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Eye, robot (Business Times Premium)

Covid-19 is helping to accelerate the healthcare sector's transition out of its age-old model of care, which could spell structural shifts in how hospitals operate, says Professor Wong Tien Yin, medical director of the Singapore National Eye Centre.

BACK in January, when the world was blissfully unaware of the disruption Covid-19 would come to wreak in our lives, Professor Wong Tien Yin sketched his vision of a digital future for the Singapore National Eye Centre (SNEC), perhaps to some bewilderment from his staff.

SNEC turns 30 this year, and the medical director was taking the opportunity at his first town hall of the year, to lay out the centre's long-term plans, which naturally includes digitalisation.

"A lot of people said, why are you talking about this?" recalls Prof Wong. "I know people in the audience are saying, well, it's kind of airy-fairy. It may happen, but some people will say, it's not my time, some people will say it doesn't really affect my work because I can't see how it can be digital for my area."

Fast forward a few months later, a novel coronavirus now known as Sars-Cov-2 has upended our world and just about changed everything we've ever known or done.

To return to some semblance of normalcy - as people practise the now-requisite safe-distancing measures - is to use technology to help us to do the things that we used to do, albeit remotely. There's even a running joke making the rounds online, asking people if it's their CEO, CTO or Covid-19 that has led their companies' digital transformation.

According to Prof Wong, digitalisation was supposed to be an "evolution". "But the current Covid-19 situation has hastened the thinking behind it, the adoption behind it and the acceptance of the need for these devices," he points out. "Now everyone feels that this is probably the most important transformation piece."

Healthcare innovation

The need to align with Industry 4.0 has in recent years become an oft-repeated refrain. The Singapore government has also been doling out cash to help companies get on the digitalisation bandwagon, while sparing no effort to transform the public sector.

Similarly for the healthcare sector, Prof Wong says that there has been a "significant innovation phase" in the last five years or so.

One major change that's a long time coming is ditching paper-based records for electronic ones. This has paved the way for the use of artificial intelligence (AI), deep learning and related technology to manage Big Data. At the same time, most physical devices are now able to connect to the Internet, as part of the Internet of Things (IoT). All this come together to form a digital ecosystem.

What's perhaps not kept pace as well is the transition from an old model of care, which Prof Wong says is based on a very long tradition.

"Long tradition of care involves, No 1, you need to physically see a doctor, you need to physically go to a clinic and you need to physically get the tests and results. Then, you go back to seeing the doctor for that consult - that is the care, essentially," he explains. "Along the way, most of it has been paper-based. So the patient likes paper records, even the MC (medical certificate) is paper. They will go to different tests that will mostly have a paper record for them. And they need to physically come to the clinic to see the doctor."

Not only is the patient comfortable with this traditional model, but the government has also supported this through its financial, legal and regulatory framework, says Prof Wong.

Upending this system is not only a challenge in terms of funding, it would require acceptance from both patients and doctors.

Then came the Covid-19 pandemic, and as Singapore entered a "circuit breaker" period akin to a lockdown in early April, it became increasingly clear that the system was not going to stay a viable model in future.

It's thus not farfetched to say the crisis has almost singlehandedly transformed the way things have been done.

"Patients are now more willing to accept whatever we can give them because they are not going to be able to get normal care," says Prof Wong, explaining that they have opened up to the idea of teleconsults and video consults.

"And the doctors have no choice. They're now all, including even my older doctors, going into electronic records from home, whereas in the past, they're so uncomfortable; they like to write things."

It's a far cry from not too long ago, when senior doctors didn't want anything to do with digital transformation as they believed they would have retired before it became mainstream, notes Prof Wong.

While most people cannot wait for this Covid-19 crisis to blow over, from the perspective of digital transformation however, the longer the crisis lasts, the more it will help to spur those needed changes and make them a permanent fixture.

"If people feel that this is going to be over in one month and I'm going to be able to physically go back to see my doctor in one month, and the doctor says I don't really need to know this, this is a fad, then it's not going to stay. But if this lasts, as we think and as some people predict this could drag on to 2021, then... you can't wait for care to happen that way," says Prof Wong.

If the sector take to these changes permanently, it could lead to dramatic improvements in productivity while saving time for the patient. For example, patients may be able to rely on home-monitoring devices to check their symptoms, and AI will be able to help them decide if they even need to visit a doctor physically. This could help streamline the process and further shorten the amount of time they need to wait at the clinic or hospital, if they do end up going, from a typically three- to four-hour visit, to one that's just 30 minutes. There would also be no need to wait at a physical pharmacy, as drugs can then be delivered to the patient.

