Singapore s National EHR Adaptive Architecture for Transformation and Innovation Peter Tan Lead Enterprise Architect HISA Porto 6 July 2012 v v 1
Agenda Singapore s Healthcare Context Healthcare Transformation Agenda 1 st wave (2004-2007): EMRX & CMIS 2 nd wave (2008-2011): NEHR Current Developments 2
Singapore 4.99 million people on 710.3 sq km Ethnically diverse: Chinese: 75 per cent Malays: 14 per cent Indians: 9 per cent Singapore Characteristics: A city state Rich technology foundations Support of the Government will of the people less legal constraints it will be done 3
National Infocomm Initiatives 3G & Free Island-wide Wireless Hotspot National BroadBand rollout Fiber Optic National 2 Factor Authentication 2015 is Singapore s 6 th National IT Masterplan, launched in 2006, http://in2015.sg Cloud infrastructure 4
Our Healthcare Ecosystem Primary Care Acute and Intermediate Care Long-term Care 35,000+ healthcare workers Community Hospital 11,580 hospital Polyclinics beds Nursing Home 429,744 hospital admissions (2007) Screening & Preventation Restructured Hospital Palliative Care Public sector Private sector People sector General Public sector Home Care Practitioners out-patient visits (2007) Specialist Outpatient Clinics 3,687,910 Rehab & Support Services A&E 752,122 Polyclinics 3,797,953 5
Vision: Integrated Healthcare System 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 6
Goal State: The Big Picture A pyramid model Anchored by regional hospitals More autonomy in dayto-day operations Own networks of general practitioners Step-down care facility in respective zones Screening & Prevention Polyclinics FPs CH RH Rehab & support services NH Home Care Screening & Prevention Palliative Care Polyclinics FPs Screening & Prevention Polyclinics FPs Tertiary Care Secondary Care CH RH Rehab & support services Screening & Prevention NH Home Care CH RH Rehab & support services Polyclinics FPs Palliative Care NH Home Care CH RH Rehab & support services Palliative Care NH Home Care Screening & Prevention Polyclinics FPs Palliative Care CH RH Rehab & support services Screening & Prevention NH Home Care Polyclinics FPs Palliative Care CH RH Rehab & support services NH Palliative Care Home Care Primary and Intermediate Long Term Care Polyclinics General Practitioners Community Hospital Nursing Home 7
One Patient One Record Strategy Goal Outcomes Strategic Thrusts 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 Well- Integrated Quality Healthcare Costeffective Healthcare Services Enable integrated healthcare services Greater ability of public to manage their health Strong clinical and health services research Enable integration between healthcare and advances in biomedical science Health Information Exchange e-enable seamless and secured information exchange in the healthcare value chain NEHR Strategies 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 Integrated Healthcare Continuum - e-enable processes and linkages across the healthcare value chain in2015 Strategic Framework From in2015 Healthcare and Biomedical Sciences Report 8
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 9
Electronic Medical Records Exchange (EMRX) 2004-2007 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 Clusters (SHS, NHG) Hospitals, Polyclinics Electronic Medical Records Allergies Medical Alerts Immunisation records Gov Agencies (HPB, Mindef) EMRX Data Interchange Central Central Database Database HPB Immunisation Records School Health Screening Results & Follow-up MINDEF NS Medical Records Private Sector (Hospitals, Step-down Care, GPs) Hospitals Electronic Medical Records Allergies Medical Alerts Step-down Care GPs Immunisation records Health Screening Mini EMR Public (My.eCitizen) Targeted Health Alerts Self-Update 10
EMRX Access Volume of documents request grown exponentially over first 3 years as more documents were made available Document Volume 40000 35000 30000 25000 20000 15000 10000 5000 0 EMRX Access Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2005 NHG Request SHS Request Total Request 60000 EMRX Access EMRX Access Document Volume 50000 40000 30000 20000 10000 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2006 NHG Request SHS Request Total Request Document Volume 500000 400000 300000 200000 100000 0 2004 2005 2006 Year NHG Request SHS Request Total Request 11
Allergy Reporting: Unsustainable practices Ministry of Health Singapore 12
