Editor’s note: COVID-19 Test Repository (CTR) was first covered in the article: COVID-19 Test Repository (CTR): A One-Stop Repository and Single Source of Truth for COVID-19 Test Results. In this article, we recap what the HealthTech system, CTR, is and the system enhancements made to support Singapore’s healthcare industry.

When COVID-19 broke out in Singapore last year, it was all hands on deck – numerous healthcare institutions, clinics and cross ministries task force stepped up to conduct thousands of swab tests daily. At the same time, various teams in the Ministry of Health were working round the clock to conduct analysis.

Many involved were using manual spreadsheets or different systems with different processes of capturing the COVID-19 test results, leading to inefficiencies. There were also duplicated processes along the chain of reporting (e.g. multiples downstream parties reaching out to the labs to get results) and avoidable human errors.

It was not long before a pressing need arose – a system that aggregates and centralises test results from many sources, minimising the need for manual compilation and removing bottlenecks in the workflow. In short, what was needed was a one stop central repository and single source of truth for COVID-19 test results that helps to aggregate results from laboratories, codifies them to a standard and consistent manner, and delivers them in a timely and reliable manner to various users groups.

Consolidating COVID-19 Lab Test Results in the COVID-19 Test Repository (CTR)

To meet the pressing need, IHiS raced against time and in eight days, developed the first iteration of the COVID-19 Test Repository (CTR) to consolidate test results from all public healthcare institutions and MOH assigned private laboratories. A key step was integrating CTR with the sources of information. This was achieved by leveraging existing data pipes between public healthcare institutions’ Laboratory Information System (LIS) with the National Electronic Health Record (NEHR) to pull and centralise tests results. For private laboratories which were not connected to NEHR at that point in time, the CTR team worked to accelerate onboarding them to contribute results in real time to CTR.

Related article: Patients First with NEHR - Enabling better CARE for you

To date, the COVID-19 Test Repository (CTR) has stored an estimated seven million COVID-19 test results contributed by 26 participating laboratories. More than 2,000 users have been given access to CTR to manage the various aspects of COVID-19, such as swab capacity planning and operations, public health actions in contact tracing, quarantine order, management reporting and analysis.

Did you know? That there are broadly three types of COVID-19 test results stored in COVID-19 Test Repository (CTR), namely:

1. Polymerase Chain Reaction (PCR)
2. Serology
3. Antigen Rapid Test positive (ART)

More than just an aggregator and database of results, COVID-19 Test Repository (CTR) also includes two dashboards of composite COVID-19 test result data to support operations planning, management reporting and analytics.

How does the COVID-19 Test Repository (CTR) help in managing COVID-19?

 For Healthcare and Laboratory Staff:

• Healthcare staff from various institutions, including those at the Community Care Facilities, are able to quickly access the results of their patients through the COVID-19 Test Repository (CTR) viewer.
  
  
• When healthcare staff at hospitals were required to be swabbed regularly after the outbreak in Tan Tock Seng Hospital in May 2021, CTR allowed them to easily and accurately monitor this, with expedient reporting to MOH.
  
  
• For LIS which are integrated to Patient Risk Profile Portal (PRPP) and Swab Registration System (SRS) to receive swab sample registration, the labs will process the samples and input the subsequent results back into COVID-19 Test Repository (CTR). Electronic and seamless submissions not only increases accuracy of information, but reduces the time needed for this step, allowing labs to focus on core lab work.
  
  

Related article: Patient Risk Profile Portal (PRPP) – Enhanced with Swab Referral System and Antigen Rapid Test Functions

• With the commencement of vaccination and the introduction of mRNA vaccines, serology tests are required to provide the distinction between anti-N and anti-S immunoglobulins. Multiple serology tests may also be ordered for a single individual. Quantitative serology tests, in addition to the qualitative tests that are in use, were also introduced.
  
  As a result, COVID-19 Test Repository (CTR) had to once again evolve to support the result interpretation for more diverse types of serology tests. The team worked with various stakeholders to distinguish the different interpretations of the test results and incorporated it into the system accordingly. Together with the vaccination status of the individual, it helps the CTR users to clearly identify the COVID-19 status and the subsequent public health actions to be taken.

For COVID-19 Operations:

• To meet operational needs, the COVID-19 Test Repository (CTR) system was enhanced to allow operational staff across various ministries to interpret lab test results accurately and consistently. This was a task typically performed by skilled clinicians and lab specialists. CTR achieved this by providing clinicians-approved logic to interpret variations of test results in a standardised codification.
  