This would also be a structural shift in how the hospital operates, and consequently, the nature of the work done by healthcare support staff will change, allowing for a redeployment of manpower.

In the near future, people who handle back-end operations, including pharmacists and the finance department, could simply work remotely with the help of a robust IT platform.

And, if fewer patients visit the clinic or hospital physically and spend less time there, it also consequently means the staff strength can be leaner.

"It does mean that we will shift a lot of staff towards being IT data-savvy and less physical. We may not need so many frontline counters. We may need a lot of pharmacy techs that are data-savvy rather than physical pharmacists in the front line," says Prof Wong.

Using technology this way could halve the number of physical consults that SNEC handles in a year from the current 400,000 to 200,000, he estimates. This has further implications on the need for physical infrastructure - hospitals could make do with less space, and perhaps there may not be a need for so many clinics in the first place.

Lessons for the future

But the question is, would patients start to feel short-changed, if they don't get as much face time with their doctors?

According to Prof Wong, this system can only work if patients feel it brings them value.

"They don't have to come in. Whatever they pay is not more than a physical examination - probably it's going to be less. But they're getting the same care, they're able to feel that their eye disease and their eye condition is properly cared for and that they have access, if needed, to physical clinic visits," he says. "They get records online, and they get accessibility so they can speak to their doctors, they can do video consults if necessary, I think patients will feel that this is going to be fantastic care."

Likening this to the banking sector, Prof Wong notes that many services have gone digital and people have been finding less reason to visit physical branches over time.

In retrospect, Prof Wong now considers it a "mistake" to have been so ingrained with the old model of care, but says that the crisis has taught them lessons for the future, even if it may have caught them unprepared at first.

"We are in a much-better position - not just for a potential crisis in the future because we would have undergone the digital transformation - but we would be able to manage patients better in a normal, non-Covid-19 situation, and I think everyone will benefit from it," he points out.

In a way, the severe acute respiratory syndrome (Sars) outbreak in 2003 laid the stone for how SNEC is handling the disruption caused by the current pandemic, says Prof Wong, who recalls being a young resident in training then.

"We were not able to effectively communicate like now, and so the isolation also had quite a bit of psychological impact because you come to work, very defined areas, you don't see anybody else, you go back for that week, and you don't know what's happening. So I think it's a very different era."

But he and other healthcare leaders recall what it was like being in the frontline, and that has helped them in managing the current crisis, having themselves experienced it firsthand. "It's a bit like... we were soldiers in Vietnam, and now you are planning for something where the strategy is a lot more real," he adds.

Business of providing care

Prof Wong took over as SNEC's medical director in 2014, and he says that healthcare leadership has evolved over the years as the industry too has become more complex.

"In the past, you would always have senior doctors becoming heads of institutes, heads of hospitals because they were very senior," he notes. But hospitals are no longer doctor- or clinic-centric like in the past, he adds, explaining that healthcare has turned into a business of providing care.

"You need to be able to have an understanding of where everybody fits in in this care model, and I think that is a lot of engagement and a lot of understanding of people.

"These six years have taught me that you need to not just provide that vision but you need to be able to bring that whole team along," says Prof Wong of the multi-disciplinary nature of the business.

He is wistful about the fact that some of SNEC's 30th anniversary celebrations have to be shelved due to the pandemic, which he thinks could be a prolonged crisis, as it would take a year or two before a vaccine or herd immunity is developed against Covid-19.

But work doesn't stop. Already, there are plans to set up a digital transformation office this year to hasten the centre's transition to the new models of care amid the pandemic and even beyond.

In addition, SNEC wants to do more for the community, whether it's philanthropy or public education to promote eye health.

In the bigger picture, Prof Wong is looking for international collaboration opportunities, to bring Singapore research and innovation abroad and create an impact on the neighbouring countries.

The core of what SNEC represents is always a thirst for staying ahead, for research and innovation, even from the get-go.

"We are competing in the top five to 10 eye centres in the world," says Prof Wong. "We look at ourselves, at every Olympics, we need to be in the finals... that means that everyone is going to come in with new innovations of their own, and we have to innovate even as we move ourselves even in that path."

It's a vision he inherited from his mentor, SNEC's founding medical director Arthur Lim, whom Prof Wong says inspired him when he was just starting out.

"I was really attracted to that vision because that vision is not (just) you come to work, you do well in your own clinic, that's good enough.

"It was a very far-reaching vision that SNEC can only do well if it is going to be competing in the finals of the Olympics. If you don't have the ability to compete for the medals and be in the finals, you're not doing well."

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