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TRANSCRIPT
1 6/7/2012
Singapore’s National EHR Adaptive Architecture for Transformation and Innovation
Peter Tan Lead Enterprise Architect
HISA – Porto
6 July 2012
v v
2 6/7/2012 2
Agenda
• Singapore’s Healthcare Context
• Healthcare Transformation Agenda
• 1st wave (2004-2007): EMRX & CMIS
• 2nd wave (2008-2011): NEHR
• Current Developments
3 6/7/2012
Singapore
• 4.99 million people on 710.3 sq km
• Ethnically diverse: • Chinese: 75 per cent • Malays: 14 per cent • Indians: 9 per cent
• Characteristics: • A city state • Rich technology foundations • Support of the Government
• will of the people • less legal constraints • ‘it will be done’
Singapore
4 6/7/2012
National Infocomm Initiatives
3G & Free Island-wide Wireless Hotspot
National BroadBand rollout – Fiber Optic
National 2 Factor Authentication
Cloud infrastructure
2015 is Singapore’s 6th National IT
Masterplan, launched in 2006, http://in2015.sg
5 6/7/2012
Our Healthcare Ecosystem
Primary Care Long-term Care Acute and Intermediate Care
Restructured Hospital
Rehab & Support Services
Community Hospital
Polyclinics
General Practitioners
Screening & Preventation
Nursing Home
Home Care
Palliative Care
Public sector
Private sector
People sector
• 35,000+ healthcare workers
• 11,580 hospital beds
• 429,744 hospital admissions (2007)
• Public sector out-patient visits (2007) • Specialist Outpatient Clinics 3,687,910
• A&E 752,122
• Polyclinics 3,797,953
6 6/7/2012
“What does it mean when we say our population will be older? It means there will be more demand on healthcare because older people are sick more often.
But this also means it is a different pattern of healthcare So we have to respond to this by putting in more resources into our hospital system, building new hospitals. … get the whole system to be structured properly so that it will be adapted to cater for the ageing population. To structure it properly means we need step-down care.”
Picture taken from asiaone.com
And one key thing we must do with this step-down care is to link up our acute hospitals […] with community hospitals, so that you can have the best of both worlds. Prime Minister Lee Hsien Loong National Day Rally 2009
“
”
Vision: Integrated Healthcare System
7 6/7/2012
Goal State: The Big Picture
Tertiary Care
Primary and Intermediate Long Term Care
Community Hospital
General Practitioners
Nursing Home
Polyclinics
RH
CH
NHPolyclinics
FPsHome
Care
Rehab &
support
services
Screening &
PreventionPalliative
Care
RH
CH
NHPolyclinics
FPsHome
Care
Rehab &
support
services
Screening &
PreventionPalliative
Care
RH
CH
NHPolyclinics
FPsHome
Care
Rehab &
support
services
Screening &
PreventionPalliative
Care
RH
CH
NHPolyclinics
FPsHome
Care
Rehab &
support
services
Screening &
PreventionPalliative
Care
RH
CH
NHPolyclinics
FPsHome
Care
Rehab &
support
services
Screening &
PreventionPalliative
Care
RH
CH
NHPolyclinics
FPsHome
Care
Rehab &
support
services
Screening &
PreventionPalliative
Care
Secondary Care
• A pyramid model
• Anchored by regional hospitals
• More autonomy in day-to-day operations
• Own networks of general practitioners
• Step-down care facility in respective zones
8 6/7/2012
One Patient One Record Strategy
Enable integrated healthcare services
Enable integration between healthcare and advances in biomedical
science
Health Information
Exchange - e-Enable seamless
and secured information
exchange in the healthcare value
chain
Integrated Healthcare
Continuum – e-Enable
processes and linkages across the healthcare
value chain
Translating Biomedical Research to Healthcare Delivery -
integrate clinical and biomedical research data
Well-Integrated
Quality Healthcare
Cost-effective
Healthcare Services
Greater ability of public to manage
their health
Strong clinical and
health services research
To accelerate sectoral transformation through an Infocomm-enabled personalised healthcare delivery system to achieve high quality clinical care, service
excellence, cost-effectiveness and strong clinical research
Strategic Thrusts
