Dr Pallab Saha - EA & Public Health

8/23/2019 Dr Pallab Saha - EA & Public Health

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RESEARCH

ArchitectingforBusinessInsightandStrategicForesight:ASystems

ApproachtoManagementofChronicDiseasesinSingapore

PallabSaha

NationalUniversity

of

Singapore

InstituteofSystemsScience

[email protected]

ExecutiveSummaryBusiness leaders operate in the realm of confounding uncertainties and

astounding complexities. These lead to incomplete and often nonactionable

informationthatmakesbusinessdecisions increasinglyspeculative.Theadvent

and diffusion of Enterprise Architecture (EA) as a metadiscipline provides

organizationsandbusinessleadersthemeanstoaddressthetwinchallengesof

businessdynamism

and

complexity.

However,

this

necessitates

the

inclusion

of

strategic(systems)thinkingwithintheEAapproach,requiringwithitacomplete

transformationofthearchitectsmentalmodelspertainingtothedevelopment

and utility of EA. As organizations become increasingly hyperconnected they

oughttobeviewedandexaminedassystems,whereintheholisticapproachand

theinterrelationshipsbetweentheorganizationalelementsplayacrucialfactor

in ensuring overall business coherency. This paper demonstrates the value of

adopting the systems approach to addressing chronic disease management in

Singapore, and provides insights to advance the impact of EA by integrating

creativethinkingtotacklecomplexproblems.

KeywordsHealthcare Systems; Public Health Transformation; Connected Health; eHealth; Coherency

Management; Chronic Disease Management; Policy Resistance; Management Agility;

OrganizationalChange;BusinessModelInnovation.

2011NUSInstituteofSystemsScience.NUSInstituteofSystemsSciencegrantspermissiontoreprintthisdocument

providedthiscoverpageisincluded.


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NationalUniversityofSingapore|InstituteofSystemsScience

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IntroductionStructured enterprise architecture (EA) approach is often used to plan and implement efficient and effective

transformationefforts.However,thestrongestdriverforEAistoimproveservicedeliveryandoverallperformance

withintheorganization'sbusinesssegments.Theprincipalchallengefacedbychiefarchitectstoday istoinstitute

anEAprogramthat isabletocoordinatesustainablechangesthroughouttheorganization,whilesimultaneously

mentoringthespecifictransformationplanningthatisneededtosupportthemission.Inanutshell,EAisarobust

planningfunction

which

helps

organizations

to

understand

the

process

by

which

business

strategies

turn

into

operational reality. Hence, establishing a standard methodology for conducting architecture planning and

implementationisvital.Metaphorically,anEAistoanorganizationsoperationsandsystemsasasetofblueprints

is to a city and its buildings. However, EA comes with additional challenges given that the primary frame of

reference, the organization, is a complex adaptive system. Even as architecture teams are architecting, the

organizationsthatarebeingarchitectedcontinueto functionandasaresultremaindynamicandeverchanging.

Traditionally,byfollowinganarchitecturebasedapproach,organizationsusuallyaimtoaddress issuespertaining

to:(1)strategicalignment;(2)informationaccuracyandintegrity;(3)infrastructuremanagement;(4)security;(5)

technology compatibility; (6) business valueof IT; (7)corporategovernance; (8)businesscollaboration;and (8)

procurementamongothers.ThoughEAisoftenassumedtofollowanorganizationsstrategyandtoalignITwith

businessobjectives,increasingly,evidenceofthereverseisalsosurfacing.Inotherwords,organizationstrategies

arebeinginfluencedbyITcapabilities.

Inthe

book

Coherency

ManagementArchitecting

the

Enterprise

for

Alignment,

Agility

and

Assurance,

authors

Doucet,Gotze,SahaandBernardpresentanddiscusstheextendedandembeddedmodesofEAinadditiontothe

traditionalmode.Theyassertthatasorganizationsstartembracingthemoreadvancedextendedandembedded

modes, the need for synergy and consistency amplifies, thus facilitating the attainment of organizational

coherence,theultimategoalofEA.TheydefineEAasthe inherentdesignandmanagementapproachessential

fororganizationalcoherenceleadingtoalignment,agilityandassurance".

This paper starts with a brief discussion on the key emerging trends in the discipline of EA. This is important

becauseitdelineatesthewayinwhichthegrowthandadoptionofEAasamanagementdisciplinewilltakeplace.

The purpose of this section is to set the context for the next section, which elaborates the role of strategic

(systems)thinkinginEA,primarilyfromawholeoforganizationperspective.Thissectionalsoexplicitlyshowshow

adoptionofITleadstonationalproductivityandprosperity.Theauthorbelievesthislinkageisimportantbecause

theoperational,

product,

service

and

business

model

innovations

that

EA

brings

in

lending

themselves

to

adoption

of technology given its ubiquity. Moving forward, the subsequent sections present a case study of the use of

strategic (systems) thinking as an integral part of architectural analysis through a detailed elaboration of its

adoption in the management of long term health conditions (also called chronic disease management) in

Singapore. It is importanttonotethatthoughthecasestudypertainstoSingapore,the issueofchronicdisease

management is the foremost healthcare challenge in several countries, hence the lessons and experiences are

easilygeneralizabletoothercountriesandjurisdictions.Theauthorhasdirectlybeeninvolvedinthisjourneyasa

leadingexpertandadvisortoahealthcareclusterinSingapore.TheprimaryobjectiveofthispaperistoelevateEA

as a management and leadership metadiscipline. Given the authors own experiences in delivering several

keynotesessionsinconferencesandseminarsworldwide,withoutdoubtthishasalreadybeenachieved.

EmergingTrendsinEnterpriseArchitectureThe emerging trends in enterprise architecture stems from key misconceptions that are currently evidenced.

AuthorsGary

Doucet,

John

Gotze,

Pallab

Saha

and

Scott

Bernard

provide

the

first

glimpse

of

the

imminent

mega

trends inEA in theirbook.Thishasbeen followedby research reportsbyGartner, the twonotableonesbeing

IntroducingHybridThinkingforTransformation,InnovationandStrategyandFromHierarchytoPanarchyHybrid

ThinkingsResilientNetworkofRenewal.Additionally,GartnersHypeCycleforGovernmentTransformation2009

and Hype Cyclefor EnterpriseArchitecture 2010 provide partial insights. Presented below are the trends and

characteristics,whicharetransformingthedisciplineandpracticeofEA:


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1. ThetransitionfromEAbeingequatedtotheEnterpriseITArchitecturetothearchitectureofenterprisedemands that it be viewed as a complete holistic metadiscipline that has the potential to link other

managementdisciplineandbring inbusinessmodel innovation.ThenextgenerationofEAwillformthe

backbone of all successful organizations, and the misconception that organizations do not have

architectureuntiltheyinitiateaformalprojectandateamtaskedwithmanagingtheprojectwillstartto

fade.Theunderlyingprinciplethateveryfunctioningorganizationhasarchitecturewilltakehold.

2. Theemphasisofarchitecturedevelopmentwillshift fromdesigningthevariousarchitecturalviewsandviewpoints to designing the interconnections between various views and viewpoints so as to achieve

organizationalcoherence.Doucetet.alhaveidentifiedthedimensionsoforganizationalcoherencewhich

are:(1)designed;(2)organized;(c)consistent;(d)connected;and(e)Institutionalized.Withinthecontext

of these dimensions, organizations will be characterized by three primary modes of EA, all operating

concurrently.

