Assoc Prof Low Lian Leng, Director, SingHealth Centre for Population Health Research and Implementation; Chairman, Division of Population Health and Integrated Care, Singapore General Hospital; Director, Research and Translational Innovation, SingHealth Community Hospitals
Dr Oh Hong Choon, Deputy Director, Health Services Research, Changi General Hospital
Ms Eunice Tong Huiying, Research Associate, SingHealth Centre for Population Health Research and Implementation
Dr Zhang Yichi, Research Fellow, SingHealth Centre for Population Health Research and Implementation

With the national shift towards population health, there has been a growing impetus on transforming the primary care landscape to improve care delivery. Read about two key initiatives by the SingHealth Centre for Population Health Research and Implementation, and how they are leveraging digital tools and research insights to benefit both general practitioners (GPs) and the community.
 

WHAT IS POPULATION HEALTH?

Population health focuses on improving the health outcomes of entire groups of people, rather than just individuals. It encompasses a broad approach that considers social, economic and environmental factors that influence health, alongside traditional healthcare delivery.

By taking a population-level perspective, healthcare providers and policymakers can implement targeted interventions that benefit larger communities, ultimately leading to better health outcomes and more cost-effective healthcare delivery.

THE GP’S ROLE IN POPULATION HEALTH

Primary care providers play a pivotal role in population health management as they serve as the first point of contact and are uniquely positioned to:

• Identify health trends
• Deliver preventive care
• Manage chronic conditions
• Coordinate care across different healthcare settings

Through their ongoing relationships with patients, they can better understand community health needs, implement early interventions, and provide continuous, person-centred care that addresses both individual and community health challenges.

The national shift towards preventive care

Healthier SG is Singapore's national populationhealth strategy that marks a significant shift from the traditional disease-based healthcare system to one focused on preventive health. Launched in 2023, this initiative encourages residents to enrol with a regular family doctor who helps develop personalised health plans and coordinates their preventive care needs.

The programme emphasises health education, lifestyle modifications and regular health screenings, supported by community partners and digital health tools. Through this coordinated approach, Healthier SG aims to help Singaporeans take greater ownership of their health while building stronger relationships with their primary care providers.
 

THE SINGHEALTH CENTRE FOR POPULATION HEALTH RESEARCH AND IMPLEMENTATION

Strategically sited in the SingHealth Regional Health System, the SingHealth Centre for Population Research and Implementation (CPHRI) bridges research and care delivery into the community, develops population health expertise to serve strategic needs, and supports the development of the national population health ecosystem. CPHRI works closely with national agencies, healthcare and social care partners to leverage big data and technology as key enablers to support our key population health initiatives.

Launched in April 2022, CPHRI aims to serve as the nexus for population health research, innovation, implementation and evaluation in the SingHealth Duke-NUS Academic Medical Centre.

In this article, we will share about two such initiatives by CPHRI:

1. EMPOWER+

2. Longitudinal Insights intoHealthier SG (LI-Healthier SG)

1. EMPOWER+Digital Health Platform for Managing Chronic Diseases

THE CHRONIC DISEASE BURDEN IN SINGAPORE

In Singapore, approximately one in 12 adults has diabetes,  over one in three has hypertension, and nearly 40% live with high cholesterol. Many patients manage multiple chronic conditions, which significantly increases their risk of cardiovascular disease and long term complications.

These individuals often face challenges, such as juggling complex medication regimens, managing dietary restrictions and sustaining motivation to stay active and engaged in their self-management. Supporting them to manage these conditions effectively– especially in between clinical visits – remains a key priority in primary care.

INTRODUCING EMPOWER+

To complement the critical work of primary care providers, CPHRI, in collaboration with the School of Computing, National University of Singapore, has codeveloped EMPOWER+, a digital health tool to support patients in their day-to-day self-management while providing timely behavioural insights to healthcare teams.