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 Clusters (SHS, NHG) Hospitals, Polyclinics Electronic Medical Records Allergies Medical Alerts Immunisation records Gov Agencies (HPB, Mindef) EMRX Data Interchange Central Central Database Database Public (My.eCitizen) HPB Immunisation Records School Health Screening Results & Follow-up MINDEF NS Medical Records Private Sector (Hospitals, Step-down Care, GPs) Targeted Health Alerts Self-Update Hospitals Electronic Medical Records Allergies Medical Alerts Step-down Care GPs Immunisation records Health Screening Mini EMR 13
CMIS Retrieval Flow Private Hospitals GPs Clinic Management System E-Service CMIS Patient Arrives Public Hospital EMR System Retrieve & Report Cluster EMRX Interface Component MINDEF Ministry of Health Singapore 14
2 nd Wave (2008 2011) National EHR Architecture Approach (1) Top Down Strategy in2015 Healthcare and Biomedical Sciences Report Focus on Governance & Control Develop Artefact Library? Focus on Delivery Future Planning & Innovation 15
Proactive Vs. Passive Architecture Passive Architecture Proactive Architecture Build the EA Organization Balancing Goals and Objectives Build the Principles and Blue Prints Develop Governance Blue Prints Mandate Uptake Passion Business Analysts, Solution Architects, Enterprise Architects Meaningful & Credible Architecture Analysis Explore The Art of Possible Involvement Excite and Encourage Committees and Boards You may make a mistake, but don t make the same mistake twice 16
Solution and Architecture Services Work collaboratively Add value early on Enterprise Architecture Take a pragmatic approach Become part of natural process It s always about delivery Be supportive Value breeds demand Implementation Solution Architecture & Design Adapted from TOGAF v9 17
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 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 selfmanagement capabilities Minimise inconvenience from unplanned encounters with the health system Confidence that personal data is protected 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 18
Planned Components To Enable Transformation and Innovation 19
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 NEHRA From Strategy to Program focus NEHR POC NHISA Value Value From problem to innovation: Deep dive into a tricky problem space & take opportunity to innovate. NEHR RFP NHIS Scoping ESB Repository Data/Doc Value Service Catalog Value NEHR detailed design Design Assurance NEHR Live NEHRA next iteration IIA Interop Specs Extending to new Business Areas CIC & PHM Architecture EA Ops & Gov Implementing operation & governance only when needed. Tooling: EA Repository Content population Gov & Operation 20
Solving wicked problems: Source Data and Operations 21
Current: Planning for Phase 2 Continue to Leverage and Extend Gap analysis of current NEHR system Look at Current vs Goal State Integration analysis of current systems Identify new business services and capabilities Options analysis Goal state architecture 22
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 23
Reference Architecture example: Goal State EMR cmp ABC-026-JHS Used to resolve the address of documents and document / referral recipients resolveendpoint resolverecordlocation Cross (cluster) EMR communication «goal state» out of cluster :EMR getotnotes getednotes getdischargesummary Required to recieve and deliver communications from other care providers / systems sendmessage getdischargesummarymetadata getimmunisations getradiologyreport getreconciledallergies getreconciledmedications getreconciledproblems getreferralletter getscr getlabresult getevent getednotesmetadata «goal state» EMR getotnotesmetadata putdischargesummarymetadata addimmunisation putradiologyreport putreconciledallergies putreconciledmedications putreconciledproblems putreferralletter putorderedmedications putdispensedmedications putlabresult putevent putednotesmetadata putotnotesmetadata 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 NEHR «OSB» NEHR-ESB Clinical data sharing Reconciliation «Initiate» NHIS Endpoint Resolution Serv ice «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 24
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 25
Business Info Svs flow vs Appln (appln. Info Information flow Svs srv.) (appln. Appln Business Flow srv.) Svs Organization Service Application Business Data 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 26
What We ve Learned 01. Focus on solving problems, not just delivering artefacts 02. Build relationships/ trust 03. Be a servant first, policeman later 04. Be pragmatic, not dogmatic 05. Evolve from where you are Revolutionaries make good Martyrs! 27
A happy occasion 28
Thank you! Peter Tan peter.tan@mohh.com.sg 29 29