Organizations are complex adaptive systems and success in the contemporary operating environment requires

innovative ways of thinking about business problems and organizations. There will be an increased drive to

integratestrategic(systems)thinkingasacorecapabilitywithinenterprisearchitecture.Asorganizationsbecome

more hyperconnected and as the wider environment (political, economic, social and technological) becomes

uncertainandunpredictable,theabilityoforganizations tosenseand respondwillbecomeas importantasthe

abilityto

plan

and

execute.

In

such

achanging

scenario,

open

loop

(straight

line)

thinking

to

business

issues

will

be

inadequatetoaddressthem.Closedloop(systems)thinkingwillalloworganizationstheabilitytothinkaboutthe

whole,whereinsynthesistakesprecedenceoveranalysis.

TheRoleofStrategic(Systems)ThinkinginEnterpriseArchitectureEAhasgainedthecenterstageasanessentialdisciplinetoenableandevendrivebusinesstransformation.Tobe

consideredasthearchitectureoftheenterprise,itisthusanimperativetounderstandtheorganizationthatisto

bearchitected,anunderstandingthatpermeatestheentireorganization.Yet,almostallcurrentEAactivitiesfocus

primarily on the operational aspects, completely ignoring the more important strategic aspects. In order for

business leaders and policy makers to comprehend the role and intended outcomes from EA programs, it is

essential that they view such programs from a strategic viewpoint in the way these are planned, designed,

embraced,managedandgoverned.Itwouldbeanunderstatementtosaythatorganizationsarecomplex.Goinga

step

further,

governments

are

even

more

complex

and

at

times

paradoxical.

This

stems

from

the

fact

that

governmentsarebyfarthelargestorganizationsandwithsizecomescomplexity.Complexitiesinorganizationsare

ofboth typescombinatorial complexityanddynamiccomplexity. Complexity arising due to sheer numberof

componentsandelementsthatareinterconnectedreferstocombinatorialcomplexity.Dynamiccomplexity,onthe

otherhand,arisesduetothevelocityofchangeandthequantumof interactionsbetweenthecomponentsand

elements. Inaddition,unpredictabledelaysbetweendecisionsand theireffects (andcountereffects)completes

the picture of what constitutes, according to Gartner, wicked problems. In short, organizations are excellent

examplesofcomplexdynamicsystems.Asystemhereisdefinedasasetofinterrelatedthingsencompassedbya

well defined andpermeable boundary, interacting with one another and an external environment,forming a

complexbutunitarywholeandworkingtowardacommonoverallgoal.

Organizationsfaceseveralchallenges,andalotofthemareverystubborninnature(i.e.,wickedproblems),andare

thereforeunderpressuretoaddressthesechallengesinamoreopen,accountableandtransparentways.Inorder

fororganizations

to

transform,

it

is

critical

that

they

are

understood

as

complex

dynamic

systems.

Organizations

characterizedbytheabove,requiremuchmorethanconventionalthinkinginordertocomprehendtheunderlying

systemandthechallengesthatthesystemfaces.Thesuccessofbusinesstransformationprogramsthusbecomes

dependentoncomprehendingtheunderlyingsystem.Forinstance,ambiguityinunderstandingthesystemisone

oftheprimaryreasonsforpublicsectortransformationshowinglessthansatisfactoryresultsandsuccessrates.It

is amply evident that countries adopt wholeoforganization EA as t he metadiscipline to trigger, design and

realizegovernment transformation.However, in thepastdecadeorso the focusofEAprogramshavebeenon

developing frameworks,methodologies, languages,guidelines,bestpractices, referencearchitecturesandother


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capacitybuildingactivities.Onthegovernmentside, it istobenotedthatcountriesareusingegovernmentasa

meanstoachievepublicsectorreformsandgovernmenttransformation.Thisisclearlyarticulatedintheperiodic

global egovernment surveys undertaken by the United Nations. Adoption of IT for government services and

programmesplaysan importantrole incraftingandfurtheringtheegovernment initiatives.RobertAtkinsonand

Andrew Mackay, in their report titled Digital ProsperityUnderstanding the Economic Benefits of Information

TechnologyRevolution, clearly demonstrate the role and influence of IT adoption on national productivity and

overall

economic

prosperity.

This

is

not

surprising

given

the

ability

of

IT

to

enable

nearly

every

aspect

of

a

modern

knowledge based economy thatcountries increasingly aspire tobe.The ubiquity of the IT makes it evenmore

compellingtoembraceandderivebenefitsoutof.Exhibit1depictsthesystemicviewofthisphenomenon.

Exhibit1:TheEconomicBenefitsofInformationTechnologyAdoption

Thereport,withoutanyambiguity,spellsouttheneedtoconsider ITadoption inacoherentmannerandwitha

longtermviewinmind.Understandingtheabovephenomenonisimpressiveforcountriestodesignandexecute

theirEA.Despitealltheseseemingly impressivebenefits, theadoptionofwholeofgovernment (WOG)EAhas

been less than expected. This is evidenced by Gartners Hype Cycle for Government Transformation 2009,

wherein WOG EA would require another 5 to 10 years before reaching full maturity and delivering benefits

justifying its immensepotential.Ontheupside,however,GartnersHypeCycleforEnterpriseArchitecture2010

doesstatethatWOGEAispastthebottomofthetroughofdisillusionment.Thereisnodearthofliteratureand


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other enabling resources for countries to build their enterprise architectures. Yet, after the initial enthusiasm,

thingsaredifficulttosustainwithquestionsoftenbeingraisedregardingtheefficacyofgovernmentEAefforts.

Thisisnotsurprisingatall.Withoutfullyunderstandingtheunderlyingsystem,thesuccessachievedandbenefits

derivedthroughtheadoptionofEAhasbeen limited.This leadstotwo logicallyexplainablereactions:(1)frantic

effortstoimprovetheframeworks,methodologies,guidelines,principles,bestpracticesandtoolsupport;and(2)

discontinuingtheEAaltogetherbytermingittoodifficultandtoocomplex.

Theneedofthemoment isnotbettersolutions,butbetterthinkingabouttheproblems.GaryHamelinhisbook

TheFutureofManagementstatesthatsolvingasystemicproblemrequiresunderstandingitssystemicrootsandit

isthefirstofthetenrulesofmanagementinnovation.Itisinthiscontextthatconventionalopenloopthinkingto

solvingbusinessproblemsneedstobereplacedwithsystems(closedloop)holisticthinking.Asystemicperspective

isusedtounderstandhowthenumerouscomponentsoftheorganizationact,reactandinteractwithoneanother

with the intent of improving the adoption of EA for a coherent organization. This provides a comprehensive,

holistic and a more coherent way of anticipating synergies and mitigating negative emergent behaviors, which

wouldfacilitatedevelopmentofpoliciesandotherrelevantinterventionmechanisms.Usingasystemicperspective

encouragesstrategicthinking.Exhibit2showsacomparisonofsystemsthinkingoverconventionalthinking.

ComparingConventionalandSystemsThinking

Conventional(Open

Loop)

Thinking

Systems

(Closed

Loop)

Thinking

StaticthinkingFocusingonparticularevents.

DynamicthinkingFramingaproblemintermsofpatternsofbehaviorover

time.

SystemsaseffectViewingbehaviorgeneratedbyasystemasdrivenby

externalforces.

SystemascausePlacingresponsibilityforabehavioroninternalfactorsand

actors.

FragmentedBelievingthatreallyknowingsomethingmeansfocusingon

thedetails.

HolisticBelievingthattoknowsomethingrequiresunderstanding

thecontextofrelationships.

Factorsthinking

Listingfactors

that

influence

or

correlate

with

some

results.

Operationalthinking

Concentrating

on

causality

and

understanding

how

a

behaviorisgenerated.