Benefits for patients

At the heart of this tool is the EMPOWER+ mobile app, which integrates multiple features to help patients set personalised goals, track progress, and stay engaged between clinical touchpoints:

• EMPOWER+ syncs with wearable devices to monitor physical activity, displaying progress via intuitive dashboards.
• Health and behavioural data such as blood pressure, glucose level and food intake can also be logged by users, with the ease of using Optical Character Recognition and food image recognition technologies, enhancing self awareness and continuity of care.
• Gamification and rewards elements are also incorporated into the app to encourage sustained engagement and reinforce healthy behaviours.
• Personalised, AI-powered nudges drawn from the above patient-generated data enable EMPOWER+ to deliver short, context-specific messages to encourage behaviour change.
• An AI-powered chatbot in the app provides credible and contextual health information (Figure 1).

Benefits for GPs and care teams

For GPs and care teams, the companion Healthcare Worker (HCW) portal (Figure 2) generates structured summaries of patients’ progress and engagement. These reports offer insights into patients’ health and behavioural snapshots between visits, supporting more targeted, data-informed clinical conversations and shared decision-making.

Providers can also assign tailored tasks or nudges through the portal to reinforce care plans and provide more personalised support. Further enhancements to the HCW portal are underway to better serve GPs’ and care teams’ needs.

DEMONSTRATED IMPACT IN HEALTHCARE SETTINGS

EMPOWER+ has been evaluated in real-world healthcare settings. In a clinical trial funded by AI Singapore, the EMPOWER+ app was used alongside health coaching and shared decision-making, demonstrating improvements in HbA1c, patient activation and physical activity levels.

In a separate clinical trial funded by the Ministry of Health Health Innovation Fund, the app was integrated with continuous glucose monitoring (CGM) and coaching support, showcasing its feasibility, acceptability and effectiveness among participants.

The Role of Technology to Support GPs in Chronic Disease Management

GPs are at the forefront of chronic disease management, and digital tools can help extend support to patients beyond the clinic encounters. Rather than replacing clinical care, tools such as EMPOWER+ are strengthening it.

• Aligned with Healthier SG's emphasis onpreventive care and patient empowerment, EMPOWER+ offers accessible, scalable and culturally relevant support that can be tailored to the individual patient’s needs.
  
  
• Data collected through the platform can further enhance shared decision-making, making consultations more targeted, efficient and impactful.

The ongoing development and evaluation of EMPOWER+ is led by a multidisciplinary team with expertise in family medicine, behavioural science, data science and social science.

Supported by national research funding, the team works in close collaboration with public healthcare institutions and community partners to ensure that the tool is practical, adaptable and sustainable.

If you are keen to learn more or explore how EMPOWER+ can support your clinical practice, we welcome you to get in touch with CPHRI.
 

2. LONGITUDINAL INSIGHTS INTO HEALTHIER SG: Understanding the Primary Care Landscape

COLLECTING FEEDBACK FROM THE GROUND

The Longitudinal Insights into Healthier SG (LIHealthierSG) project is a SingHealth initiative which aims to continuously:

1. Evaluate changes in ground sentiments
2. Evaluate implementation
3. Recommend improvements to refine future implementation of Healthier SG

In collaboration with College of Family Physicians Singapore and National University Health System, online surveys were administered to participating Primary Care Physicians (PCPs) to collect their feedback on the current primary care landscape in Singapore.

These include their needs in delivering preventive health services, existing supporting systems, and opportunities for better collaboration between primary and tertiary care.

Findings from this four-year study (2023 to 2026) will offer pragmatic insights on possible strategies which can enable PCPs to be better positioned in shaping policies and interventions – to better support our PCPs in strengthening primary care delivery in Singapore.
 

BASELINE SURVEY RESULTS

Healthcare infrastructure

Our baseline survey of 148 PCPs (including those practising in private GP clinics and public polyclinics across the three clusters) in 2023 revealed that the primary care landscape has strengths which suggest PCPs’ readiness for Healthier SG. Nevertheless, the survey results also uncovered improvement opportunities in the implementation of Healthier SG.

The existing healthcare infrastructure provides astrong foundation to support the implementation and delivery of Healthier SG:

• Nearly 90% of surveyed PCPs worked in clinics that already had permanent doctors registered under the Register of Family Physicians
• 96.6% of surveyed clinics utilised IT systems fo rclinical operations
• 95.9% of surveyed clinics were participating in at least one national scheme or programme (Community Health Assist Scheme - CHAS, Public Health Preparedness Clinic - PHPC, Chronic Disease Management Programme -CDMP, Healthier SG Screening, Vaccination and Childhood Development Screening Subsidies - VCDSS, or GPFirst)*

Chronic care delivery

Our survey examined PCPs' chronic care delivery using the Assessment of Chronic Illness Care Short (ACIC-S), a validated tool that measures healthcare support systems across different aspects of chronic care delivery.

