After a well-needed break last month, this hobbit is back with some New Year Wishes for 2019. Yes, some of these wishes are not exactly new stuff but hey, it’s like new year resolutions to lose weight. If it doesn’t happen, then you wish or resolve again in the new year!

Wish #1

MOH will finally fix all the lacunae in healthcare regulation – those “grey” area that have hitherto been deemed to be not worthy of direct regulation by MOH: Managed Care, Third Party Administrators, Medical Concierges and even Referral Portals that claim to represent all doctors.

These folks working in the shadows have been making a lot of dough because of MOH’s inattention and inertia!

Wish #2

Now that we have fee benchmarks for doctors’ procedure fees in place, it’s time to expand the scope and look at hospital, facility and implants charges etc. If not, private healthcare costs will continue to rise at an unsustainable rate.

Wish #3

Someone should look at public healthcare financing. The recent incident where an SNEC patient was only reimbursed for $4.50 from MediShield Life (MSL) is plainly unacceptable. Apparently, it’s because in this case, the patient went for the same procedure for both his eyes but MSL only allowed the claim to be made for one eye.

If possible, operating on both eyes actually is more cost-efficient and saves money in the long run. But if the funding mechanism cannot support such practices and generate bad press, then surgeons have no choice but to operate on one eye at a time. So much for innovation and efficiency.

Wish #4

The big healthcare news of 2018 was the Singhealth Cyberattack. We should learn from this incident and take a hard look at how IHIS is structured and governed. There is nothing much worse than a “monopoly vendor” whereby customers have to buy essential services or products from only ONE vendor. That’s what IHIS is – the public healthcare clusters have to buy essential IT services from ONE vendor – IHIS. Think about it, if you had to buy rice or toilet paper from only ONE supermarket operator….

Wish #5

Also arising from the ashes of the SInghealth Cyberattack – new laws should be passed that spell out clearly and safeguards patients’ privacy, confidentiality and security rights. The current situation whereby a National Medical Record (NMR) is exempt from PDPA requirements and the MOH/MOHH/IHIS guys “ownself regulate ownself” is unsatisfactory. Even if there are no new laws enacted, the whole NMR programme should be placed under PDPA to instill public confidence. Only with public confidence restored will public buy-in be re-established and the NMR initiative be put back on track.

Wish #6

Leadership renewal should be managed sensitively and transparently, especially in public institutions with a sizeable pool of talent and experience. In choosing a leader, one must balance the need to have a person who is perfectly aligned and loyal to the masters, as well as having a record of excellence and service to the institution. If it is too tilted towards one way or the other, either the larger system suffers or the institution in question suffers. If this sounds rather cryptic, just look at one of these institutions, resignations are spreading faster than a poorly differentiated cancer. The pool of talent and experience there is evaporating faster than a puddle in a dessert. Even neutrals will quit quickly when they realise meritocracy is a distant second to alignment.

Wish #7

The Courts are setting the pace in medical negligence, with their landmark rulings in the last few years. The Modified Montgomery Test is one such example. The recent judgment on the liposuction death is another. This hobbit hopes the SMC can also say something on important medical legal matters before the Courts issue definitive judgments (by which ‘case law’ is made). If SMC speaks up and provide guidance beyond the Ethical Code and Ethical Guidelines as well as the Handbook of Medical Ethics, the Courts will certainly have to take into account what the SMC has said on a certain subject before judgments are made and new case laws are set in stone.

The advantage SMC has is that it can say a lot of things about a medical-legal subject at any time even when there is no existing SMC case ruling, with the objective of educating the medical profession. The Courts on the other hand, can only develop new case law when there is a case before them to judge.

Wish #8

Someone should really look at the number of people studying medicine, whether locally or overseas. We all can feel it in our bones that too many doctors are being trained. The legal profession and Ministry of Law have taken swift steps to address their glut. What about MOH and SMC?

The same principles must apply downstream to specialty training. The boom and bust in residency positions in recent times is really embarrassing.

Wish #9

ACGME-I Residency – Kill it or keep it? This is a tough call politically even if logic dictates otherwise. Even if no one wants to press the kill button, at the very least, we should really remove the double-yoke from our residents immediately – of having to fulfill ACGME-I requirements and passing the UK exams. Just let them choose one or the other. Stop testing them or examining them to death.

Wish #10

Family Medicine should be made a specialty and those with the FCFP qualification should be recognised as specialists by the Specialist Accreditation Board (SAB). Plain and simple

It had to come. Sooner or later. Like head lice or scabies when you live in the tropics and you don’t bathe for three months. “Making it harder for errant doctors to cheat” (The Straits Times, Opinion Page A28, 25 October) looks like another Salma Khalik hit job. It is also timed to be the journalistic equivalent of a Halloween trick or treat; designed to scare doctors and dentists by entreating the authorities to witch-hunt. She wants someone to clean up the houses of the medical and dental professions by writing this long opinion piece when all that is needed is for someone to pass Ms Salma a broom. This Hobbit happens to think she will look decidedly befitting with a broom. Preferably an anti-gravity one placed between the adductors.