StraightlinethinkingViewingcausalityasrunninginonedirection,ignoringthe

interdependenceandinteractionbetweenandamongthe

causes.

LoopthinkingViewingcausalityasanongoingprocess,witheffectfeeding

backtoinfluencethecausesandthecausesaffectingone

another.

Exhibit2:ComparingConventionalandSystemsThinking

Thispaperusescausalloopdiagramstocapturenonlinearcauseandeffectrelationships inordertorealizethe

systemsthinkingdescribedearlier.Theconventionsofcausalloopdiagramsarenotdescribedhere,asexcellent

literatureisalreadyavailableinthisarea.Inordertodemonstratetheabove,thehealthcaresegmentisusedasan

illustration.This isdeliberatebecausethehealthcare issuesarecomplex,dynamic,timelyandrelevanttomany

countries.Developedcountriesaroundtheworldaresaidtofacefivecriticalhealthcarechallengesintheyearsto

come.These

are:

(1)

patient

safety;

(2)

long

term

conditions;

(3)

outcome

based

models;

(4)

cost

containment;

and

(5)servicedeliveryreforms.TheseapplytoSingaporeaswell.Thesheercomplexityofthehealthcaresystem is

mindboggling.Thissegmentishuge,multifaceted,andselfcontained.Forthese purposes,managementoflong

termconditions(alsoknownaschronicdiseasemanagement)isselectedandexamined.Aswouldbeevidentover

the course of the next few sections, the management of chronic diseases exhibits all of the complexities and

nuances described in the previous. This makes it an excellent illustration for demonstrating the potential of

embracing strategic (systems) thinking. A note of caution here for all readers the content and approach

describedinthispaperrepresentstheleadingedgeinEAdiscipline,henceitismeantfororganizationswhohave


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thematurity toadopttheemergingbygoingbeyondwhat isalreadyestablished. Inareasonedway, thepaper

doesnotemphasizeonthetechnologicalaspectsofEA.This isdeliberatebecauseatthe levelthatthebusiness

concernhasbeendescribedandexamined,technologylooksoutofplace.

TheHealthcareConundrumHealthcare isacomplexadaptivesystemwithastrongsocialfocus.Exhibit3showsthekeystakeholders inthe

healthcare

ecosystem

as

identified

by

the

World

Health

Organization

(WHO).

Further,

the

WHO

also

highlights

the

interconnectednessthatisbothexistinganddesirabletoensurehighqualityhealthcareataffordablecosts.

Exhibit3:StakeholdersintheHealthCareEcosystem(Source:WHO)

Health care systems operate in a heterogeneous environment of public and private services, with numerous

businessoperatingmodelsthatmakeacoherentdesign,implementationandoperationofintegratedhealthcare

systemschallenging.Ingeneral,healthcaresystemsaroundtheworldareonatroublesomeanddangerouspath

with a combination of high costs, uneven quality, frequent errors, and limited access to care. The situation is

furtherexacerbatedbychangingdemographicsthatbringforth issuesthathavehithertoneverbeenanalyzed in

totality. Michael Porter and Elizabeth Teisberg in their book Redefining HealthcareCreating Value Based

CompetitiononResults listoutkeycausesofthe illsthatafflictthehealthcare industry.Broadly,theseare :(1)

prevalenceof thecommoditymindset; (2) focuson reducingshorttermcosts; (3)variation inqualityandcosts

basedongeographical location; (4) incentives to the the healthcareproviders toblend inand follow standard

procedures; (5) continued practice of academic specialties replicated in health care providers; (6) questionable

patientattitudes

and

motivations;

(7)

patient

care

cenetered

on

medical

conditions;

and

(8)

incentives

to

health

planandhealthcareproviderstoaimforshorttermgoalsandperformancemetrics.

Furthermore,theoverallhealthcaresystemsgetevenmoremuddledwiththeadventofnewandemergingissues

that get amplified due the ever changing demographics. The disease profile of the world is changing ever so

rapidly,andlongheldnotionsabouthealthcaresystemsarenolongertrueandatmosttimesevenmisleading.A

health care phenomenon that is confounding governments across the world is the ever growing issue of

management of long term conditions (or chronic disease management). Chronicdiseases have emerged as the


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largest causeof death and sourceofhealth care costs indevelopedcountries. In many countries,deaths from

chronic diseases now outstrip mortality for traditional health concerns such as injuries and communicable

diseases.Whiletheprimarypurposeofthispaperisnottopresentadetailedreviewofchronicdiseasesandtheir

management.Thenextsectiondiscussesthetrendsandinformationpertainingtochronicdiseases.Thesetrends

andinformationarepresentedastheyarecriticaltounderstandingthebusinessdomainwiththeaimofproviding

critical inputs to the systems models presented in the subsequent sections. The quantum of background

information

on

chronic

diseases

provided

is

deemed

to

set

the

context

and

fulfill

the

objective

of

this

paper

i.e.,

to demonstrate the use and value of strategic (systems) thinking as an integral element of the EA discipline,

therebymakingEAmoreforwardthinkingandbusinesseffectivenessorientedratherthanfocusingonoperational

efficiencies.ThischangeinthewayEAitselfisviewedisneccesitatedtosupportthemassiveshiftsthatarebeing

observed.

UnderstandingChronicDiseasesToset thecontext for the restof thepaper,Exhibit4 showsacomparisonofchronicandacute illnesses.As is

evident,thecharacteristicsofchronicconditionsarealltoodifferentwhencomparedtoacute illnesses. In fact,

theyareastudyincontrastandistheprimaryrootcauseofamajorityofthehealthcarechallengesthatcountries

todayface.It isclearlyevidentfromExhibit4thatpolicies,procedures,processes,systemsandothersupporting

mechanisms established for acute illnesses would be grossly inadequate and even incorrect when applied to

chronicillnesses.TheWHOlistsheartdisease,stroke,cancer,asthmaandchronicobstructivepulmonarydiseases

anddiabetes

as

the

major

ones.

This

paper

does

not

examine

any

specific

chronic

disease.

Instead,

it

views

chronic

diseasesinacollectiveaggregatedmanner.Itissufficientfortheobjectiveofthepaperasthelessonslearntand

otherfindingscanbegeneralized.

Exhibit4:ComparingAcuteandChronicIllness

Withtheabove informationascontext,the followingarethemegatrends inchronicdiseasesthatarecurrently

underway.Theyareexaminedsincetheyprovidearichsourceoffactorsandvariablestobeusedasinputsforthe


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systemsmodelselaborated insubsequentsections.It istobenotedthatthepurposeofthesemegatrends isto

understandandgainadequate insights intothephenomenonsoastoderivesufficient informationtoeffectuate

strategic(systems)thinking.The intent isnottoprovideadetaileddiscourseaboutchronicdiseasemanagement

perse.ThesefactsandfiguresarelargelytakenfromrelevantliteraturemadeavailablebytheWHO.

1. Anestimated388millionpeoplewilldiefromchronicdiseasesinthenext10years.Withincreasedinvestmentinthepreventionordelayofchronicdiseaseonset,itwillbepossibletoprevent36millionprematuredeaths

inthesametimehorizon.Withoutactiontoaddressthecauses,deathsfromchronicdiseaseswithincreaseby

17%between2005and2015.

2. Themacroeconomicimpactofchronicdiseaseswillbesubstantial.Largecountrieswilllikelyforegoinexcessof$500billioninnationalincomeoverthenext10years.Averteddeathswithbettermanagementofchronic

diseaseswouldtranslateintosubstantialgainsinthenationaleconomicgrowth.

