Embracing the Transformations

The CDD at the DEM has been very well-received by the senior doctors and nurses. A senior doctor
described the system as “magical”, since all medical records are now so readily and easily accessible.
Perhaps the attitude of the doctors with regard to the transformations and the corresponding use of
technology can be summarized by the senior doctor in the following manner:

“These are new toys to the boys. We enjoy it. We want more.”

The nurses have also displayed a willingness and ability to adapt to the new ways of working. The
overall positive attitude of the staff at DEM towards the implementation of the CDD as well as the
other workflow changes can be summarized by Nursing Officer 1 as follows:

“So far for those who work here at the department, they have been quite cooperative.
They adapt very well.”

Project Specialist 1 shared her experience of working with the users of CDD:

“The users and the doctors do cooperate. In fact, they have very good team spirit.
When I worked with them, I find it a very pleasant experience. [It’s] nice to work with
them. We all are working towards the same goal.”

Providing User Training

The user-friendly design of the CDD eased the learning process for all the users. According to
feedback, all the users had virtually no difficulties picking up the new system. In fact, they described
that the system as “a joy to use” and was “very easy to learn”. The Head of Nursing commented that
she completed training her nurses in an hour session. Similarly, training at Ward 13 and BMU on the
BMS was a breeze. The Project Specialist 3 explained:

“I just gave them an overview and I did it within half an hour.”

Project Specialist 2 revealed that no major issues were raised after training:

“So far, other than the first week, I never get got phone calls from Bed Management
Unit on any problems or [that they] cannot do things.”

Credit must be given for making the two ES user-friendly. For example, Project Specialist 2:

“We design the system simple so that it is not so cumbersome to update. If it is

cumbersome to update, system operators and support units may not like it too.”

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This is supported by Project Specialist 3, who does not believe in complicated applications:

“If you look at it, nurses would like to have something that is very simple to use. If you
are implementing something very complicated, like I need to do so many steps in order
to get one status done, I would not want to use that. You also have to consider there’s a
group of people here who might have never used a phone before.”

In general, the Director of Projects felt that the projects at the DEM and BMU/Ward 13 were
considered to be very successful:

“We only spent a very short period of time for user training. That to me is a
resounding success. We don’t need a lot of hand-holding and teaching etc, and that is
productivity gain.”

A Culture of Innovation and Change

According to a nurse, the staff at AH are generally very receptive to changes, and are willing to try
and see new ideas through and take advantage of them, especially if they are meant to create a hassle-
free experience for patients. The Assistant Director of Projects pointed out:

“If you look at the culture here, they are basically working together as a team to solve
problems. And, everyone has a vision…that coming very [strongly] from the top and
from the ground. It is not just top-down.”

One of the strengths of AH is the staff’s culture of embracing changes and working for the benefit of
the patients. According to Project Specialist 1:

“I think it is cooperativeness, keenness to learn and their keenness to try new things.
They like to change and accept changes. When there is something new, we all work
together. The top people ask them to do, they don’t mind, they stay happy.”

She also suggested that this learning culture seemed to have stemmed from and been passed down
from the top management and that it had since deeply influenced the thinking and behavior of the staff
at AH:

“I think what is important is the management, the culture they want to cultivate, so that
everybody can think alike and have the same goals and objectives.”

Institutionalizing Strategy for Future Initiatives

Continuous Process Improvements

According to one of the informants, continuous improvements to the already refined workflow so as
to further enhance the patient experience at AH are seen as something that is ongoing, and is regarded
as a routine activity. Over the past few years, work improvement teams at AH executed no less than
70 “Kaizen” (continuous improvement) projects in the process of engendering a hassle-free hospital.
In fact, the process of identifying and solving any new problems that surface remains part and parcel
of everyday work, says the Director of Projects.

AH is always in a state of continuous improvement, as explained by Project Specialist 1:

“We always look for challenges to overcome. If there is a problem, we have to fix it
fast. If something is wrong, then we will fix it. And if something is right, then we just
move on, and improve on it.”

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Alexandra Hospital ES-002

Taking advantage of useful and appropriate applications in itself is also a form of process
improvement, as explained by the Director of Projects. He cited the example of the process changes at
the DEM, indicating that further improvements can be expected in the near future:

“I anticipate that there will be a few major iterations along the way [in] the overall
change and improvement.”

System Enhancements
Although the CDD has generally been able to serve its purposes since rolling out, the project team is
always on constant lookout for ways to further enhance its capabilities to improve its contributions to
the DEM. For example, it seems that the CDD can easily produce summary reports of a patient’s
visit, the symptoms, the doctor’s diagnosis, and the recommended treatment plan. However, the
reporting function of the CDD seems to be lacking in the provisions of statistical and performance
analysis capabilities, as implicitly suggested by Project Specialist 1:

“[In the] first stage, I cannot extract the data, cannot do statistics, cannot do much. So
we make sure [in] the second phase they give me all these things.”