Let’s first go back a little to 15 October 2018; in the article “Penalties are lower if doctors own up”, she wrote, “There is a big difference between tax avoidance and tax evasion. In avoidance, the person fully declares his income, but tries to pay lower taxes by using possible loopholes, such as setting up a company simply for tax breaks, or claiming personal expenses as legitimate business expense. The penalty for an “omission” is two times the taxable amount”

She moves seamlessly from tax evasion, tax avoidance to “omission”, giving the impression that the omission refers to avoidance. But actually, are they the same? Tax avoidance is NOT a crime or an offence. The person deemed to have committed tax avoidance by IRAS will be asked to pay up the difference between what he would have paid and what he actually paid and not “two times” the taxable amount.  The reasonable student of the English language on reading this, would probably infer that tax avoidance (like “omission”) is a crime and that it may be punished with a penalty of two times the taxable amount. No one really knows what is this omission she is talking about. Does omission equate to avoidance, or is she referring to evasion? Only she knows.

As for tax avoidance, the principle is simple – no one wants to pay more taxes if he can avoid doing so legally, just like you wouldn’t want to pay more for a pair of shoes if another shop offers the same pair at a lower price. IRAS is merely asking for information from some doctors and asking a few others to pay up for tax avoidance. If you agree to pay up, it stops there. There is no criminal record if you pay up. Has IRAS charged a doctor for a tax crime yet this year? Not that this hobbit knows of. And certainly, no doctor or dentist has been convicted of tax crimes this year yet.

In any case, with the obfuscating word “omission” in place, she launches her major offensive 10 days later with the aforesaid long opinion piece. Highly predictable; almost boring already.

Her strategy is to use the highly evocative and bewitching word “cheat”. She suggests many doctors and dentists are cheating, and gives a litany of examples: cheating Medisave money, cheating CHAS, cheating taxes, cheating insurance etc.

At last count, there are some 15,000 doctors and dentists in Singapore. Is there a cheating epidemic?  In the same article of 15 October, it was mentioned the last time a doctor was jailed for tax evasion was 2011 and he was subsequently suspended by SMC for four months. One case in 7 to 8 years doesn’t sound like an epidemic to me.

Then what is the whole point of her latest tirade against the medical and dental professions? Is she asking for

• Stricter or better laws or ethical codes?
• Better enforcement?
• More punishment?

She seems to be saying that doctors and dentists should be held to higher standards when they commit tax offences because they are “not ignorant” and doing so out of greed. The first principle of law is that the law shows no preference to any group of persons. All men are equal under the law. The same standards and burden of proof applies to everyone. A doctor should not be more easily convicted of tax offences just because he has a MBBS degree. Likewise, a doctor or dentist should not be punished more for tax crimes versus say a banker, journalist, accountant, lawyer, hawker or taxi driver.

As for ethical codes, the latest SMC Ethical Code and Ethical Guidelines (ECEG) as well as the accompanying Handbook of Medical Ethics (HME) are two of the lengthiest and most detailed publications of this sort in the world. And SMC is already empowered to strike-off a doctor. What else is there? Lengthen the SMC ECEG and HME some more? Empower the SMC to give 10 strokes of the rotan?

The doctor or dentist already suffers from “double jeopardy” of being punished by the professional board for bringing the profession into disrepute after he has been also punished by the other authorities. If a journalist is found cheating on taxes, he pays the fine, and he maybe goes to jail as well. He doesn’t have a Journalist Board or Council to suspend or strike him off the Journalist Register because there isn’t such a thing.

As for cheating CHAS, well, last I looked, I signed a CHAS contract with a public sector Polyclinic Group. It is what it is – a contract. If I am found to have filed claims wrongly, they can claw-back the monies as per contractual terms. There is no specific legislation for CHAS (unlike Medisave, which is covered under the CPF Act), so enforcement of a contract between contracting parties is quite different from enforcement of a law.

Then she complains about doctors who do not give adequate MC to foreign workers. Well, they should be punished. But do notice that she is completely uncritical of the other elephant in the room – the employers and supervisors. Is this just purely a doctor problem?

As for insurance, yes, she claims insurance patients with full first-dollar coverage may be over-serviced or over-charged and that compulsory co-payment will be introduced to address this. Well, evidence and experience around the world have shown that insurance claims are always higher when there is full first-dollar coverage. This is bad insurance design leading to bad doctor and patient behaviour. These outcomes have been replicated time and again all over the world. What does Ms Salma Khalik expect? Are Singapore and its doctors expected to be so different from the rest of the world?