3. Globally, a misconception that chronic diseases mainly affect high income countries is widely prevalent.Furthermore, there isalsoabelief that lowandmiddle incomecountriesmust focuson infectiousdiseases

before chronic diseases. These misconceptions are contrasted by the fact that 80% of all chronic disease

deathsoccuronlowandmiddleincomecountries.

4. Globalization, urbanization and population ageing are the key underlying socioeconomic, cultural, politicaland environmental determinants contributing to modifiable and nonmodifiable risk factors. The most

common modifiable risk factors leading to chronic diseases include unhealthy diet, physical inactivity and

tobaccouse.Thenonmodifiableriskfactorsincludeageandgenetics.

5. Chronic diseases and poverty are interconnected in a vicious cycle. On one hand, poor people are morevulnerable for several reasons, including increased exposure to risks and limited access to health services.

Whileontheotherhand,chronicdiseasescanleadtopovertyinindividualsandtheirfamilies.Together,these

two have thepotential to lead to a downward spiral of worsening disease and poverty. This phenomenon

directlybringsdowntheindividualandnationalproductivities.

6. Ingeneral,healthcareservicesandsystemsareprimarilydesigned foracutecare.Servicesandsystems forchroniccareareusuallycarvedoutbytweakingthemfromtheacutecare.This,despitethefactthatchronic

diseases constitute 70% of the disease burden, thus creating a massive mismatch between supply anddemand.

7. Thedifferentchronicdiseasesthemselveshavesomedegreeofinterconnectedness,thatis,theincidencesofcomorbidities which usually worsens with age, plays an important role in complicating treatments and

interventions.ThisisdepictedinExhibit5.

8. Thetotalnumberofpeopleaged70yearsandaboveworldwide isexpectedto increasefrom269million in2000 to 1 billion by 2050. Age is an important factor in the accumulation of modifiable risks for chronic

diseases;thatistheimpactofriskfactorsincreasesoverthelifecourse.Exhibit6showstheagepyramidsfor

Singaporein2008and2025,andthedemographictransitioncurrentlyunderwayistrulydramatic.Thatsaid,it

isimportanttonotethatmostdevelopedcountrieshavearapidlyageingpopulation,primarilyduetothedual

affectsof

increasing

life

expectancy

and

dangerously

low

birth

rates.

For

example

countries

in

East

Asia

have

atotalfertilityrateofunder1.2.Thiscomparesveryunfavorably,giventhatacountryrequiresatotalfertility

rateof2.1justreplace itspopulation.Anothernegative impactofanageingpopulation isthat it leadstoa

shrinkingpoolofpotentialcaregivers,thusaffectingtheveryqualityofchroniccare,pushingthewholehealth

systemtoafurtherdownwardspiral.


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Exhibit5:PotentialCoMorbiditiesAssociatedwithMainChronicDiseases

Alloftheabovefactsandfiguresinsomesensecapturethesymptomsailingthemanagementofchronicdiseases.

Themostnatural reactionwouldbe toaddress thesesymptoms throughshort termquickfix typeof solutions.

Such an approach would be conventional (openloop) thinking demonstrating the characterisctics are shown in

Exhibit2earlier.

There

is

substantial

literature

elaborating

the

dangers

of

open

loop

thinking.

In

contrast,

bringing

in the closedloop thinking provides the ability to look at the big picture in a unified collective manner,

understand the interconnectedness and interdependencies between the various elements and parameters

involved.Inotherwords,inthecontextofthechronicdiseases,alloftheabovefactsandfigureswouldhavetobe

looked at collectively in a systemic perspective. There is no doubt that management of chronic diseases is a

wicked problem that requires deeper holistic thinking. It is to be noted that the megatrends above look at

chronicdiseasescollectivelyinagenericmanner,anddonotgranularize itintermsofindividualdiseasetypesor

patterns.

Exhibit6:SingaporePopulationPyramidsin2008and2025


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EmbracingStrategic(Systems)ThinkingAccording to Edward Deming, 94% of all organizational issues are systemic in nature. Usually, leaders and

managers do not fully understand the systemic issues. This is absolutely true with regard to management of

chronic diseases. The work presented in this paper was carried out for a healthcare cluster in Singapore. The

clusterconsistsofagroupofpolyclinics, largehospitals,specialistcentersandotherproviderentities lookingat

communityandhomecareservices.Theclusterisalsosupportedbyagroupofenlistedgeneralpractitionersand

otherbusiness

partners.

In

summary,

all

the

elements

of

the

health

care

ecosystem

shown

earlier

in

Exhibit

3exist

inthiscluster.Someoftheseelementsoftheecosystemare intheirownright largeandcomplexorganizations,

havingtheirownstrategy,managementandoperations.Thebusinessareaswithinthepurviewofthehealthcare

clusteraredepcited inExhibit7.Thisrepresentstheclustersbusinessreferencemodel(BRM).TheBRMdepicts

the outsidein perspective of the health care cluster. It only shows the business areas and business functions

withoutdepictingwhichproviderentity(organization)withintheclusterprovidestheservice.Thisperspective is

importantasitorganizestheclusterbusinessinawaythatmakessensetotheservicerecipients(i.e.citizensand

patients). The service recipients do not need to be aware of the health care clusters internal administrative

structure. This makes the cluster more enduser (patient) centric without cluttering them with administrative

details.The implicationofviewing thebusiness fromapatientcentricperspective includesdisintermediationof

individualproviderentitiesandassumesseamlessintegrationbetweenthem.Inshort,tothepatientsandcitizens

the cluster appears as one, the manifestation of connected health paradigm. This is absolutely essential for

countriesaimingtoreformtheirpublichealthsector.Thoughnotcentraltothispaper,aninterestingsidenote is

thatsuch

aconnected

paradigm

in

the

health

care

sector

is

an

essential

precursor

to

the

success

of

electronic

healthrecord(eHR)programsthatmanycountrieshaveenthusiasticallyinitiated.

Purelyfromatechnologyperspective,theBRMneedstosupportedandenabledbyotherreferencemodels(e.g.

the Data Reference Model (DRM),Application Reference Model (ARM) and Technical Reference Model (TRM)).

However,thispaperdoesnotdiscusstheDRM,ARMandTRManyfurther.

Despiteeach individualproviderentitytaskedwithdifferentaspectsofthecaredeliveryvaluechain, itwasvery

clearupfront that tacklingchronicdiseasemanagement requiredaholisticand integratedapproach,because it

hadbothclusterwideandnationwideramifications.Chronicdiseasemanagementtouchedeverybusinessarea

showninExhibit6,thustheintegratedapproachisanimperative.Thecaredeliveryvaluechain(CDVC)proposed

byMichaelPorterandElizabethTeisbergintheirbookRedefiningHealthcareCreatingValueBasedCompetitionon

Results,

is

a

powerful

technique

to

capture

the

integrated

view.

The

CDVC

provides

an

excellent

technique

to

identifyandsequence thecare functionsandsubfunctions inan integratedmannerworking through thecare

journeythatapatienttraversesviathedifferentstages.TheCDVCalsodepictsthevariousparticipatingprovider

entitiesinthedeliveryofthecare.Thishighlightsthecollaborativeaspectsinthecaredeliverywhich isessential

forbetterandeffectivecare.However,inorderforustounderstandanddissectacomplexproblem,notonlyisit

importanttounderstandthe interactionsbetweenthevariousproviderentitiesandthefunctionstheyperform,

butalsotocaptureandfullyunderstandtheinteractionsbetweenthevariousfactorsandvariablesthatformthe

core and contribute to the complexity and dynamism. This is achieved through adopting strategic (systems)

thinking.Thesubsequentparagraphselaboratetheadoptionofstrategic(systems)thinkingfactoringinthemega

trends thathavealreadybeenpresentedearlier.Thiscontrastsverywellwith theusualapproach,wherein the

approachwouldbetoidentifyafewkeybusinessfunctionsfromtheBRM,sometimescalledhotspots,prioritze

them and analyze them to address the issues in consideration. This analytical approach characterized by its

divideandrule mindset is reductionist in nature and put forths all the ingredients thatusually tend to make

organizationsmicro

smart

and

macro

dumb.

