singapore national ehr for hisa at porto jul 2012
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16/7/2012
Singapore’s National EHR Adaptive Architecture for Transformation and Innovation
Peter Tan Lead Enterprise Architect HISA – Porto 6 July 2012
v v
26/7/2012 2
Agenda
• Singapore’s Healthcare Context
• Healthcare Transformation Agenda
• 1st wave (2004-2007): EMRX & CMIS
• 2nd wave (2008-2011): NEHR
• Current Developments
36/7/2012
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
46/7/2012
National Infocomm Initiatives
3G & Free Island-wideWireless 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
56/7/2012
Our Healthcare Ecosystem
Primary Care Long-term CareAcute andIntermediate 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
66/7/2012
“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 structureit 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 LoongNational Day Rally 2009
“
”
Vision: Integrated Healthcare System
76/7/2012
Goal State: The Big Picture
Tertiary Care
Primary and Intermediate Long Term Care
Community Hospital
General Practitioners
NursingHomePolyclinics
RH
CH
NHPolyclinics
FPs Home Care
Rehab & support services
Screening & Prevention
Palliative Care
RH
CH
NHPolyclinics
FPs Home Care
Rehab & support services
Screening & Prevention
Palliative Care
RH
CH
NHPolyclinics
FPs Home Care
Rehab & support services
Screening & Prevention
Palliative Care
RH
CH
NHPolyclinics
FPs Home Care
Rehab & support services
Screening & Prevention
Palliative Care
RH
CH
NHPolyclinics
FPs Home Care
Rehab & support services
Screening & Prevention
Palliative Care
RH
CH
NHPolyclinics
FPs Home Care
Rehab & support services
Screening & Prevention
Palliative 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
86/7/2012
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 FrameworkFrom 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
96/7/2012 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
106/7/2012 10
Electronic Medical Records Exchange (EMRX) 2004 - 2007
Public(My.eCitizen)
Targeted Health AlertsSelf-Update
Hospitals, PolyclinicsElectronic Medical RecordsAllergiesMedical AlertsImmunisation records
HPBImmunisation RecordsSchool Health Screening Results & Follow-up
MINDEFNS Medical Records
HospitalsElectronic Medical RecordsAllergiesMedical Alerts
GPsImmunisation recordsHealth ScreeningMini 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
116/7/2012 11
EMRX Access
EMRX Access
0
100000
200000
300000
400000
500000
2004 2005 2006
Year
Do
cum
ent
Vo
lum
e
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
cum
ent
Vo
lum
e
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
cum
ent
Vo
lum
e
NHG Request SHS Request Total Request
126/7/2012 12
Allergy Reporting: Unsustainable practices
Ministry of HealthSingapore
136/7/2012 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 AlertsSelf-Update
Hospitals, PolyclinicsElectronic Medical RecordsAllergiesMedical AlertsImmunisation records
HPBImmunisation RecordsSchool Health Screening Results & Follow-up
MINDEFNS Medical Records
HospitalsElectronic Medical RecordsAllergiesMedical Alerts
GPsImmunisation recordsHealth ScreeningMini 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
146/7/2012 14
CMIS Retrieval Flow
Private Hospitals
Public HospitalEMR System
CMIS
PatientArrives
GPs Clinic Management SystemE-Service
Cluster EMRX Interface Component
Ministry of HealthSingapore
Retrieve &
Report
Retrieve & Report
Retrieve & Report
MINDEF
Retrieve & Report
156/7/2012
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
?
166/7/2012
Proactive Vs. Passive Architecture
Proactive Architecture
PassionBusiness Analysts, Solution Architects, Enterprise Architects
Meaningful & Credible
ArchitectureAnalysis
Explore“The Art of Possible”
InvolvementExcite 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
176/7/2012
Solution and Architecture Services
Implementation
Enterprise Architecture
Solution Architecture & DesignAdapted 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
186/7/2012
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
196/7/2012
To Enable Transformation and InnovationPl
anne
d Co
mpo
nent
s
206/7/2012
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 & PHMArchitecture
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 & OperationContent
population
NEHRA next iteration
NEHRLive
Implementing operation & governance only when needed.
216/7/2012
Solving wicked problems: Source Data and Operations
226/7/2012
Current: Planning for Phase 2Continue 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
236/7/2012 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
246/7/2012 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 blackthey 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 / referralrecipients
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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256/7/2012 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
266/7/2012 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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276/7/2012
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
whereyou are
04. Be pragmatic, not dogmatic
Revolutionaries make
good Martyrs!
286/7/2012
A happy occasion
296/7/2012 29
Peter Tanpeter.tan@mohh.com.sg
Thank you!
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