Over-servicing is not just a doctor thing. Over-servicing can also originate from the patient. The patient, with full and first-dollar insurance coverage, often requests for more expensive services from the doctor. The doctor, being a patient-advocate, will happily oblige. For example, why should a doctor not use the best implant for his full-cover insurance patient and choose something inferior (but adequate)? After all, if my patient has paid for it through his insurance premiums, I will use the best. In fact, if I don’t use the best implant (which is often also the most expensive), the patient may be unhappy with me afterwards. He may tell me “Doc, what didn’t you use the best Brand Z pacemaker for me and instead used the cheaper, inferior Brand Y one when my insurance covers everything?”. Is that dishonesty on the part of the doctor? In fact, in the era of the Modified Montgomery test, I better use the best, lest I be accused of not considering a relevant consideration from the patient’s perspective that should lead me to offer the best pacemaker later on. You never know. Better safe than sorry.

Bad insurance product design probably drives patient and doctor behavior more than human greed, so to speak. Fear of the new medical legal climate also plays a part too.

As for her example about the probability of getting a procedure for unspecified gastritis, it really depends. There are more foreign patients in the private sector. They come here wanting to get a definitive diagnosis and treatment as quickly as possible and then go home, hence the bigger demand for “a procedure” (probably a gastroscope). Also, many patients seek treatment in the public sector first for gastritis, and when the problem recurs, they often wrongly lose faith in our public hospitals, and seek care in the private sector, where again the pressure on the doctor to come to a diagnosis quickly results in more scopes. Yes, money does matter and some doctors do more procedures to earn the dough. But one must realise that in the private sector, there are also other factors that favour doing a scope which are not pecuniary. When you are the first doctor dealing with the problem, the patient is more patient (pun intended). When you are the second, third or fourth doctor dealing with the same problem, the patient has often run out of patience and is already very emotionally distressed. In addition, private hospital bed charges are a lot more than public ones and observing a patient for a few more days in the private hospital may cost as much as doing a scope. And even after observing the patient for a few more days, you may still not get a definitive diagnosis.

Shouldn’t a senior health correspondence with decades of experience in healthcare reporting give much more balanced analyses than this shallow sweep of “cheating” doctors and dentists?

Actually, she seems like a sulking kid who refuses to admit a mistake. “Salmatologists” (This hobbit is one) will recall that she wrote another long opinion piece on 26 March 2018 (Sunday Times) where she made the claim, “Drilling down, the MOH concluded that much of the higher claims was the result of overcharging and overtreatment by doctors in the private sector”. (“Diagnosing the cause of rising costs”).

This was clearly refuted by MOH and guess what, The Straits Times itself! On 30 March, the newspaper clarified that “This is incorrect, the Ministry of Health did not draw such a conclusion”. It was a mistake by her, pure and simple.

And now, once again, she is again asserting essentially the same erroneous claim, only albeit in a more convoluted way, and wisely not attributing this to MOH but to the insurance industry instead, presumably to “one insurer” and the COO of AIA, Ms Melita Teo.

So what’s the message here – that like Ms Salma Khalik, the “one insurer” and AIA’s Ms Melita Teo disagrees with MOH – overcharging and over-servicing by private sector doctors are the main reasons for rising insurance claims?

There is a pattern to all this of course. Her usual and favourite trick is to drive a wedge between MOH and the medical profession; then she entreats the government to come down hard on the medical profession. This can be seen on at least three occasions:

• FIn 2005, she made the assertion that the then DMS will remove dispensing rights from medical clinics, which the then DMS refuted.
• Then in March this year, she made the claim that MOH is of the position that higher insurance claims was the result of overcharging and over-treatment by doctors in the private sector, a position that the Straits Times has since said MOH didn’t arrive at.
• Now, she is asking MOH and other authorities to go tough on cheating and unethical doctors and dentists. And she has also apparently roped in the insurance folks to beef up her claims (pun unintended).

You have to give it to her. As an object of antiquity, she has enormous energy. Apparently, she’s 63 years old (give or take a year or two), and this hobbit can only wonder how long more can she keep going like this. But seriously folks, other than Salmatologists, no one really reads these long opinion pieces anymore in the age of Instagram and Twitter.

In the meantime, will someone give her a broom? This hobbit is thinking of giving her a hat as a year-end gift. The two gifts will go nicely together. Hopefully they will come in handy when she finally retires.

Happy Halloween

Even as the dust on the SingHealth cyberattack has barely settled, another piece of bad news has surfaced on healthcare IT systems offered by Integrated Health Information Systems (IHIS). IHIS is the IT arm of MOHH that oversees IT development and implementation in the public healthcare sector, and increasingly influences the private sector as well. It involved the mis-labelling of drugs affecting 400 GP patients who saw GPs who are using the GP Connect software that IHIS offers. Two days later it was reported that the affected number of affected patients is more likely to be double that of the original number – 836 patients seen in 104 clinics.