The

underlying

rationale

for

adoption

of

strategic

(systems)

thinkingisthatanyassumptionthattheeffectivenessofthewholewillbeachievedautomatically,aslongasthe

partsareoptimal,cannolongerbesustainedwiththesystemicparadigm.Strategic(systems)thinkingisableto

capturethewisdomofdiversestakeholders.ThisnotionisstrengthenedbytheWHOWorldHealthReportwhich

statesthattheresponsesofmanyhealthsystemssofarhavebeengenerallyconsidered inadequateandnave.

Inadequate,insofarastheynotonlyfailtoanticipate,butalsotorespondappropriatelytoooftenwithtoolittle,

too lateortoomuch inthewrongplace.Nave insofarasasystemsfailurerequiresasystemssolutionnota

temporaryremedy.


11/24

That said, strategic (systems) thinking is not a silver bullet. Its adoption does not automatically mean that

addressingcomplexbusinessissuesbecomeseasierwithoutchangingthemindsetthatcausedtheproblemtostart

andaggravate.

Exhibit7:HealthCareClusterBusinessReferenceModel(Level0View)

Takingthe

chronic

disease

facts

and

figures

presented

earlier,

the

problem

framing

process

starts

with

the

common modifiable risk factors (like unhealthy diet, physical inactivity and use of tobacco) triggered by the

underlying determinants of globalization, urbanization and ageing population; this increases the overall risk of

chronicdiseases,whichleadstotheeventualonsetofchronicdiseases.Theonsetofthediseaserequiresfinancial

resources to provide for adequate care and treatments, thus increasing the overal economic burden for the

individual.Thesituationisfurtherexacerbatedbythefactthatthepopulationwithchronicdiseasesarelikelytobe

lessproductive(ascomparedtohealthypopulation),leadingtoforegoneincome.Thisleadstoadropinresources

andfinancialcapabilitytoaffordpropercare,furtherincreasingthenegativeimpactofthechronicdiseases.Thisis

depictedinExhibit8,andcollectivelytermedastheavoidableburdenloop.Thisisapositiveloopasitrepresentsa

downwardspiralandclearlydemonstratesthe longtermnegativeconsequencesofchronicdiseasesbothonthe

individualsandcountries.The loop isdeliberatelynamedsobecause it implicitlycapturesaphenomenonthat is

largelyaviodableifindividualsandcountriesfocusonreducingthecommonmodifiablerisks.Thisthinkingisinline

with

the

WHO

recommendations.

The

avoidable

burden

loop

thus

becomes

the

central

core

of

the

problem

frame,

aroundwhichotherchronicdiseasefactorsandvariablesareprogressivelyaddedintheformofmoreloops.This

processiselaboratedinthesubsequentparagraphsofthissection.


Page11of24


12/24

Exhibit8:UnderlyingFactorsandtheChronicDiseaseOnset

Astheincidencesofchronicdiseasecarebecomesmoreprevalentandexpensiveduethedownwardspiralshown

inExhibit7,thereisincreasedpressurebythecitizensandthecivilsocietyonthegovernmenttosubsidizedisease

care.Beingapoliticalhotbed,mostgovernmentsprovidesubsidyenmasse,i.e.thereisagreatlikelihoodthatthe

sectionofthesocietythatnotneedthesubsidyarealsosubsidized.Toaddressthis,theconceptofmeanstesting

isrightlybeingintroducedinSingapore.Thissubsidyisrealizedthroughvariousmeans,forinstancethepatientcan

directlybesubsidized,orthehealthcareproviderscanbecompensatedfortreatingpatientswithchronicdiseases.

Usuallygovernmentsadoptamultiprongedapproachtodeliverthesubsidiesasitprovidesthemgreaterleverage.

Irrespective of the means of providing the subsidy, the impact on the national income and the economy is

inevitable.Thisistheshowninthesubsidyresponseloop.Thisleadstofurthernegativeimpactontheresources

availableforthehealthcaresectoringeneral(andchronicdiseasemanagementinspecific).Hencethesubsidyhas

thepotentialtobecomeanationalburden,ifitisnotcarefullytargetedasshowninthenationalcostloop.These

two

loops

together

work

in

tandem

and

have

the

potential

to

create

serious

shortcomings

in

the

healthcare

ecosystembyconstraining theavailabilityof resourcesandopportunitiestomanagechronicdiseases.This then

feeds intothecoredownwardspiraldepictedbythepreviouslydescribedavoidableburden loop.The foregone

national incomehasdirectnegative impacton theavailable resourcesand leads to thedeteriorationofoverall

qualityoflife,eventuallyleadingtohigherrisksofchronicdiseases.Inotherwords,individualandnationalpoverty

aggravates the problem of chronic diseases even further. On top of this, increasing life expectancy actually

worsenstheproblemevenfurther.Thisisdepictedinthelifeexpectancymattersloop.Exhibit9showsthethree

new loopsandalsoamplydemonstrateshowthesethree loopsactuallyworsenthedownwardspiral.This isan

interestingphenomenonwhereinonedownwardspiralisstrengthenedbyaseriesofotherinterconnectedloops,

viacommon factorsandvariables.Strategic (systems)thinkingmakesthisbehaviorexplicitandapparent.This is

precisely how whole systems thinking propagates and makes the approach more amenable to effective

interventionsbyanticipatingandyetformallystructuring.

Longterm

evidence

proves

that

with

timely

and

effective

interventions

and

proper

medication

management,

most

patientswithchronicdiseasescanactuallyleadnearnormalliveswithminimalinterruptions.Thisisfurthermade

possible with recent advancements made in medical sciences. This means that most patients can actually

drasticallyreducetheirvisitstospecialists.Inotherwords,inmostsituationsgeneralpractionersandpolyclincsare

sufficienttocontinuetotreatmentsandkeepthediseasesatbay.Reducing interactionswithspecialistsdirectly

leadsto lowercostsforpayersandalsoensuresthatspecialists,whoarealways inshortsupply,donotbecome

bottleneckinthewholeecosystem.


Page12of24


13/24

Exhibit9:RoleofSubsidies,ForegoneNationalIncomeandLifeExpectancy

Withthepreviousnotions inmind,there isalsoempiricalevidencetoprovethatassubsidy is increased(bythe

government),itbecomesmoreattractivetoreferaspecialistandtheusualinclinationistoreferaspecialistasthe

first level intervention, irrespective of whether it is needed or not. This demonstrates normal human behavior

which is driven by incomplete and misconceived mental models on part of the patients. This behavior is the

evidence of questionable patient attitudes and motivations that Michael Porter and Elizabeth Teisberg have

identifiedandhighlightedintheirbook.Thisbehaviorleadstocrowdedhospitalsandspecialistcenters,elongating

queuesand

waiting

times.

This

has

an

impact

on

the

national

productivity

and

eventually

the

gross

national

income.Thisphenomenoniscapturedintheinvolvingspecialistsloop.

