​The NHCS iECG team: (Front row, L-R) Assoc Prof Lim Soo Teik and Asst Prof Daniel Chong from Department of Cardiology; (Back row, L-R) Chiong Siau Chien and Loh Peh Rong from Cardiac Laboratory, and Poticar Mary Jane, Zubaidah Bte Hassan and Jonathan Sim from Nursing.

Electrocardiogram (ECG) is one of the world’s most widely prescribed cardiac diagnostic test, and key to the detection and management of heart conditions. Presently, when the doctor sees a patient at the cardiac clinic, he can review the ECGs that the patient has previously taken for example, at the polyclinic, with just a click of the mouse. This was certainly not the case prior to June 2020 where a separate system housed the ECG records and was not synced to the electronic medical records (EMR) system.

Digitalisation transforming healthcare
SingHealth has been at the forefront of the digital transformation journey, promoting and championing data-driven culture to enhance workflow and patient management. The iECG initiative, a cluster project to better integrate and improve access to patients’ ECG information across its network of institutions, is one key move in this journey. Partnering with Philips, NHCS was the first in the cluster to implement.

Assoc Prof Lim Soo Teik, Senior Consultant, Department of Cardiology was the project lead. He shared, “There are significant opportunities to harness the power of technology, and partnership between healthcare institution and technology is crucial to break down barriers and complexity to deliver better health and lower cost of care.” 

Prior to the implementation, Assoc Prof Lim shared that it was time-consuming for hardcopy ECGs to be manually transferred from the previous platform to the EMR, and the manual process was prone to potential human errors. In addition, the platform worked on a legacy operating system with no analytical capability.

“In the distant past, oftentimes, clinicians would have difficulty looking for previous ECGs because they would need to manually hunt for that piece of ECG printout among archived files. Sometimes, some of the ECG printouts from old records had faded, which made it difficult for the clinician to decipher the patient's previous ECG waveform,” shared Asst Prof Daniel Chong, Senior Consultant, Department of Cardiology, who was the clinical user project manager.

The team shared that from 2007 to 2020, there was an earlier version of digital ECG management system in place at NHCS. The system was installed when the ECG ecosystem was not fully matured. Though the system had some technical shortcomings, it nevertheless housed closed to 1 million digital ECGs acquired during that period. These ECGs were subsequently migrated onto the newer iECG platform, providing extremely useful reference for serial ECG comparison.
NHCS leading the change
A cross-institutional multidisciplinary team comprising medical, nursing and allied health staff brought this project to fruition. Jonathan Sim, Assistant Director, Nursing, who was also the cluster nursing lead, said, “When the team first got together, we realised that the work process varied greatly between institutions. However, with representatives openly sharing their concerns and working amicably together, we managed to address the issues and harmonised the process for the new iECG workflow.”

NHCS being the first institution to implement iECG, certainly met with challenges along the way. “The UAT (a test exercise prior to implementation) was conducted on a Sunday morning with everyone on-site – including the cardiologists, cardiac technologists, nursing informatics team, BME engineers and IHIS team members! We ran through each step of the entire process – first, having a doctor ordered the ECG through the EMR, followed by the cardiac tech performing the ECG and ensuring the result was sent back to the EMR. Finally, with the doctor’s acknowledgement of the ECG results in the EMR,” shared Chiong Siau Chien, Assistant Director, Cardiac Laboratory and NHCS’ Cardiac Tech Lead. She added, “This entire process was the ‘closed loop’ ECG workflow implemented in the project. Only when we confirmed that everything worked without a hitch, did we then, declare the UAT a success!”

It is also exceptional to note that the project went live on 23 June 2020 during the pandemic when there was visitor restriction imposed in campus. Instead of getting support from the vendors, the job of appropriately configuring the ECG machines for the new system became the responsibility of the cardiac techs and BME engineer. Siau Chien mused, “With the gung-ho team members and clear instruction guides, we successfully managed the sophisticated ECG machines on our own!”

Comprehensive step-by-step guides such as above, were painstakingly put together by the team to aid staff in using the new iECG system.

Of particular mention is the comprehensive user guide compiled by clinical staff, combining inputs from IT and vendors. The guide serves as a useful training material for new users and support staff.

Increased efficiency and staff experience
With the successful implementation of iECG in NHCS, other institutions soon embarked on the similar solution where clinicians across SingHealth are able to review and analyse patients’ previous and current ECGs real time from multiple connected locations. 

“If a patient comes into the emergency department with chest pain or palpitations, we can quickly compare his previous ECG and the new ECG for any changes. This has helped improve care delivery for the patient. The EMR has also allowed us to extract data and provide insights on information such as the number of ECGs performed in a particular location and the number of abnormal readings in a certain number of ECGs,” said Assoc Prof Lim.
Assoc Prof Lim said that the roll out of this smart solution is a significant next step in our digitalisation journey, closing the gap in the entire paperless EMR ecosystem, and demonstrating how healthcare digitalisation can enhance patient as well as staff experience. 


Thank you to the NHCS iECG team for bridging the care delivery for our patients!

The NHCS iECG Team:

Project Lead, Cluster and NHCS: 
Assoc Prof Lim Soo Teik, Senior Consultant, Department of Cardiology, NHCS

Clinical User Project Manager, Cluster and NHCS:
Asst Prof Daniel Chong, Senior Consultant, Department of Cardiology, NHCS

IT Project Manager, Cluster
Henry Goh, IHIS

Nursing User Lead, Cluster and NHCS: 
Jonathan Sim, Assistant Director, Nursing, NHCS

Cardiac Technologist User Lead, Cluster and NHCS: 
Chiong Siau Chien, Assistant Director, Cardiac Laboratory, NHCS

Biomedical Engineering Lead, Cluster and NHCS:
Jayden Siew, Biomedical Engineering, NHCS

NHCS Members:
Physician Lead - Dr Eric Lim, Senior Consultant, Department of Cardiology
Nursing - SNM Jasmine Lee, Ward 44/47B; SNM Foong Jia Yi, Ward 56; NC Zubaidah Bte Hassan and SSN Poticar Mary Jane, Nursing Informatics 
Cardiac Tech User Champions - Loh Peh Rong and Julinda Yeo, Cardiac Laboratory; and Jocelyn Lee and Chua Ping Ping, Cardiac Laboratory - SKH

For more Stories from the Heart, click here.