An egregious example given was that a patient who was supposed to take 10ml of cough mixture would be asked to take 10 bottles in instead. For codeine addicts, that’s like hitting the casino jackpot.

When such an incident happens, we need to ask a couple of inconvenient questions. First- if the patient indeed was dispensed 10 bottles and worse, took the amount as stipulated, who will be responsible for the unfortunate consequences?

The short answer to this question is “YOU, the GP”. (are you surprised?) As a GP in the private sector using GP Connect, it is quite unlikely you had hired a pharmacist or staff nurse to perform dispensing. If you did, then the pharmacist or staff nurse, both registered with the state and licensed to perform dispensing duties independently, has to bear the brunt of the responsibility. If not, the dispensing staff are dispensing under your supervision and you will have to take professional responsibility even if the IT system had printed out the labels wrongly. This is because you are supposed to have checked and realised the labels did not reflect what you had prescribed earlier on. You may be punished by MOH, Health Science Authority and/or SMC for dispensing the drug in wrong dosages.

What about the IHIS and the IHIS folks? Presumably, the people in there who developed GP Connect are NOT state-registered doctors, pharmacists and nurses. So, the most you can do is perhaps sue them for civil damages and get some money back. The people won’t be suspended or struck-off by some authority regulating the IT profession (IT professionals are not state-licensed).

This is what the financial and business world calls “skin in the game”. You, the doctor, have a lot more skin:- epidermis, dermis and hypodermis, in the game then the IT folks. This inequality or asymmetry in risk exposure leads to the inevitable cultivation of unhealthy behaviour. That’s not to say IT people are evil people, they are not. It’s just that if that is how the system is badly set-up, then suboptimal behaviour and outcomes are sure to follow. This phenomenon is pretty well described in famous economist Nassim Nicholas Taleb’s new book “Skin In The Game”. (He also wrote The Black Swan which sold 3M copies)

On 6 Sep 18, 2 days after the news first broke, it was revealed that this glitch was due to a “planned system update”. Frankly, this sounds terrible and this hobbit is not sure what is the messaging aim here. If a “planned” system update could mess up life like this, one should ask what if the update was unplanned? Would it have been far worse? Is it being “planned” a mitigating factor or an exacerbating factor? Are we supposed to commiserate with the patient, the GP, or get angrier with IHIS? Would the mess have been less if there wasn’t any update, whether planned or otherwise? I don’t know about you, but this hobbit is really confused.

Next on the radar screen are the anaesthetists in the private sector. Apparently, many of them have been targeted by the taxman. Let this hobbit be clear from the onset: he firmly believes the taxman is to more feared than the hitman. The hitman can’t do anything after you are dead. The taxman will get you, in this life or the after-life: he will hit your estate. They are even more powerful than forensic pathologists.

As we all know, most anaesthetists set up companies. Professional fees are paid to and recognised as revenue in these companies, and anaesthetists then get their income from these companies in the form of salaries, dividends and directors’ fees after expenses have been deducted.

Apparently, the taxman now thinks that because these companies who have no office, hire no staff other than the anaesthetists, they are nothing more than tax shelters providing tax avoidance for the owner-employee anaesthetists. The taxman now wants to claw back the difference in taxes the doctors have paid to the government had the doctor been taxed as an individual only when the doctor had paid taxes as a blend of different tax schemes (personal income tax for salary of up to 22%, 22% for director’s fees, 17% corporate tax rate for dividends).

This problem arose because the maximum tax rate for income tax now (22%) is significantly higher than for corporate tax (17%). Certain amounts of dividends are also given tax breaks and certain cost items can be “expensed off”, such as meals with colleagues or the purchase of your Ipad which you need for your work. Some people have received letters saying their claw-back will be up to 5 years. So now, an anaesthetist may now find himself owing the taxman hundreds of thousands of dollars.

It is therefore no surprise that many private sector anaesthetists are up in arms. I know many of them, and they have sought professional accounting and tax advice in the past to set up these companies to avoid paying more tax. They did so in good faith under professional advice. Why should they be penalised for something in the past, just because the taxman applies new rules of interpretation of (purportedly) Section 33 of the Income Tax Act? Who wants to pay more tax than what one is supposed to legally and in good faith?

In any case, tax avoidance may not also be the main reason why doctors set up companies. A private limited company, as the name suggests, is a way of limiting one’s exposure to damages arising from business activity. If you work for and under a company, your business liability is limited to the assets of the company, even though your professional liability is not. For example, the damages, say, your supplier, can get from you is limited to the company’s paid up capital and assets. Your supplier cannot touch the assets that you own personally which are not part of the company, such as your home or your personal-use car. As this hobbit sees it, this is the main advantage of setting up and working under the umbrella of a private limited company.

