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

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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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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

29 6/7/2012 29

Peter Tan

peter.tan@mohh.com.sg

Thank you!