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This article explains how two AI systems have been incorporated into the everyday operations of two Singapore public healthcare nation‐wide screening programs. The first example is embedded within the setting of a national level population health screening program for diabetes related eye diseases, targeting the rapidly increasing number of adults in the country with diabetes. In the second example, the AI assisted screening is done shortly after a person is admitted to one of the public hospitals to identify which inpatients—especially which elderly patients with complex conditions—have a high risk of being readmitted as an inpatient multiple times in the months following discharge. Ways in which healthcare needs and the clinical operations context influenced the approach to designing or deploying the AI systems are highlighted, illustrating the multiplicity of factors that shape the requirements for successful large‐scale deployments of AI systems that are deeply embedded within clinical workflows. In the first example, the choice was made to use the system in a semi‐automated (vs. fully automated) mode as this was assessed to be more cost‐effective, though still offering substantial productivity improvement. In the second example, machine learning algorithm design and model execution trade‐offs were made that prioritized key aspects of patient engagement and inclusion over higher levels of predictive accuracy. The article concludes with several lessons learned related to deploying AI systems within healthcare settings, and also lists several other AI efforts already in deployment and in the pipeline for Singapore's public healthcare system.


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Two Singapore public healthcare AI applications for national screening programs and other examples

Show Author's information Andy Wee An Ta1,§Han Leong Goh1,§Christine Ang1,§Lian Yeow Koh1,§Ken Poon1,§Steven M. Miller2,§§ ( )
Department of Data Analytics and AI, Integrated Health Information Systems (IHiS) Private Limited, Singapore, Singapore
School of Computing and Information Systems, Singapore Management University, Singapore, Singapore

Abstract

This article explains how two AI systems have been incorporated into the everyday operations of two Singapore public healthcare nation‐wide screening programs. The first example is embedded within the setting of a national level population health screening program for diabetes related eye diseases, targeting the rapidly increasing number of adults in the country with diabetes. In the second example, the AI assisted screening is done shortly after a person is admitted to one of the public hospitals to identify which inpatients—especially which elderly patients with complex conditions—have a high risk of being readmitted as an inpatient multiple times in the months following discharge. Ways in which healthcare needs and the clinical operations context influenced the approach to designing or deploying the AI systems are highlighted, illustrating the multiplicity of factors that shape the requirements for successful large‐scale deployments of AI systems that are deeply embedded within clinical workflows. In the first example, the choice was made to use the system in a semi‐automated (vs. fully automated) mode as this was assessed to be more cost‐effective, though still offering substantial productivity improvement. In the second example, machine learning algorithm design and model execution trade‐offs were made that prioritized key aspects of patient engagement and inclusion over higher levels of predictive accuracy. The article concludes with several lessons learned related to deploying AI systems within healthcare settings, and also lists several other AI efforts already in deployment and in the pipeline for Singapore's public healthcare system.

Keywords: AI applications, AI for national screening programs, influence of clinical context on AI design and usage

References(40)