  This removed the bottlenecks in the results verification process as approved users can now access the repository to identify affected individuals themselves. As the functionality and usefulness of the COVID-19 Test Repository (CTR) grew amid the active mass testing strategy, system enhancements were carried out to support the safe re-opening of Singapore through testing at events, pre-departure, on arrival, and regular rostered routine testing (RRT) for front line workers and special surveillance operations using pooled tests and Antigen Rapid Tests (ART).

• An important outcome of COVID-19 Test Repository (CTR) is enabling COVID-19 test results to be made readily available to relevant stakeholders once the samples have been processed. The test results from CTR are fed into NEHR and HealthHub, allowing clinicians and individuals to be kept informed of test results in a timely, reliable and convenient manner.

• The COVID-19 Test Repository (CTR) viewer also allows approved users to access test results to support day-to-day ground operations in incidence tracking of cases. With close integration with downstream systems, CTR allows swift and integrated public health actions such as contract tracing, quarantine order and capacity planning to be taken, reducing possible cases of transmission.
  
  With the recent announcements from the Government that, moving forward, one of the key steps to managing COVID-19 is to intensify testing and contact tracing, CTR’s seamless integration of many systems will be even more important to support Singapore’s healthcare industry.

• As COVID-19 Test Repository (CTR) sends test results in frequency intervals of one minute to most downstream systems it supports (ten in total), such as VISION CMS that handles contact tracing and quarantine orders, and MOM ACE that manages foreign workers fitness to work, it helps to facilitate swift and integrated follow up actions. For example, when a positive case is detected, it alerts the contract tracing team to commence tracing of close contacts and to issue quarantine notifications. It also sends information to Case Management Task Group (CMTG) to convey the confirmed cases. Should the confirmed case be a foreign worker, alerts are provided to the worker and also promptly sent to a system to notify their employers who can then take pre-emptive measures.

“[COVID-19 Test Repository (CTR) provides] … expedient identification of foreign workers’ swab status. There were quite a few instances where they declared that they were either negative or uncertain of their swab status. Before obtaining CTR access, it took my team up to a day to track down the results. But with CTR access, it took us mere minutes.”
Doctor, SingHealth, CCF@Expo

“[COVID-19 Test Repository (CTR)] … allowed me to perform my job as Coronavirus Consultant to confirm test results performed elsewhere and develop a greater appreciation for the variation in PCR results when performed in different settings.”
Senior Consultant, Division of Infectious Diseases, National University Hospital (NUHS)

Continuous System Enhancements to Expand the Role of COVID-19 Test Repository (CTR)

Ever since the first version of COVID-19 Test Repository (CTR) was developed in April 2020, it was gone through many system enhancements to incorporate new functions as well as to take on more roles.

For example, CTR evolved from supporting foreign worker operations to become the single source of truth for all COVID-19 test results in Singapore. This was made possible by collaborating with several ministries and integrating all the relevant systems together. It has now gone on to be the system used to support pre-event testing and pre/post travelling. With vaccination well under way now, it is also used to track the vaccine efficacy of an individual’s vaccination status and the test results.

Given its central role in COVID-19 management, IHiS uplifted CTR system earlier this year by developing an internet viewer for users to access the test results in CTR through SingPass. This system enhancement improves usability as users no longer require a virtual private network to be connected to CTR.

COVID-19 Test Repository (CTR) was enhanced to support expedited turnaround time of test results from labs to CTR to downstream systems from 24 hours to eight hours. One of the enabling factors was reducing the intervals of file transfers from CTR to supporting systems from one hour to twenty minutes, and then eventually to one minute, which helped to provide almost real time updates. This was made possible after many rounds of coordination with relevant partners and the subsequent uplifting of the CTR infrastructure and its interface with downstream systems.

In light of the recent increase in COVID-19 community cases and subsequent swab tests in May 2021, the CTR team quickly established a 24/7 helpdesk support so that any problems could be investigated even during off peak hours.

Looking ahead, the COVID-19 Test Repository (CTR)’s usage and system architecture will also be useful as a model for future disease outbreaks, in which lab and point-of-care test results are key to the diagnosis and management of infectious diseases.

For all of CTR’s contributions to COVID-19 management, it was recognised as one of the winners at Singapore Computer Society’s IT Leader Awards 2021 (Infrastructure Category), themed Tech Heroes from Crisis. It also won two Public Service Transformation awards under the Agility Award and One Public Service Award category.

We congratulate everyone involved in making COVID-19 Test Repository (CTR) possible!

Related article: COVID-19 Test Repository (CTR): A One-Stop Repository and Single Source of Truth for COVID-19 Test Results