This liability limitation objective can be evinced by the fact that some companies set up by older anaesthetists have been in existence for decades. In the 80s and 90s, income tax was actually lower than corporate tax. These senior anaesthetists probably paid more money than they could have had they not sought a company structure to house their activities. Can they now claw-back the excess money from the taxman? In the name of fairness, surely there is is some merit in this argument?

Even if the taxman wants to take a new interpretation and get anaesthetists to pay more taxes, this new interpretation should not be applied retrospectively in claw-backs. It should at best be applied to current and future income. And the fact that because the anaesthetists don’t have an office and hire staff, they are then penalised to pay more taxes doesn’t make much sense. If 30 anaesthetists hired 5 receptionists and a tea lady and housed them in a 500 square-foot office in Yishun at $2 per square feet means paying much less taxes, then they may just do it. But what does that do to Singapore and the government’s drive for more productivity? Nothing. It may just mean more low productivity jobs that the Singapore economy doesn’t need.

Someone needs to see the Big Picture here. Obviously the taxman’s visual field and visual  acuity in the context of the Future Economy needs to be questioned here. If not, the road to lower taxes through lower productivity will surely be taken.

SingHealth Cyberattack 2018

The cyberattack into Singhealth dominated healthcare news not just in Singapore, but in the world as well. News of the attack was made public on 20 July 2018, exactly 5 months to the day when this Hobbit published “NEHR: A Patient’s Perspective from A Doctor’s Eyes”. In the section on “Security” in the aforesaid article, this Hobbit wrote:

“The last point I would like to deal with is that of security. Security can basically be defined as measures put in place to prevent breaches of confidentiality. How secure is the NEHR? I am confident that the planners and implementers have tried their reasonable best to ensure best practices in IT security have been put in place or are being put in place. After all, the NEHR, being backed by government, has enormous resources to do so.

Even then, no IT system, especially one that is internet-based and cloud-based, with literally unlimited number of entry points (every clinic or hospital computer that is linked to the internet is an entry point into the NEHR) is hack-proof. If it were not so, there would be no need for the government to delink civil servants’ work computers and intranet from the internet last year. It was reported this affected all 143,000 civil servants. That is a tacit admission that no security system is fool-proof or hack-proof. I suppose this shows cyberthreats cannot be wished away, but they can be effectively partitioned away.

This hobbit is sure the NEHR is as secure as can be, but not quite more secure from the civil servants’ work computers before they were delinked from the Internet. In fact, the fact that the NEHR exists must in itself be a very tempting trophy database for hackers from all over the world to try and test and breach.

In the event a breach happens and records and medical information are stolen, what is the liability of the NEHR or the government with regard to this breach, and what are the rights of the affected patients? Can he seek redress, compensation, damages etc.?”

Sometimes, this Hobbit wishes he isn’t so spot-on, although he was referring to the NEHR and not the current IHIS-Singhealth Electronic Medical Records (EMR) that had been hacked into. But if you replace “NEHR” with “IHIS-Singhealth EMR”, everything else pretty much applies. In fact, DPM Teo Chee Hean pretty much said so too when he said in hindsight, that internet surfing separation for public hospital separation should and could have been done earlier.

And it was just as well that this attack occurred before the NEHR was rolled out to the private sector. If that had already happened, then the cyber-attacker would have even more access points to hack via any computer in any of the 2000+ private clinics and laboratories all over Singapore.

This hobbit supposes that all the computer terminals in the three public healthcare clusters are well maintained with up-to-date antiviral software, server firewalls and robust security measures such as high security passwords etc. The public healthcare sector has dedicated IT teams and resources to ensure this. The same cannot be said for the private clinics. Do they have anti-viral software? Let alone up-to-date ones? And what about passwords? I won’t be surprised if many passwords are “qwerty”…

So, it was fortuitous that NEHR hasn’t been made mandatory yet in the private sector, if not the cyber-attackers would have found it even easier to launch a cyberattack, and probably an even more massive and debilitating one.

The authorities also said that the data that had been exfiltrated was “not sensitive”, and were “basic demographic data”. This was an attack on 1.5 million people, which is about 25 to 30% of the populace on this island. It is really an attack on Singapore, plain and simple. Singhealth was probably chosen because many, many influential people seek care in SGH, and the Outram Campus, which are part of SingHealth. If you want to dig out medical information on most of Singapore’s VVIPs and CIPs, the most ‘rewarding’ place to look would be SingHealth. It wouldn’t be NHG or NUHS. Anyone in healthcare long enough knows this.

I am not sure downplaying the impact of the cyberattack is the right strategy here. Sure, someone needs to strike a balance between unnecessarily pressing the panic button and euphemising a clear and present danger. I can decide what is “sensitive”, thank you. My birthday and my NRIC number are sensitive data alright.