A senior doctor also suggested that the patient registration process could be further streamlined by
using barcode scanners to scan the identification card numbers of the patients, so as to obtain their
personal information, rather than having to repeatedly ask the patient for the information. Such
information should then be captured by and retained in the CDD, and shared across the department so
as to reduce the need for patients to provide the same answers to the same basic questions at every
contact point.

Project Specialist 1 hinted that voice recognition could be a possibility in the future, although she
conceded that the existing technology has yet to reach a stable stage such that it is suitable and ready
for deployment. On a more serious note, the security of the system must be enhanced to prevent the
unauthorized leakage of patients’ confidential data residing in it. As clarified by a senior doctor:

“We do worry about the security of the data. Who can access it? Also the hackers… if
they are determined to get information, they will find it.”

As for the BMS, since communication now is only between the BMU and Ward 13, the most crucial
improvement that is needed is the extension of bed management of Ward 13 to simultaneous
management of multiple wards. There were already plans to extend the BMS to the wing level (four
wards). That already requires complex configurations of the map display of the different wards as
well as the escalation paths in the wireless IP phones.

The Nurse Call system is the next item on the list. According to Director of Projects:

“Now that the Cisco Medical-Grade Network is up and running, we can foresee that
this open standard network will indeed cover all our applications together and be able
to develop and support other new and exciting ones to improve the quality of services
to our patients.”

The implementation of “Nurse Helper”3 that can predict if a patient is going to get out of bed has also
started. There are also plans to integrate the “Nurse Helper” system with the GlobeStar ConnexALL
software, which is after all a “signaling tool” capable of interpreting and redirecting signals. In fact,
bed manufacturing companies could potentially supply beds with sensors that can link to the
Monitoring and Alert System at the nurse station, as suggested by Project Specialist 3.

3
Source: Call it a smart bed, viewed on 24 June 2008,
<http://www.ps21.gov.sg/Challenge/2006_06/innovation/innovation.html>
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Alexandra Hospital ES-002

AH has so far operated on a “taking small steps in rapid succession” approach, where it is open to try
different types of technologies and deploys them if suitable. In coming months, it plans to try out
other modules under the CCS, namely Nurse Call, Patient Monitoring, Location-based Services, and
Collaborative Care.

The Director of Projects’ role is to realize the hassle-free hospital concept for the Alexandra Hospital
based on the collaborative efforts from members of the hospital. The hospital is now moving towards
the other stage of transformation in providing a better patient service. It is a bold achievement for a
small hospital with limited resources to dawn on a new model of healthcare services in Singapore
history. His passion and expertise in IT has optimized AH’s potential in services delivery. His
achievement in this field is an ongoing process.

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Alexandra Hospital ES-002

Figure 1: An example of the CDD application

Figure 2: An example of the CSS application

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Alexandra Hospital ES-002

Author Information
Teoh Say Yen
RMIT University
School of Business Information Technology
Building 108, Level 17
239 Bourke Street Melbourne
Victoria 3000, Australia

Email: sayyen.teoh@rmit.edu.au
Tel: +613 9925 5788

Say Yen is currently a Lecturer in the School of Business Information Technology, RMIT University.
She holds a PhD in Information Systems from the National University of Singapore and a BBus Com
(Hons) from the Monash University. She is interested in exploring the effective and efficient use of
medical informatics, with regards to issues relating to the development of methods and strategies in
the healthcare sector. Especially, she is focused on understanding the complex issues relating to the
adoption, implementation and use of medical informatics within the healthcare institutions. She has
also conducted several case studies in Singapore and Malaysia.

Shan-Ling Pan
Department of Information Systems
School of Computing
3 Science Drive 2
Singapore 117543

Email: pansl@comp.nus.edu.sg
Tel: (65) 65166520

Shan-Ling Pan is the coordinator of the Asia IT Case Series, NUS. He is a faculty member in the
Department of Information Systems, School of Computing, National University of Singapore. His
research interests include enterprise system implementation, eGovernment, IT-enabled organizational
transformation and knowledge management. As a case study researcher, Dr. Pan has conducted and
published more than 30 case studies on Asian organizations. He has published two case books in 2004
and 2006: “Managing Strategic Enterprise Systems and E-Government Initiatives in Asia: A
Casebook” and “Managing Emerging Technologies and Organizational Transformation in
Asia: A Casebook”.

Paul Wang
Director
National Healthcare Group
6 Commonwealth Lane
GMTI Building, #05-01/02
Singapore 149547

Email: paul_wang@nhg.com.sg

Paul is currently a director in the CIO's Office in the National Healthcare Group. Prior to this
appointment, he was a director with Alexandra Hospital driving the innovation activities. Paul holds
degrees of PhD in Strategic Management, MSc (Management of Technology) and BSc (Comp Sc &
Info Sys) from the National University of Singapore. He is interested in technology discontinuity and
how emerging technological platform can influence and be influenced by innovation activities in the
healthcare sector.

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