1 6/7/2012
Singapore’s National EHR
Adaptive Architecture for Transformation and Innovation
Peter Tan
Lead Enterprise Architect
HISA – Porto
6 July 2012
2
6/7/2012 2
Agenda
•
Singapore’s Healthcare Context
•
Healthcare Transformation Agenda
•
1
st
wave (2004-2007): EMRX & CMIS
•
2
nd
wave (2008-2011): NEHR
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’
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
Acute and
Long-term Care
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
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
“
”
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 NH Polyclinics FPs Home Care Rehab & support services Screening &
Prevention Palliative Care
RH CH NH Polyclinics FPs Home Care Rehab & support services Screening &
Prevention Palliative Care
RH CH NH Polyclinics FPs Home Care Rehab & support services Screening & Prevention Palliative Care RH CH NH Polyclinics FPs Home Care Rehab & support services Screening &
Prevention Palliative Care
RH CH NH Polyclinics FPs Home Care Rehab & support services Screening &
Prevention Palliative Care
RH CH NH Polyclinics 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
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
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
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
11 6/7/2012 11
EMRX Access
EMRX Access 0 100000 200000 300000 400000 500000 2004 2005 2006 Year D o c u m e n t V o lu m eNHG 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 D o c u m e n t V o lu m 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 D o c u m e n t V o lu m e
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 & ReportMINDEF
15 6/7/2012
2
nd
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
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
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
lann
ed
Compon
en
ts
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 Programfocus 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:
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
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-CDR
Note: 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 p u tD isch a rg e S u m m a ryM e ta d a ta g e tD isch a rg e S u m m a ryM e ta d a ta g e tI m m u n isa ti o n s a d d Im m u n isa ti o n g e tR a d io lo g yR e p o rt p u tR a d io lo g yR e p o rt g e tR e co n ci le d A lle rg ie s p u tR e co n ci le d A lle rg ie s g e tR e co n ci le d M e d ica ti o n s p u tR e co n ci le d M e d ica ti o n s g e tR e co n ci le d P ro b le m s p u tR e co n ci le d P ro b le m s g e tR e fe rr a lL e tt e r p u tR e fe rr a lL e tt e r p u tO rd e re d M e d ica ti o n s p u tD isp e n se d M e d ica ti o n s p u tL a b R e su lt p u tE ve n t p u tE D N o te sM e ta D a ta p u tO T N o te sM e ta D a ta g e tS C R g e tL a b R e su lt g e tE ve n t g e tE D N o te sM e ta D a ta g e tO T N o te sM e ta D a ta re so lve E n d p o in t re so lve R e co rd L o ca ti o n getDischargeSummary getEDNotes getOTNotes se n d M e ssa g e
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 Bus ine s s Da ta A pplic a tion Orga niza tion Bu s ine s s S e rv ic e A ppln S v s Informa tion Flow Info flow ( a ppln . s rv .) Info flow ( a ppln . s rv .) Bu s ine s s S v s vs A ppln S v s
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