Department of Statistics Singapore. Population and population structure. Note that Singapore's population was just under 5.7 million as of mid‐2020, but shrunk to just under 5.5 million one year later due to the economic slowdown due to Covid‐19. https://www.singstat.gov.sg/find-data/search-by-theme/population/population-and-population-structure/latest-data
Ministry of Health (Singapore). Promoting overall healthier living while targeting specific sub‐populations. March 9, 2022. https://www.moh.gov.sg/news-highlights/details/promoting-overall-healthier-living-while-targeting-specific-sub-populations
Ministry of Health (Singapore). Diabetes: the war continues. August 22, 2017. https://www.moh.gov.sg/news-highlights/details/diabetes-the-war-continues
International Diabetes Foundation. IDF Diabetes Atlas 10th edition, Singapore, 2021 update. https://www.diabetesatlas.org/data/en/country/179/sg.html
DOI
Ministry of Health (Singapore). Update on the war on diabetes, fact sheet for Committee on Supply parliamentary budget discussions. March, 2020. https://www.moh.gov.sg/docs/librariesprovider5/cos2020/cos-2020---update-on-war-on-diabetes.pdf. Also see “Speech by Mr. Ong Ye Kung, Minister of Health, at World Diabetes Day,” November 14, 2021. https://www.moh.gov.sg/news-highlights/details/speech-by-mr-ong-ye-kung-minister-for-health-at-world-diabetes-day-202110.2337/dc11-1909
DOI
Bee YM, Tai ES, Wong TY. Singapore's war on diabetes. Lancet Diabetes Endocrinol. 2022. .https://www.thelancet.com/journals/landia/article/PIIS2213-8587(22)00133-4/fulltext
Yau JW, Rogers SL, Kawasaki R, Lamoureux EL, Kowalski JW, Bek T, et al., Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care. 2012; Mar 35(3):556–64. . https://pubmed.ncbi.nlm.nih.gov/22301125/
Teo ZL, Tham YC, Yu M, Chee ML, Rim TH, Cheung N, et al. Global prevalence of diabetic retinopathy and projection of burden through 2045: systematic review and meta‐analysis. Ophthalmology. 2021; Nov 128(11):1580–91. ; https://pubmed.ncbi.nlm.nih.gov/33940045/
National Centre for Healthcare Innovation (Singapore). Selena+: early detection of diabetic retinopathy. https://nhic.sg/web/index.php/our-projects/medtech-list/119-projects/medtech/neurological-and-sense-disorders/194-selena-early-detection-of-diabetic-retinopathy
The Eye Diseases Prevalence Research Group. The prevalence of diabetic retinopathy among adults in the United States. Arch Ophthalmol. 2004;122(4):552–63. . https://jamanetwork.com/journals/jamaophthalmology/fullarticle/416212
Wong TY, Sun J, Kawasaki R, Ruamviboonsuk P, Gupta N, Lansingh VC, et al. Guidelines on diabetic eye care: the international council of ophthalmology recommendations for screening, follow‐up, referral, and treatment based on resource settings. Ophthalmology. 2018; Oct 125(10):1608–22. . https://pubmed.ncbi.nlm.nih.gov/29776671/
Xie Y, Nguyen QD, Hamzah H, Lim G, Bellemo V, Gunasekeran DV, et al. Artificial intelligence for teleophthalmology‐based diabetic retinopathy screening in a national programme: an economic analysis modelling study. Lancet Digit Health. 2020; May 2(5):E24049. 10.1016/S2589-7500(20)30060-1. https://www.thelancet.com/journals/landig/article/PIIS2589-7500(20)30060-1/fulltext
Nguyen HV, Tan GS, Tapp RJ, Mital S, Ting DS, Wong HT, et al. Cost‐effectiveness of a national telemedicine diabetic retinopathy screening program in Singapore. Ophthalmology. 2016; Dec 123(12):2571–80. ; https://www.aaojournal.org/article/S0161-6420(16)30975-7/fulltext
Singapore National Eye Centre. SingHealth, “Singapore integrated diabetic retinopathy programme (SiDRP).” April 2, 2018. https://www.singhealth.com.sg/news/medical-news/singapore-integrated-diabetic-retinopathy-programme-sidrp
Wong TY. “Implementation of AI & digital innovations in healthcare: reflections and pearls in management,” presentation to Singapore Healthcare Management Congress, slide 43, SingHealth. August 4, 2021. https://www.singaporehealthcaremanagement.sg/Speakers/Documents/SHM2021%20Slides/SHMC/HM%209%20Prof%20Wong.pdf
Li F‐F, Krishna R. Searching for computer vision north stars. Daedalus. 2022;151(2):85–99.
GOH Timothy. “An A. I. for the Eye,” Straits Times. July 6, 2019. https://www.nus.edu.sg/newshub/news/2019/2019-07/2019-07-06/A%20I-st-6july-pA35.pdf
Ting DSW, Cheung CYL, Lim G, Tan GSW, Quang ND, Gan A, et al. Development and validation of a deep learning system for diabetic retinopathy and related eye diseases using retinal images from multiethnic populations with diabetes. JAMA. 2017;318(22):2211–23. . https://pubmed.ncbi.nlm.nih.gov/29234807/
Ministry of Health (Singapore). “Efficacy of the SELENA+ system,” response to a member of parliament question. July 5, 2021. https://www.moh.gov.sg/news-highlights/details/efficacy-of-the-selena-system10.1109/BHI.2018.8333429
DOI
Wong TY. “Implementation of AI & digital innovations in healthcare: reflections and pearls in management,” presentation to Singapore Healthcare Management Congress, slides 52−55, SingHealth. August 4, 2021. https://www.singaporehealthcaremanagement.sg/Speakers/Documents/SHM2021%20Slides/SHMC/HM%209%20Prof%20Wong.pdf
EyRis. “About us.” https://eyris.io/aboutus.cfm