Building up from the life expectancy matters loop, and ageing population leads to a drop in working (and

productive)adults,whichhasanegative impacton thegrossnational income;aneventualdrop in investments

available for healthcare occurs as it erodes the tax base over time. Typically governments respond to this by

increasing the retirementage limits,as iscurrentlybeingseen inmanycountries.However, thedownside isan

older working population would also be more prone to chronic diseases. An erosion in the tax base results in

governmentsearninglowerrevenuesthroughtaxesandotherlevies.Inotherwords,astheproportionofworking

adultsdroptherearelesspeopletocontributeintothecountrysfinancialsystem,andanincreasingnumberwho

requirefinancialassistanceduringtheirnonproductiveyears. Inaddition,adroppingbirthratealsoensuresthat

notadequatenumberofworkingadultscomeintothesysteminthedecadestocome,furthererodingfuturetax

base. Thiseffectively has long term negative implications on the national economy and resources available for

healthcare,thereby

increasing

the

chronic

disease

morbidity

and

mortality,

further

strengthening

avoidable

burdenloopdescribedearlier.Thisbehavioriscapturedinthechronicdiseasedeathsloop.Thisaffectsthequality

of life and eventually leads to greater risks of chronic disease onset. There is evidence that as gross national

incomefalls,theproportionofthepopulationinthelower incomecategorybulgesandusuallytendstobemost

badlyaffected.Inotherwords,thepoorersectionsofthesocietybecomeevenpoorer,thusenlargingthechasm

betweentherichandthepoor,primarilybecauseof inequaldistributionofwealth.The inequality(measuredas

theGINIindex)increasestheintensityandthespreadofpoverty.This,withoutdoubt,leadstoincreasesinchronic

disease morbidity and mortality as shown in the poverty hurts loop. The WHO has clearly demonstrated the


Page13of24


14/24

existenceofadownwardspiralbetweenchronicdiseasesandpoverty.Exhibit10depictstheinvolvingspecialists,

chronicdiseasedeaths,healthcareinvestmentsandpovertyhurtsloops.

Exhibit10:MacroeconomicConsequencesofChronicDiseases

Chronicdiseasesconstitute70%ofthediseaseburden.Thesupplydemandmismatchbetweenacuteandchronic

careisalreadyanobservedphenomenon.Wrongpatientattitudesandmotivationsleadingtocrowdedhospitalsis

a result of the involving specialists loop, examined earlier. This is further worsened by the fact that crowded

hospitalshaveagreatertendencytofocusonthewrongpriorities(i.e.focusonimmediatepriorities)attimeseven

hurting the long termeffectiveness.Given the immediacyofneedsandotheroperationalpressures,healthcare

providersusuallytendtospendgreaterproportionoftheirtimeandresourcesinprovidingacutecareandtreating

patients with infectious diseases. This is captured in theunclearpriorities and priority for acute care loops in

Exhibit11.

AccordingtoasurveydonebytheWHO,thecostofchronicdiseasecareisbyfarthemostsignificantchallengefor

both individualsandgovernments. Ingeneral, theescalation in thecostofhealthcare faroutstrips thebroader

inflation.Thesituation isevenmoreacutewhenviewedfromthechronicdiseaseperspective.Ascostofchronic

care treatments escalate, people attempt to cover through insurance (wherever possible). With wrong patient

attitudes and motivations, the typical behavior is for patients to prefer specialists over general practitioners

(alreadydiscussedearlier).This inflatestheoverallcosts inthewholeofthehealthcareecosystem.Ascostsrise,

insurance firmsare forced tobecomemore stringent in their checksandapprovals.Given that insurance firms

haveaprofitmakingmotive,thisworsensthesituationevenfurther.Thisincreasestheincidentsofnoncoverage

for existing customers and lengthens the list of exclusions for potential new customer, leading to insurance

becoming lessattractive.As insurancebecomes lessattractive,the insuredtendtooptoutoftheprogramsand

potentialnewcustomersnot finding insuranceattractivearenot inclinedto insurethemselvesor their families.

This creates twin headwinds for the insurance sector as existing customers optout and new customer base

expansionslowsdown.Theoverallcollectiveinsurancebasegetsseverelyrestricted.Forthepopulationwhostay

backaspartoftheinsuranceprograms,thepremiumsgoupbecausetherearenotenoughhealthypeopletopay

into the programs and plans. All of these happen, even as the whole ecosystem is plagued by increasing life

expectancies and fallingbirth rates.The paradox is in the fact that insurance firmswant to insure thehealthy,

whereasthehealthydonotwanttogetinsuredbecauseoftheoverallunattractivenessoftheprogramsandplans.

Thisdeathspiral isdepicted inExhibit12,throughthecostsoftreatment,questionable insuranceeffectiveness

andgapsinqualityofhealthcareloops.


Page14of24


15/24

Exhibit11:AmplificationoftheSupplyDemandMismatchandUnclearPriorities

The loops inExhibit11alsoamplifythemismatchbetweensupplyanddemand.Thecurrent insuranceplansand

programsaredesignedforacutecare,andthentweakedtoworkforchroniccare.Inaddition,upwardstrendin

theGNIprovidethefodderforsocioeconomic,cultural,politicalandenvironmentdeterminants,magnifyingthe

globalization

and

urbanization

pre

factors

that

lead

to

increase

in

risks

of

chronic

diseases.

This

is

shown

in

Exhibit

11inthepriceofgrowthloop.

Exhibit12:TheHealthInsuranceDeathSpiral


Page15of24


16/24


17/24

DesigningStrategicInterventionsPeter Senge in The FifthDiscipline argues that to solve difficult problems one needs to understand the inter

relationshipsratherthanthings, forseeingpatternsofchange ratherthanstaticsnapshots.Todesigneffective

interventionstrategies, it iscritical todiagnose the issuescorrectlyand frame theproblemspace. Insightand

foresightarebothcrucial.Exhibit12depictsproblemspace inasynthesizedview.Itcapturesseveralfactorsand

connectsthemviaseriesofloops,allofwhichhavebeendiscussedearlier.Itisimportanttonotethatthefactors

andthe

loops

are

specific

to

the

local

conditions

in

Singapore.

They

need

to

be

suitably

adapted

prior

to

use

in

othersituations.Needlesstomention,thespecificinterventionswoulddependonthecontextofspecificnuances.

Designingtherightinterventionsareasimportantasthelocationtheseinterventionswouldbeapplied.However,

partofthestrategicinterventiondesignshouldalsoincludeuncoveringandunderstandingthe inherentdelaysin

thesystem,forthesystemwithlongtermdelaycannotrespondtoshorttermchanges.Inacomplexsystem,there

areplaces where a small shift inonethingcanproduce largechanges in (almost) everything.The placesare

termedleveragepointsthepointsofpower.DonellaMeadowsinherarticleLeveragePointsPlacestoIntervene

inaSystem identifiesandelaboratesgeneric leveragepointswhere interventionsaremost likelytobe impactful

and resultsbearing.Moving forward, thenext logicalstep fromanarchitecturalperspective is toproposesteps

thatcouldbetakentoaddressthechronicdiseasepandemic.Thesestepsarecalledstrategic interventions,as

theytendtobe longterm innatureandoftenrequireseriesofaction itemstobeexecutedandoperationalized.

The WHO recommends ten steps to applying systems perspective in the design and evaluation of strategic

interventions. Exhibit 14 depicts the synthesized view with the strategic interventions (as arrows) and the

significantdelays

are

also

shown.