In addition, the 160,000 medication records that had been exfiltrated was surely sensitive information. Any healthcare worker, be it a doctor, pharmacist or nurse can quite easily infer from the medication records with reasonable accuracy what disease(s) the patient is being treated for. And if you think about it, this is the most efficient way to know about a patient’s medical status. If you go and look at his investigation results, there will be many ‘uninteresting’ normal results. If you look at the record of procedures done, you may miss the pure medical diagnoses the patient has. But when you look at the medication records, almost everything there is sensitive and ‘useful’. This is a medically-intelligent cyber-attacker.

The externalities of this attack are significant. The attack does not only affect the 1.5m people or the 160,000 medication records. The Monetary Authority of Singapore (MAS) has already instructed all bank to take more steps to verify the identity beyond the basic demographic data that was exfiltrated. Unless you do not have a bank account or use only human teller services, we will all have to answer more questions to verify our identity, beyond name, NRIC, address and birthdate. In other words, practically everyone is affected adversely.
NEHR

Since we are on the subject of NEHR, let’s discuss security of the NEHR in the wake of the attack. The authorities have categorically stated that the move towards NEHR is inexorable. There is NO turning back. It is true that the move away from paper cannot be avoided. But it is also true the NEHR has many issues that need serious re-thinking and ironing out.

This Hobbit senses that there is an almost religious fervour amongst those in power to developing a monolithic glorious NEHR that will be the pride of Singapore and establish the country amongst the pantheon of IT gods as soon as possible. To be in the pantheon of IT gods is the geek’s ultimate fantasy. But we need to face up to reality beyond geek-ish obsessions. Perhaps it is wise to take a leaf from Steven Spielberg latest directorial effort, the hit movie “Ready Player One”. In this movie set in the future (2045AD), most people in the world are living in slums and finding happiness only in a virtual reality gaming world called OASIS. The founder James Halliday becomes the richest man on the planet, with a fortune of $1trillion. But at the end of his life, he realised that “reality is real”; not OASIS.

Indeed, reality is real. Reality involves looking at the NEHR with detached objectivity. But it is difficult. The people right in the thick of things can get easily enamoured with the whole idea. Even a tech giant like Facebook is not immune to such failings. In the wake of the Cambridge Analytica scandal, Facebook CEO Mark Zuckerberg said in an interview on 18 July 18 that “we were too focused on just the positives and not focused enough on some of the negatives”. When you make a Golden Calf and worship it, you seldom look at its negatives.

If you look at the NEHR publicity so far, it is all about the positives: continuity of care, ease of care, more efficiency, patient safety etc. It’s terrific spin. Nobody talks about the potential negativities. But one must wonder if the people driving this believe in their spin? As the saying goes – never believe in your own spin.

Former editor of The Straits Times, Han Fook Kwang had his finger on the pulse when he wrote, “(NEHR is) A no brainer for the medical fraternity? You would have thought so. But doctors are divided over it”. (Singapore needs to get smarter about digital world, 5 Aug 2018)

He also said’ “It is easy to be seduced by the appeal of placing everything in a common system under one control: It can be more efficient and is easier to manage. Very Singapore Inc, you might say”. The key word here is “seduced”. Mr Han goes on to explain the pros and cons of a centralised system versus a distributed one. He used to be an elite Administrative Officer with experience working in MOH so he obviously knows more than a bit about healthcare.

For sure, many doctors in the private sector, like this Hobbit, don’t buy the spin. Many have quietly voiced their reservations about the security dangers, loss of privacy rights and costs of maintaining the system etc. But the feedback has always been “We are going full-steam ahead”. Until this massive cyber-attack happened and Smart Nation projects was paused for a total of 14 days (20 July to 3 Aug). A cyberattack that affected 1.5 million people did not quite put a dent in the Charge of the NEHR Brigade beyond 14 days.

This hobbit hopes someone in authority is finally looking at the negatives seriously even as we continue to brandish the positives. For one, if internet surfing separation is going to be permanent, does it mean that there will be at least one computer terminal in each clinic dedicated to just NEHR and which is not connected to the Internet? Who pays for that and its upkeep as well? Even if that happens, what is there to prevent hackers from physically breaking into a GP clinic located in the HDB heartlands at night and launching a cyber-attack from there? Does it mean we have to physically secure each clinic to the same level as SGH?

Regulation of the Public Sector

On 4 Aug, NUS Law Dean Simon Chesterman wrote eruditely in The Straits Times that we should not waste the opportunities afforded by this Singhealth cyber-attack crisis and take a good look at revisiting the issue of privacy on top of addressing the obvious issue of security. He was obviously not enthusiastic of the fact that the entire Singapore public sector was exempted from the “relevant legislation” (i.e. the Personal Data Protection Act or PDPA in short) that governs data protection. (Singhealth breach may give privacy new life, 4 Aug 2018).