Nova Group. “Nova Invests In New Medical Deep‐Learning System.” August, 2018. https://www.nova-hub.com/novanews/nova-invests-in-new-medical-deep-learning-system/10.1109/BHI.2018.8333429
DOI
EyRis. “EyRIS awarded 5‐year contract to deploy SELENA+.” September 7, 2020. https://eyris.io/latest_news.cfm?id=23
Singapore National Eye Center, SingHealth. “Singapore Integrated Diabetic Retinopathy Programme (SiDRP).” April 2, 2018. https://www.singhealth.com.sg/news/medical-news/singapore-integrated-diabetic-retinopathy-programme-sidrp10.1016/j.ophtha.2016.08.021
DOI
Nguyen HV, Tan GS, Tapp RJ, Mital S, Ting DS, Wong HT, et al. “Cost‐effectiveness of a national telemedicine diabetic retinopathy screening program in Singapore,”. Ophthalmology. 2016; Dec 123(12):2571–80.
Ibid.
DOI
Internal information from Integrated Health Information Systems (IHiS), Data Analytics and AI Group.
DOI
Sabanayagam C, Xu D, Ting DSW, Nusinovici S, Banu R, Hamzah H, et al. A deep learning algorithm to detect chronic kidney disease from retinal photographs in community‐based populations. Lancet Digit Health. 2020; Jun 2(6):e295–e302. . https://www.thelancet.com/journals/landig/article/PIIS2589-7500(20)30063-7/fulltext
EyRIS news. “New deep learning algorithm to detect chronic kidney disease.” October 11, 2021. https://eyris.io/latest_news.cfm?id=41
Cheung CY, Xu D, Cheng CY, Sabanayagam C, Tham YC, Yu M, et al. A deep‐learning system for the assessment of cardiovascular disease risk via the measurement of retinal‐vessel calibre. Nat Biomed Eng. 2021; Jun 5(6):498–508. ; https://www.nature.com/articles/s41551-020-00626-4
Integrated Health Information Systems. “The Singapore Eye LEsioN Analyzer, or SELENA.” https://www.ihis.com.sg/healthai/Pages/Selena.aspx See webpage section on “Beyond SELENA+, enhancing the ability to predict cardiovascular diseases.”
EyRIS news. “EyRIS Partners Topcon Healthcare Solutions To Roll Out SELENA+ in Harmony RS for 18 Asian Countries.” November 11, 2020. https://eyris.io/latest_news.cfm?id=30
DOI
EyRIS news. See various news announcements about international approvals, trials and usage over the 2020 to 2022 time period. https://www.eyris.io/all_news.cfm?archive_year=2022
Integrated Health Information Systems. “Nationwide Predictive Model for Admission Prevention.” https://www.ihis.com.sg/Awards/Pages/2018%20NHITEA/Cat-A-Predictive-Model-for-Admission-Prevention.aspx10.3389/fphar.2022.801928
DOI
Ta WA, Goh HL, Tan CS, Sun Y, Yu Aung KC, Woon Z, et al. Development and implementation of nationwide predictive model for admission prevention: System architecture & machine learning. IEEE EMBS International Conference on Biomedical & Health Informatics (BHI), 2018, pp. 303−306. https://ieeexplore.ieee.org/document/8333429
Integrated Health Information Systems. “Multiple Readmissions Predictive Model.” https://www.ihis.com.sg/Project_Showcase/Healthcare_Systems/Pages/Multiple-Readmissions-Predictive-Model.aspx
Ministry of Health (Singapore). “Chronic Disease Management Program,” https://www.moh.gov.sg/policies-and-legislation/chronic-disease-management-programme-(cdmp)
For example, see this description of an ongoing Singapore nationally funded R&D effort targeted at creating an AI‐based risk assessment tool for primary care providers to support the management of patients with one or more of the “3Hs”—high blood sugar (diabetes), high blood pressure (hypertension) and high levels of cholesterol (hyperlipidemia). https://aisingapore.org/grand-challenges/health/
Wang Z, Ong CLJ, Fu Z. AI models to assist vancomycin dosage titration. Fron Pharmacol. Feb 2022;13. https://www.frontiersin.org/articles/10.3389/fphar.2022.801928/full
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Publication history

Received: 17 June 2022
Accepted: 21 June 2022
Published: 19 August 2022
Issue date: October 2022

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© 2022 The Authors.

Acknowledgements

We thank the support and guidance received from the Ministry of Health (Singapore), Integrated Health Information Systems (IHIS) Senior Management, and all of our partners from the Singapore Public Healthcare sector: Agency of Integrated Care (Singapore), Changi General Hospital, Khoo Teck Huat Hospital, National University Hospital, Ng Teng Fong General Hospital, Singapore General Hospital, Tan Tock Seng General Hospital, Singapore National Eye Center (SNEC), and Singapore Eye Research Institute (SERI). We also thank Professor Emeritus of Marketing Jerry Wind of the Wharton School of Business for his encouragement to create this article in order to share information on how AI is changing the nature of customer engagement in healthcare. There was no direct funding involved in creating this case study article. The lead author, Professor Emeritus Steven Miller, did all the required work to prepare and write this article on a volenteer basis. All of the other co‐authors are full‐time employees of Integrated Health Information Systems. Their efforts to provide inputs to this article and to reveiw multiple drafts was all done on an "extra‐curricular" basis on top of their every day work. No additional funds or compensation was provided to them for working on this article.

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