Exhibit14:SynthesizedViewoftheChronicDiseaseManagementPhenomenonwithSuggestedInterventions

Managementofchronicdiseases isanationalpriorityinSingapore,as inmanyothercountries.Thisisevidenced

by the fact that the Singapore Government has always been viewing this from a long term perspective and

designingpoliciesandprogramstosuitcurrentandemergingneeds.Healthcareservices inSingaporeareoneof

themostadvancedandarguablyoneofthebest intheworld.Withregardtochronicdiseasesthegovernment


Page17of24


18/24


Page18of24

clearlydemonstrates longtermvision,which isachievedbyaseriesofsmallyetfocussedandprogressiveaction

items.Inthenationalbudgetannouncementfor2011,madeinMarch2011,thegovernmentannouncedaseries

ofaction itemsthatare intendedtotacklethisgiganticpublichealth issueofchronicdiseasemanagement.The

actionitemsannouncedinclude:

1. EstablishingtheGeriatricEducationandResearchInstitute.2. ExpandingtheHomeNursingFoundation.3. ScalingupoperationsoftheAgencyforIntegratedCare.4. ContributingtotheCommunitySilverTrust.5. ExpandingtheMedifundbudget.6. ExtendingtheMedicationAssistanceScheme.7. EncouragingstepdowncarewiththeexpandedPrimaryCarePartnershipScheme.These

action

items

have

not

been

elaborated

in

detail

as

that

is

not

the

intent

of

this

paper.

LeveragingthePowerofStrategic(Systems)ThinkingItisobviouslyclearfromtheabovethattheactionitemsaretargetedtomeetspecificneedsandaddresssomeof

the strategic interventions depicted in Exhibit 14 earlier. Comparing the strategic interventions and the action

itemsshowsthatthestrategicinterventionsaremorelongterminnature,whiletheactionitemstendtobemore

tactical and executable in nature. The strategic interventions are excellent inputs for governments to develop

policyenablers.Furthermore,strategic thinkingalso facilitatesdeeperunderstandingofpolicy resistance that is

oftendisplayedbystubbornproblems.

Exhibit15showstheauthorsownassessmentofthestrategic interventionscoveredwiththeannouncedaction

items.Itisclearlyseenthattheactionitemsputforthreflectthepreemptiveanticipatorythinkingonpartofthe

government.

The

problem

at

hand,

chronic

disease

management,

is

a

complex

and

stubborn

one.

Hence

the

action

itemsdemonstrate theprogressiveseriesof tasks thatarebeingplannedandperformed totackle it. It is tobe

noted that the Singapore government already has existing plans and schemes for management of long term

conditions,examplepoliciesandprogramspertainingto:(1)ageingworkforce;(2)chronicdiseasecarecosts;(3)

programsmitigatingmodifiablerisk factors; (4)preemptivescreening;and (5)GNI/GDPgrowthandeconomic

wellbeing. InExhibit15theaction itemsare limited toonesspecificallyannounced intheMarch2011national

budget. Insummary,agreatstarthasbeenmadeand it iscomfortingtoseethatprogress isbeingmade inthe

rightdirection.Thisishoweffectivestrategic(systems)thinkingisintendedtobe.Itisimperativethatthecomplex

effects, synergiesandemergentbehaviorof system interventionsare fullyunderstood inorder to takebenefit.

Additionally, any intervention with systemwide implications cannot be considered simple and allows

organizationstocapitalizeoncomplexity.


19/24

Exhibit15:MappingtheStrategicInterventionstotheAnnouncedActionItems

Strategic thinking establishes the vision, while action items realize the vision. This is an essential element for

enhancingthe

effectiveness

of

the

EA,

as

often

EA

is

perceived

of

being

overly

skewed

towards

housekeeping

typeofactivities,ratherthanfacilitatingtheorganizationstothinkforwardandenablethevisioningprocess.The

perceptionisnotentirelyincorrectandcurrentEAframeworksreinforcethisevenfurther.Organizationsfindthe

currentframeworks intimidatingastheytendtoquicklytakethem intoajourneyofdeepandgranularanalysis,

without spending adequate time for future thinking. Organizations overly focus on improving the operational

enablersatthecostofstrategicwisdomanddirection.Ignorance,complexityandcapabilitygapsarecitedmost

frequentlyastheprimaryreasons.Operationalenablersmean:(1)frameworks;(2)methodologies;(3)reference

architecturesandmodels;(4)toolcapabilities;(5)competencybuildingactivities;(5)guidelinesandstandards;(6)

best practices and the like. The skewness in favor of operational enablers is hard to miss. Though operational

enablers are important, they, by no means have the ability to supplant the strategic perspective. Their role is

primarly in supplementing strategic wisdom and direction. In the absence of the strategic perspective, the EA

programvirtuallynavigatespartblind leading tocynicism, lackofpersistence,erosionofconfidenceand lossof

attentionby

the

organization

leaders.

It

almost

takes

acrisis

to

make

deep

change.

And

when

it

is

time

to

address

thecrisis,thefocus isonsymptoms,notcauses.Embracingstrategic(systems)thinkingaspartoftheEAprocess

notonlyaddressestheperception,butalsoelevatestheroleofEAasamanagementandleadershipdiscipline.This

upsthe innovationstakes,movingupfromoperationalinnovationtobusinessmodelinnovation,whichgoesto

theverycoreofbusinessdesign.Thisfactors inand influencesthevaluepropositionandtheoperatingmodelof

theorganization.Becausethisinvolvesamultidimensionalandcoherentsetofactivities,innovationatthislevelis

bothchallengingtoexecuteanddifficulttoimitate.Thereisempiricalevidencethatprofitoutperformersfocuson

business model innovation by a substantial margin. The author has personally been involved in guiding such a


Page19of24


20/24

mindsetchange,hencebeingabletovouchforit.Thatsaid,itwouldbeawhileforcurrentEAframeworkstomake

strategic(systems)thinkingasanintegralpartoftheirmethodologiesandapproaches.

Inthecurrentstateofpractice,EAprogramsandinitiativesareoftenconceivedanddrivenbytheITdepartment.

In this context, there already are substantial literature and other supporting evidence that the IT department,

moreoften thannot, finds itchallengingtodeeplyengage thebusinessorthedomainsideof theorganization.

AccordingtotheIBMGlobalCIOstudy,realizingbusinessinnovationhasbeenidentifiedasthefirstandforemost

activity as being increasingly expected from CIOs. Questionable credibility on part of the IT department

exacerbatesthelackofcommunication,leadingtodisengagementandeventuallossofmomentumandinterestin

EA. It gets relegated as an IT project. Embracing strategic (systems) thinking allows for: (1) a business

understandingofbusinessconcerns/problems;(2)synthesistotakeprecedenceoveranalysiswhichisessentialto

manifest the organizationwide view of the architecture; (3) triangulation of emergent strategy development

with the more traditional topdown strategic planning; (4) identification of leverage points wherein the

interventionstendtobemost impactful;(5)framingtheproblemsspace inawaythat iscomprehensiblebythe

senior executive leadership in the organization; (6) deemphasizing on the siloed mindset; (7) establishment of

collective strategic priorities; and (7) designing for coherence (consistent, collaborative, connected). Once the

aboveareachieved, identifyingthemostrelevantbusinessservices,businessfunctionsandprocessestoexecute

theactionitemsbecomesthenextlogicalstep,followedbytheotherdownstreamstepsinthedevelopmentofthe

ITarchitecture.ThispaperdoesnotattempttoelaboratethedownstreamITarchitecturestepsasthereisalready

aplethora

of

literature

available

that

covers

the

topic.

Exhibit

16

summarizes

the

phases

and

steps

that

are

typicallyrequiredtoeffectuatethebusinesstransformationthatisdrivenbyEA.Thephases,steps,sequenceand

theotherelementsdepictedinExhibit16areindicativeinnatureandthereisnofurtherelaborationinthispaper.