Many official sources have said that the NEHR is subject to even higher standards than what the PDPA requires so no one should be worried. But that is NOT the point. The point here is when the public sector fails the public and fails the standards that it is supposed to meet, what happens? The PDPA provides for clear penalties to be meted out and the rights of the private individual is clearly spelled out. What is the equivalent of that in the public sector? Can the patients now sue IHIS or Singhealth? Who regulates IHIS and Singhealth under which piece of legislation when a cyberattack is successful and patients’ privacy and confidentiality suffer?

A private hospital administrator said to this hobbit that if this cyberattack had happened in the private sector, the PDPA would have been enforced and in all likelihood, the party involved, say a private hospital, would have been punished under the clear provisions of the PDPA with hefty fines etc. But since the PDPA doesn’t apply to the public sector, it’s anyone’s guess.

The SMA-AMS-CFPS Survey on Patient Perspectives of NEHR

This point is in fact quite well echoed in the results of a survey which was commissioned recently by the Singapore Medical Association, College of Family Physicians and Academy of Medicine, Singapore which has been released to the members of SMA and AMS. Out of the 2100 people surveyed, no less than 81.7% were concerned that the NEHR was not subject to the requirements of the PDPA. A whopping 82.9% (1741 of 2100) were concerned that their medical information would be used for matters of public interest by the Ministry without their consent.

Other significant findings include:
• 581 of 2100 (27.7%) definitely wanted to have their records maintained in the NEHR
• 1175 of 2100 (56.0%) would like their records maintained in the NEHR but did not want any healthcare provider to access it without their explicit consent except in emergencies. (i.e. privacy concerns)

On the issue of security:
• 77.5% (1627 of 2100) of the respondents were confident that their data in the NEHR was secure,
• 70.8% (1487 of 2100) were confident that their data would not be misused by others.

This survey was done before the cyber-attack. Will 77.5% of people still be confident of the security of the NEHR now?

But there is good news for the authorities. Singaporeans understand the importance of having a NEHR. 92.2% of those surveyed were supportive to varying degrees of having an NEHR. But of course, the devil is in the details. And as this Hobbit has said some five months ago, the concerns and dangers are lurking somewhere in the alleys of privacy and security which need to be faced squarely and addressed adequately.

As you can see, many people who had been surveyed were already concerned with some of the potential negatives of the NEHR, even though they saw the need for electronic medical records. The findings are not surprising.

Time For A Rethink, Repositioning and Redirecting ?

This hobbit feels that the NEHR urgently needs a re-positioning. In the wake of the cyber-attack, it is not just enough to say the NEHR is good for continuity of care, efficiency, cost-effectiveness, patient safety etc. Yes, the NEHR works for the patient’s interest in these areas. But the NEHR must also work for the patient’s rights and interests in other equally important areas such as privacy, confidentiality and security. And it is not just spin. The public that is now “sensitised” to such issues will want to know what are the concrete policies and measures taken to do so.

The public will also want to know what are their rights to redress, compensation and damages if their privacy and confidentiality rights have been compromised. This is still unclear in the context of the Singhealth cyber-attack and even more nebulous with regard to the NEHR.

What has happened in the last few weeks with the cyberattack calls for deep reflection,  serious repositioning. It may even need some redirecting – a change in course if necessary. But this hobbit doesn’t think there will be much of these. Instead, the focus is still on achieving rapid deification through the NEHR.

Come to think of it, this hobbit feels the NEHR is turning out to be something between a sacred cow and a golden calf…..

Perhaps it is time to revisit Lord Alfred Tennyson’s famous poem, “Charge of the Light Brigade”, in particular, the 2nd stanza:

“Forward, the Light Brigade!”
Was there a man dismayed?
Not though the soldier knew
Someone had blundered.
Theirs not to make reply,
Theirs not to reason why,
Theirs but to do and die.
Into the valley of Death
Rode the six hundred.

We all know that doctors are talented folks. Even though Hippocrates said that learning the art (of medicine) is long but life is short (Ars Longa, Vita Brevis), many doctors still find time to excel in a whole lot of things other than medicine.

For a start, these obvious overachievers are in politics. Across the Causeway, both the Prime Minister and Deputy Prime Minister are now doctors: Dr Mahathir and Dr Wan Azizah. If you think Dr Mahathir is the biggest or best example of a doctor-politician, overturning 61 years of UMNO rule, many will argue that Dr Sun Yat-Sen (Graduate of Hong Kong University) may have achieved something even greater. In 1912, he overturned more than 2000 years of dynasty rule in China with the founding of the Republic of China. He is recognised as the Father of modern China. But even if maybe not the greatest, Dr M certainly gets the prize of being the oldest medically-trained national leader at 92.

