Development of a Population Health Data Mart (PHDM) to enable monitoring of population health indicators

Summary: With Singapore’s recent launch of Healthier SG (HSG), there is increasing focus on measuring population health-centric indicators, which has spurred National Healthcare Group (NHG), as the Regional Health Manager (RHM) for residents in the Central-North region of Singapore, to develop the Population Health Data Mart (PHDM). Background: Singapore recently launched HSG, which is a national initiative that aims to shift its healthcare delivery strategy to preventive care. Through HSG, the Ministry of Health (MOH) seeks to encourage residents to build a lifelong relationship with their family doctor, who will work within an ecosystem of health (consisting of Regional Health Managers and community partners), to focus on holistic care and achieve better health outcomes. NHG’s role, as the RHM for residents in the Central-North region, is responsible for health outcomes for approximately 1.5 million residents. To address future healthcare needs, NHG is shifting to a longitudinal care model anchored by a population health paradigm, aligning interests across payers, providers and patients, supported by finance transformation and key enablers such as data and digital transformation. PHDM: With NHG’s population health strategy, it has concurrently devised indicators to monitor its progress in achieving its aims. NHG’s Population Health Data Mart (PHDM) is a key data enabler to support this. The PHDM aims to collect and link up individual-level medical, lifestyle and social data of its residents (and not just patients) across NHG’s network of providers and partners in an integrated, comprehensive and secure manner. The PHDM allows NHG to understand the health profile and needs across the care continuum of its residents, allowing NHG and its partners to develop appropriate targeted interventions for them, while monitoring its progress in achieving health goals. This includes the ability to conduct process and impact evaluation of programmes and performance monitoring as well as population segmentation to identify high-risk patient groups and/or regions. Previously, data marts from NHG institutions existed in silos where each institution would only have patients’ information limited to encounters within each institution. The PHDM has helped consolidate data across various data sources, allowing users to access residents' data with a longitudinal view across the entire healthcare ecosystem. At present, PHDM contains clinical data from NHG institutions, such as diagnoses, prescriptions and laboratory results. PHDM continues to add data sources to its repository and will, in the future, include data from other healthcare providers (e.g. private doctors), community partners and government agencies. Together with PHDM, an interactive dashboard will be built to monitor NHG’s performance as an accountable care organization, allowing aggregated performance analysis at NHG level. For a start, the dashboard will provide an overview of NHG’s performance in achieving population health goals, with a focus on indicators required by MOH. Subsequently, dashboards will be developed to support NHG’s various clinical condition-specific steering committees, with fit-for-purpose indicators relevant to the committees’ focus (e.g. diabetes, mental health). This provides a high-level monitoring tool that will inform NHG of the efficacy of its population health efforts and provide a feedback loop to NHG’s programmes.