In our baseline survey, the mean (SD) ACIC-S score of participating PCPs was 6.01 (2.21) which was within the 'advanced support' range, indicating that the primary care landscape has robust systems and processes in place to support chronic disease management. Evidently, this would offer a strong foundation for enhanced care delivery in Healthier SG rollout.

Confidence levels

PCPs who are Primary Care Network (PCN) members (60.2% of surveyed PCPs) reported higher confidence levels (3.08 on a 5-point confidence scale, compared to 2.79 in non-PCN members) in delivery of Healthier SG services.

This difference in confidence levels suggests potential benefits of PCN membership among PCPs in Healthier SG implementation. Future studies could examine if PCN resources such as shared care teams, administrative support and peer support networks contribute to this difference in confidence levels.

Opportunities for improvement

When PCPs were asked to rate themselves in domains such as resources, skills and familiarity, they reported lower ratings for lifestyle interventions compared to other preventative health services like breast and cervical cancer screening which are offered to their patients. The participating PCPs also highlighted time constraints as a key barrier to the offering of lifestyle interventions to eligible Healthier SG enrolees.

These findings suggest opportunities to explore ways to support PCPs in delivering preventive health services, particularly in addressing their time and resource constraints.

In the initial implementation of Healthier SG, over70% of participating PCPs reported difficulties in understanding the drug subsidies and subventions, logistical procedures and administrative processes for Healthier SG enrolment. This finding highlights the need to improve information sharing with PCPs and support in these operational areas.

Overall, the key strengths of our primary care landscape and the improvement opportunities are summarised in the table below.

Our Primary Care Landscape

THE ROLE OF GPs IN RESEARCH

Research will continue playing a vital role in understanding and supporting Healthier SG implementation. Through PCPs’ participation in LI-Healthier SG, we have identified both strengths in our healthcare infrastructure and opportunities for enhancement in Healthier SG implementation.

To build on these insights, SingHealth will continue to monitor and evaluate Healthier SG implementation through multiple research activities which include:

• Regular satisfaction surveys to measure PCPs’ experience and identify areas for improvement (SingHealth Partner Satisfaction Surveys)
• Focused group discussions to deep dive into specific challenges and opportunities in the implementation of Healthier SG

PCPs’ continued participation in such research activities will be crucial in enabling SingHealth to make informed decisions which can enhance Healthier SG implementation further, and contribute to the transformation of the primary care landscape in Singapore.

HOW GPs CAN TAKE PART IN CPHRI’S RESEARCH PROGRAMMES

We invite GPs to take part in the two aforementioned population health initiatives and be part of the care journey with SingHealth.

GPs can contact CPHRI at cphri@singhealth.com.sg for more details.

To find out more about the SingHealth Centre for Population Health Research and Implementation and its initiatives such as EMPOWER+and LI-Healthier SG, please email cphri@singhealth.com.sg.

Associate Professor Low Lian Leng is the Director of the SingHealth Centre for Population Health Research and Implementation (CPHRI) and Chairman of the Division of Population Health and Integrated Care in Singapore General Hospital. He has a deep interest in health services research, especially in the areas of population health, innovative integrated care delivery models, value-based care and data analytics.

Dr Oh Hong Choon heads the Health Services Research department in Changi General Hospital while concurrently serving as Deputy Director at the SingHealth Centre for Population Health Research and Implementation (CPHRI). His research interests are in the areas of prescriptive and predictive analytics, and cost-effectiveness evaluation.

Ms Eunice Tong is a Research Associate at the SingHealth Centre for Population Health Research and Implementation (CPHRI). Her interests lie in evaluating and strengthening health programmes to improve outcomes through data-driven insights and collaboration.

Dr Zhang Yichi is a Research Fellow at the SingHealth Centre for Population Health Research and Implementation (CPHRI). Her research interests include digital health implementation and evaluation, as well as the use of big data to support population health improvement.