Exhibit16:SuggestedMethodologyforArchitectureDrivenBusinessTransformation


Page20of24


21/24


Page21of24

MovingForwardAManifestoforManagementLeadersandArchitectsMichael Porter has asserted that strategic planning in most organizations has not contributed to strategic

thinking.InthecaseofEAthisstatementcannotbedisputedoroverstated.Strategic(systems)thinkingmakesit

possibletotranslatecomplex informationthat is interconnected intosimple,yetcompellingexplanationsofnot

onlywhatishappening,butmoreimportantlywhy.ThereisnodearthofliteraturethatidentifypitfallstoEAand

proposed solutions to avoid such pitfalls. There is also abundant guidance literature available as to how

governments(and

other

organizations)

must

adopt

EA.

On

the

other

hand,

none

of

the

currently

available

literature explain the underlyingcomplexities of EA adoptionper se.GaryHamelscontention thatoperational

efficiencydoesnot equate to strategic efficiency makes absolute sense in a scenario where governments are

graduallytransformingfromahierarchytoalattice(bothbyneccessityanddesign).Theadventofsocialmediais

hastening this transformation.And ina latticewhich ismore likely tocharacterizedbycollaboratingnodes that

form part of value networks, effective coordination and orchestration makes the difference. Moving forward,

governmentsofthefuturewillembraceprinciplesofcocreation,accountability,collaborationandconnectedness.

These will definitely be expolated to the healthcare sector. Innovation and personalization will trump

standardizationandcommoditization.Drivingchangeofanykind ischallengingby itself,butatthefundamental

levelofbusinesscoherency,suchchangerequirescommitment,insight,foresightandleadership.Allfourofthese

distinguishing characteristics are evident in the way Singapore views it chronic disease management plans and

programs.

EAis

avery

large

undertaking

for

any

organization.

EA

for

awhole

industry

sector

is

even

larger,

more

complex

and

more dynamic, making it an imperative to comprehend the underlying complexities in a holistic and coherent

manner.CurrentthinkingpositionsEAasanITmanagementdiscipline.Theresearchthispaperembodiesintends

to dispel this thinking and positions EA literally as the architecture of the enterprise, where knowledge is

supplemented with understanding and foresight is as important as insight. It is wellknown that adopting EA

requires and demands much more thanjust good frameworks, methodologies, tools and technical capabilities.

Therehavebeen someefforts to identifydistinguishing factors.However,all theseeffortshave lookedat such

distinguishing factors in a piecemeal manner and hence their proposed solutions are seldom convincing or

effective. The strategic (systems) thinking approach addresses the why of EA adoption in the context of

connectedorganizationanduncoversnonobvious interdependenciesbetweenthe factorssuchas: (1)different

organization units within the enterprise; (2) corresponding actions taken by these organization units; (3)

quantitative tangible variables (such as healthcare investments) and qualitative ones (such as operational

diversity);(4)

short

and

long

term

consequences

of

management

decisions;

(5)

uncovering

virtuous

and

vicious

cycles.EAforstrategicleadershipandadvantageisalongtermendeavor.Thetechnicalprocessofarchitectingis

difficultenough,butunderstandingtheunderlyingcomplexitiesandtheinterconnecteddynamicsthatcontribute

to particularly intractableand difficulttosolveproblems makes it intimidating formanyorganizations.Systems

thinking,used in thispaper, looksat theseproblemsandanalyzes themwith thecore intentof: (1)motivating

peopletochange;(2)generatingcollaborationbetweengroupsthatblameeachotherforthecurrentsituation;(3)

concentratelimitedresourcestopointsofgreatestleverage;and(4)ensurecontinuousongoinglearningafterkey

decisionswithregardtointerventionshavebeenmade.

Current EA frameworks and methodologies consider organizations as functional hierarchies, which employ the

commandandcontrolparadigm,astopdown,separated fromwork,targetandbudgetdrivenwithanethosof

centralcontrolandreaction.Thisbeingthestartingpoint,therestofthearchitectureactivitiesembedandeven

amplify thismindset, thuscreatingabiasedandoften incorrect viewof theorganization, leading to ineffective

architecture.Edward

Deming

has

asserted

that

organizations

need

to

be

viewed

and

managed

as

systems.

Through

the integrationofstrategic (systems)thinking,supportedwith itsapplication inthehealthcaresectorthispaper

hasattemptedtofurtherthedisciplineandpracticeofEA.

The author gratefully acknowledges Singapore Healthcare Services (SingHealth) and Integrated Health

Information Systems (IHiS) for their involvement and contribution to this work. Their inputs and enthusiastic

participationhavebeeninvaluable.


22/24


Page22of24

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AbouttheAuthorDr. Pallab Saha is with the National University of Singapore, Institute of Systems Science (NUSISS). His

current research,consultingand teaching interests includeEnterpriseArchitecture (EA)andGovernance.

Dr.Sahahaspublishedthreebooks,HandbookofEnterpriseSystemsArchitecture inPractice;Advances in

Government Enterprise Architecture; and Coherency ManagementArchitecting the Enterprise for

Alignment,AgilityandAssurance.Hisbooksarewidely referredby practitionersand researchersaround

theworld,makingittotheTopSellerlistin2008and2009.Hispapershavebeentranslatedandpublished

inKorean,

Russian

and

Polish.

Dr. Saha is the primary author of the MethodologyforAGency ENTerpriseArchitecture (MAGENTA) and Government EA

GuidebookfortheGovernmentofSingaporeandhasledthemtointernationalprominence.TheyareavailableinIDSScheers

ARISToolset.He isa recipientof theMicrosoft researchgrant in theareaofGovernmentEA supportedby theUNand the

WorldBank.Heconsultsextensivelybothinthepublicandprivatesectors.HehasprovidedconsultingservicestotheMinistry

of Defence, Defence Science and Technology Agency, Infocomm Development Authority of Singapore, Integrated Health

InformationSystems,IPOfficeofSingapore,CPFBoard,SingHealth,GovernmentsofOmanandKazakhstan,andGreatEastern

LifeAssuranceamongothers.Hehasbeen invitedasakeynote/distinguishedspeaker to theWorldBank,CarnegieMellon

University,UNUniversity,TheOpenGroup,Microsoft,SAPLabs,DenmarkITSociety,KoreaInstituteforITArchitecture,IEEE,

SGGovCamp,NanyangBusinessSchool,Governments of SouthAustralia, Jordan,UAE, Macau, Korea, Kazakhstan, Colombia,

BangladeshandseveralSingaporeGovernmentAgencies(AGO,WDA,MUIS,IDA,CIOForum,MHA,SPRING).Hisworkhasbeen

featured and cited by the UN, WHO, United States DoD, Carlsberg and The Open Group and has contributed to the World

Banks EA Guidelines for Vietnam. Featured as anArchitect in the Spotlight by theJournal of EA he has been an external

examinerfor

research

degrees

to

the

University

of

New

South

Wales,

University

of

Indonesia,

aVisiting

Researcher

to

the

UN

University,andhasbeeninstrumentalinbringingAsiasfirstGovCamptoSingapore.

Earlier,asHeadofDevelopmenthehasmanagedBaxter'soffshorecentre inBangalore.Hehashadengagements inFortune

100organizationsinvariouscapacities.Dr.SahaholdsaPh.DinManagement(InformationSystems)fromtheIndianInstituteof

Science, Bangalore and has received the best research design and best thesis awards. He is an alumnus of the MIT Sloan

[email protected].


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