Outcomes
Goal
Strategies
iN2015 Strategic Framework From iN2015 Healthcare and Biomedical Sciences Report
Health Information Exchange – e-Enable seamless and secured information exchange in the healthcare value chain
Integrated Healthcare Continuum - e-Enable processes and linkages across the healthcare value chain
NEHR
9 6/7/2012 9
First Steps:
Electronic Medical Records Exchange (EMRX)
• Launched in April 2004
• Operating Principles
– Focus on improvement of patient care outcomes
• Other purposes such as research are secondary
– Living with Diversity
• Minimise impact on existing systems, lightest touch possible
• Standardise only where necessary
– Hybrid model
• Largely decentralised storage with some information
centralised
– Pragmatic & Incremental implementation
• Don’t aim for perfection
• Deploy quickly, learn and refine at next iteration
• Think BIG Start SMALL
10 6/7/2012 10
Electronic Medical Records Exchange
(EMRX) 2004 - 2007
Public
(My.eCitizen)
Targeted Health Alerts
Self-Update
Hospitals, Polyclinics
Electronic Medical Records
Allergies
Medical Alerts
Immunisation records
HPB
Immunisation Records
School Health
Screening Results &
Follow-up
MINDEF
NS Medical Records
Hospitals
Electronic Medical
Records
Allergies
Medical Alerts
GPs
Immunisation records
Health Screening
Mini EMR
Step-down Care
EMRX
Data Interchange
Central Database
Clusters
(SHS, NHG)
Gov Agencies
(HPB, Mindef)
Private Sector
(Hospitals, Step-down
Care, GPs)
Central Database
• Documents with different formats transmitted within standard XML “envelopes” • Inpatient Discharge, Prescriptions, Lab results,
Radiology results, OT, Endoscopy, Imaging & ED notes
• Documents pulled at the point-of-care & discarded thereafter
• Ownership remains with the source organization • Avg 47,000 documents retrieved monthly (as at
2007) • Participants linked up
• National Health Group, SingHealth Group • Ministry of Defence Medical Service • Health Promotion Board
• Immunisation, School Health records
11 6/7/2012 11
EMRX Access
EMRX Access
0
100000
200000
300000
400000
500000
2004 2005 2006
Year
Do
cu
men
t V
olu
me
NHG Request SHS Request Total Request
• Volume of documents request grown exponentially over first 3 years as more documents were made available
EMRX Access
0
10000
20000
30000
40000
50000
60000
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2006
Do
cu
men
t V
olu
me
NHG Request SHS Request Total Request
EMRX Access
0
5000
10000
15000
20000
25000
30000
35000
40000
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2005
Do
cu
men
t V
olu
me
NHG Request SHS Request Total Request
12 6/7/2012 12
Allergy Reporting: Unsustainable practices
Ministry of Health Singapore
13 6/7/2012 13
Critical Medical Information Store (CMIS)
• Launched in October 2005
• Leverage on EMRX infrastructure
• Semantic interoperability with data standardization
• Centralized storage of
• Medical alerts
• Drug allergies
• Adverse drug reactions reports to the Health Sciences Authority
• Now average 61,266 retrievals & reports on MA and DA monthly
Public
(My.eCitizen)
Targeted Health Alerts
Self-Update
Hospitals, Polyclinics
Electronic Medical Records
Allergies
Medical Alerts
Immunisation records
HPB
Immunisation Records
School Health
Screening Results &
Follow-up
MINDEF
NS Medical Records
Hospitals
Electronic Medical
Records
Allergies
Medical Alerts
GPs
Immunisation records
Health Screening
Mini EMR
Step-down Care
EMRX
Data Interchange
Central Database
Clusters
(SHS, NHG)
Gov Agencies
(HPB, Mindef)
Private Sector
(Hospitals, Step-down
Care, GPs)
Central Database
14 6/7/2012 14
CMIS Retrieval Flow
Private Hospitals
Public Hospital
EMR System
CMIS
Patient
Arrives
GPs Clinic
Management
System
E-Service
Cluster EMRX
Interface
Component
Ministry of Health Singapore
Retrieve & Report
MINDEF
15 6/7/2012
2nd Wave (2008 – 2011)
National EHR – Architecture Approach
Focus on Governance
& Control
Develop Artefact Library
Focus on Delivery
Future Planning & Innovation
(1) Top Down Strategy iN2015 Healthcare and Biomedical Sciences Report
?