Then there is the Marxist guerilla leader of Cuba – Che Guevara. He’s really Argentinian and a doctor. He is most revered in Cuba and has been called “Castro’s brains”. He lived from 1928 to 1967 before he was gunned down in Bolivia.

President Georges Clemenceau who led France for two spells: 1906 to 09, 1917 to 1920 was also a doctor.

Finally, there is the infamous President Bashar Al-Assad of Syria. Thousands have died in the ongoing civil war with one quarter of the population fleeing as refugees abroad and another quarter being internally displaced refugees. Guess what? Until he was recalled by his father (the original President Assad) to Syria to take over from his elder brother who died in an accident, he was a low-key guy practicing ophthalmology in London.

Many doctors also excelled as a man of letters. Many famous writers were doctors. The creator of Sherlock Holmes, Sir Arthur Conan Doyle, was a doctor. He applied a fair bit of medical knowledge to the mysteries he wrote. The late Michael Crichton, author of Jurassic World and the original Westworld, was a doctor.

Famous short-story writers, Russian Anton Chekhov and Chinese Lu Xun, were also medically trained. Lu Xun dropped out of medical school in Japan. But Anton Chekhov practiced medicine most of his life. In fact he said “medicine is my lawful wife and literature is my mistress”.

Somerset Maugham, the famous short-story writer author and playwright studied medicine in St Thomas Hospital (Now King’s College London). He recalled that medical education was beneficial to him as an author, “”I saw how men died. I saw how they bore pain. I saw what hope looked like, fear and relief”

For the realm of poetry, there is the Romantic Poet John Keats, who lived only for 26 years (1795 to 1821) and studied medicine in Guy’s Hospital (Now also part of King’s College) and wrote famous poems such as “Ode to a Nightingale”, “Sleep and Poetry” and “On First Looking into Chapman’s corner”.

Representing the female gender is Han Suyin. She wrote the famous novel “A Many Splendoured Thing” which was made into a film starring Jennifer Jones and William Holden. It was even made into a soap opera series that lasted 6 years in the United States. She was half Chinese, half Flemish and studied medicine in Brussels and she practiced medicine for quite a few years. In fact, she was a physician in Nanyang University (the original “Nantah”, precursor to NTU) in Singapore when it was founded in the fifties. She was actually invited by the University to teach literature then, but she refused, saying she wanted “to make a new Asian literature, not teach Dickens”.

In the area of mass media entertainment, there are also examples of doctors who made it big. Korean -American actor Ken Jeong  who starred in the over-the-top comedy trilogy  of “Hangover” movies is actually a licensed physician in California.

The famous Taiwanese singer Lo Ta-Yu (罗大佑) is also medically trained. He is generally regarded as one of the godfathers of Taiwanese rock.

New Age spiritual guru Deepak Chopra is also a doctor. And also a very well-trained one. He graduated from a top Indian medical school – All India Institute of Medical Sciences before completing his residency training in the United States in internal medicine and endocrinology. And then he gave that all up to be a guru. He is currently actually a voluntary full professor in the University of California, San Diego, in the Department Family Medicine and Public Health.

In the area of sports, there is the legendary Sir Roger Bannister. In 1954, he became the first man to run the mile under 4 minutes. He later became a much-respected neurologist in Pembroke College, Oxford. Interestingly, he wanted to be remembered more for his work in medicine than in sports. But alas, it is the latter that he is now famous for.

Then there is the captain of the Brazil football team in the 1982 World Cup, Socrates. He is recognised as one of the most accomplished footballers Brazil ever had. He actually earned his medical degree while playing world-class football! This is in contrast to many sportsmen and women who studied medicine after they had given up their sporting careers. A notable example of this is USA swimmer Jenny Thompson, winner of eight Olympic gold medals. She went on to pursue a career in medicine after retiring from swimming.

Lastly, there is an interesting area that many doctors, especially in Australia, like to venture into – the field of winemaking. Many Australian wine estates are named after their founders. These wine estates were generally founded in the 19^th or early 20^th century. Many wine drinkers will recognise these names instantly:

Penfolds, Hardy, Lindeman, Angove, Cullen, Houghton

They were all doctors. Dr Penfolds, Dr Lindeman, Dr Hardy etc….I guess doctors back then already knew that a glass or two of wine was good for you.

These names are some of the largest and most famous wineries Down Under. For example, Penfolds is the largest wine brand in Australia. Hardy and Lindeman are in the top five- or top-ten lists as well. They are now no longer run by doctors.

A living example of a famous winery that is run and owned by a practicing doctor is Catena of Argentina. Catena is often credited for putting Argentinian wine on the world map. The 4^th generation owner and managing director of the winery, Laura Catena Zapata is actually a graduate of Stanford Medical School and still practices medicine.

Perhaps there is more to life than being a doctor, after all.