16 6/7/2012
Proactive Vs. Passive Architecture
Proactive Architecture
Passion
Business Analysts, Solution Architects, Enterprise Architects
Meaningful & Credible
Architecture Analysis
Explore
“The Art of Possible”
Involvement
Excite and Encourage
Balancing Goals and Objectives
You may make a mistake, but don’t make the same mistake twice
Passive Architecture
Build the EA Organization
Build the Principles and Blue Prints
Develop Gover-nance Blue Prints
Mandate Uptake
Committees and Boards
17 6/7/2012
Solution and Architecture Services
Implementation
Enterprise Architecture
Solution Architecture & Design
Adapted from TOGAF v9
• Work collaboratively
• Add value early on
• Take a pragmatic approach
• Become part of natural process
• It’s always about delivery
• Be supportive
Value breeds demand
18 6/7/2012
Envision for each Stakeholder
Vision: The EHR in Singapore will revolutionise the timely and accurate communication of clinical information, which will help promote a healthier population. “No Singaporean will have their clinical care compromised by lack of access to clinical information”
Vision of Patients Vision of Clinicians Vision of Health Administrators
• Reputation for providing outstanding service to patients & families
• Culture of wanting to share clinical information with partners in care delivery
• Support to deliver the highest level of clinical care outcomes
• Streamlined transfer of care
• More time for direct patient care due to less manual / paper based processes
• Trust in data analysis and entry of other clinicians
• Confidence in the quality of data
• Exceeded expectations of
consumers & staff
• Value for investment meets / exceeds the promise
• Pre-eminence in Health IT and clinical research
• Innovative, evidence based systems
• Satisfaction from the knowledge that the health system is sustainable
• Belief that the future population will be healthier than before
• Able to attract, develop and retain high quality clinicians
• Confidence that health policy is based on decisions and insights from robust operational data
• Trust that clinicians have information required to deliver the best possible care
• Streamlined interaction with high calibre providers across the healthcare sector
• Encouragement to seek answers to clinical questions
• Empowerment delivered by self-management capabilities
• Minimise inconvenience from unplanned encounters with the health system
• Confidence that personal data is protected
19 6/7/2012
To Enable Transformation and Innovation P
lan
ned
Co
mp
on
ents
20 6/7/2012
In the last 4 years…
3Q ‘08
4Q ’08
1Q ’09
2Q ’09
3Q ’09
4Q ’09
1Q ’10
2Q ‘10
3Q ‘10
4Q ’10
1Q ’11
2Q ’11
3Q ’11
4Q ’11
Work Packages
EA Ops & Gov
CIC & PHM
Architecture
Extending to new
Business Areas
NHISA
NEHRA
ESB
Service Catalog
IIA
From
Strategy to
Program
focus From problem to
innovation:
Deep dive into a
tricky problem space
& take opportunity to
innovate.
NEHR POC NEHR RFP
NHIS
Scoping
NEHR
detailed
design
Repository
Data/Doc
Interop Specs
Design
Assurance
Value Value
Value
Value
Tooling: EA
Repository Gov & Operation
Content
population
NEHRA next iteration
NEHR
Live
Implementing operation
& governance only
when needed.
21 6/7/2012
Solving wicked problems: Source Data and Operations
22 6/7/2012
Current: Planning for Phase 2
Continue to Leverage and Extend
Gap analysis of current NEHR system
Look at Current vs Goal State
Identify new business services
and capabilities
Integration analysis of current systems
Goal state architecture
Options analysis
23 6/7/2012 23
Extended: Healthcare Capability Model
The Healthcare Capability
Model is used to:
• Develop a ‘good practice’
goal state architecture
• Communicate to
Stakeholders
• Manage Business and IT
Portfolio
Existing
Newly added
To be extended
24 6/7/2012 24
Reference Architecture example:
Goal State EMR
A conceptual goal state EMR
system has been modeled to
add context to the application
architecture and integration
pattern.
The conceptual goal state
EMR’s capabilities are:
• Integration
• Clinical data sharing
• Reconciliation
cmp ABC-026-JHS
NEHR
«OSB»
NEHR-ESB
«goal state»
EMR
«HTB»
NEHR-CDRNote: whilst some existing
interfaces are shown in black
they are not exposed via
NEHR-ESB at present - i.e.
NEHR portal retrieves the
information directly
«goal state»
out of cluster :EMR
Used to resolve the
address of documents
and document / referral
recipients
Cross (cluster) EMR
communication
«Initiate»
NHIS
Endpoint Resolution
Serv ice
Required to recieve
and deliver
communications from
other care providers /
systems
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25 6/7/2012 25
Architecture repository Meta-Model
Example:
• Singapore’s Rising
Healthcare Costs are a
Business Driver
• which is tackled by the
improved sharing of clinical
information whose Goal
• is supported by the example
of improved sharing in the
Imaging - Capability
• This capability contains the
resolveRecordLocation -
Application Service
• Found in the NHIS -
Application
• That can be implemented on
Linux - Technology
Component
26 6/7/2012 26
Goal State Architecture
operationalized in repository
EArepository manages indexes
of the major entities, physical and
logical, within the MOHH
enterprise.
• Business Data Inventory
• Application Inventory
• Organisation Inventory
• Business Svs Inventory
• Appln Svs Inventory
• Information Flow
• Info flow (appln. srv.)
• Appln vs Appln Svs
• Business Svs vs Appln Svs
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ata
A
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O
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B
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Se
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Ap
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In
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Flo
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Info
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ap
pln
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rv.)
In
fo f
low
(a
pp
ln.
srv
.)
Bu
sin
es
s S
vs
vs
Ap
pln
Svs
27 6/7/2012
What We’ve Learned
01. Focus on solving
problems, not just delivering
artefacts
02. Build
relationships/ trust
03. Be a servant
first, policeman
later
05. Evolve from
where you are
04. Be pragmatic, not dogmatic
Revolutionaries make
good Martyrs!
28 6/7/2012
A happy occasion