Singapore National EHR for HISA at Porto Jul 2012
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Sharing of the Singapore national case study at Health Information Sharing Architecture conference in Porto, Portugal on 6 July 2012
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Singapore National EHR for HISA at Porto Jul 2012
- 1. Singapore’s National EHR Adaptive Architecture for Transformation and Innovation Peter Tan Lead Enterprise Architect HISA – Porto 6 July 2012 v 6/7/2012 1v
- 2. Agenda • Singapore’s Healthcare Context • Healthcare Transformation Agenda • 1st wave (2004-2007): EMRX & CMIS • 2nd wave (2008-2011): NEHR • Current Developments 6/7/2012 2
- 3. Singapore • 4.99 million people on 710.3 sq km • Ethnically diverse: • Chinese: 75 per cent Singapore • Malays: 14 per cent • Indians: 9 per cent • Characteristics: • A city state • will of the people • Rich technology foundations • less legal constraints • Support of the Government • ‘it will be done’ 6/7/2012 3
- 4. National Infocomm Initiatives 3G & Free Island-wide Wireless Hotspot National BroadBand rollout – Fiber Optic 2015 is Singapore’s 6th National IT Masterplan, launched in National 2 Factor Authentication 2006, http://in2015.sg Cloud infrastructure 6/7/2012 4
- 5. Our Healthcare Ecosystem Primary Care Acute and Long-term Care Intermediate Care • 35,000+ healthcare workers Community Hospital • 11,580 hospital beds Polyclinics Nursing Home Palliative • 429,744 hospitalRestructured Screening & Preventation admissions (2007) Hospital Care General • Public sector out-patient visits Care Practitioners Home (2007) Public sector • Specialist Outpatient Clinics Rehab & 3,687,910 Support • A&E Services 752,122 Private sector • Polyclinics 3,797,953 People sector 6/7/2012 5
- 6. 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 Picture taken from asiaone.com So we have to respond to this by putting in more resources into our hospital system, building new hospitals. “ And one key thing we must to with this step-down care is do link up our acute hospitals […] … get the whole system to be structured properly so that it will with community hospitals, so be adapted to cater for the ageing population. To structure that you can have the best of it properly means we need step-down care.” both worlds. ” Prime Minister Lee Hsien Loong National Day Rally 2009 6/7/2012 6
- 7. Goal State: The Big Picture • A pyramid model • Anchored by regional Tertiary hospitals Care • More autonomy in day- to-day operations Secondary Care • Own networks of Screening & Prevention Polyclinics CH RH NH Palliative Care general practitioners Home FPs Care Rehab & support services CH CH CH Polyclinics NH Polyclinics NH • Step-down care facility Polyclinics NH Screening & Palliative Screening & Palliative Prevention RH Care Prevention RH Care Screening & Prevention RH Palliative Home Home Care FPs Care FPs Care Home FPs Care Rehab & Rehab & support support Rehab & services services support CH in respective zones services CH Polyclinics NH Polyclinics NH Screening & Palliative Screening & Prevention RH Palliative Prevention RH Care Care Home Home FPs Care FPs Care Rehab & Rehab & support support services services Primary and Intermediate Long Term Care General Community Nursing Polyclinics Practitioners Hospital Home 6/7/2012 7
- 8. One Patient One Record Strategy To accelerate sectoral transformation through an Infocomm-enabled personalised healthcare delivery Goal system to achieve high quality clinical care, service Health Information Exchange – excellence, cost-effectiveness and strong clinical research e-Enable seamless and secured Greater Strong information exchange in the Well- Cost- Integrated effective ability of clinical and healthcare value chain Outcomes Quality Healthcare public to health manage services Healthcare Services their health research Strategic Enable integrated Enable integration between healthcare and NEHR Thrusts healthcare services advances in biomedical science Health Integrated Translating Information Exchange - e- Healthcare Biomedical Integrated Healthcare Continuum - Continuum – Research to Strategies Enable seamless and secured e-Enable Healthcare e-Enable processes and linkages processes and Delivery - information exchange in the linkages across integrate clinical across the healthcare value chain the healthcare and biomedical healthcare value value chain research data chain iN2015 Strategic Framework From iN2015 Healthcare and Biomedical Sciences Report 6/7/2012 8
- 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 6/7/2012 9
- 10. 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 HPB 2007) Immunisation Records Gov Agencies School Health • (HPB, Mindef) Screening Results & Follow-up Participants linked up Hospitals, Polyclinics Electronic Medical Records Hospitals • National Health Group, SingHealth Group Allergies Electronic Medical Medical Alerts MINDEF Records Immunisation records NS Medical Records Allergies Medical Alerts • Ministry of Defence Medical Service EMRX Private Sector • Health Promotion Board Clusters Data Interchange Step-down Care (Hospitals, Step-down (SHS, NHG) Care, GPs) Central Database Central Database • Immunisation, School Health records GPs Immunisation records Health Screening Mini EMR Public Targeted Health Alerts (My.eCitizen) Self-Update 6/7/2012 10
- 11. EMRX Access EMRX Access 40000 35000 Document Volume 30000 • Volume of documents 25000 20000 request grown 15000 10000 exponentially over first 3 5000 0 years as more documents Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec were made available 2005 NHG Request SHS Request Total Request EMRX Access EMRX Access 60000 50000 Document Volume 500000 Document Volume 40000 400000 30000 300000 20000 10000 200000 0 100000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 0 2006 2004 2005 2006 NHG Request SHS Request Total Request Year NHG Request SHS Request Total Request 6/7/2012 11
- 12. Allergy Reporting: Unsustainable practices Ministry of Health 6/7/2012 Singapore 12
- 13. Critical Medical Information Store (CMIS) • Launched in October 2005 • HPB Immunisation Records Leverage on EMRX infrastructure Gov Agencies (HPB, Mindef) School Health Screening Results & • Follow-up Semantic interoperability with data Hospitals, Polyclinics Electronic Medical Records Allergies Hospitals Electronic Medical Medical Alerts MINDEF standardization Immunisation records NS Medical Records Records Allergies • Medical Alerts Centralized storage of EMRX • Medical alerts Clusters Data Interchange Private Sector (Hospitals, Step-down Step-down Care • Drug allergies (SHS, NHG) Care, GPs) Central Database Central Database • Adverse drug reactions reports to the GPs Immunisation records Health Screening Health Sciences Authority Mini EMR • Now average 61,266 retrievals & Public (My.eCitizen) Targeted Health Alerts Self-Update reports on MA and DA monthly 6/7/2012 13
- 14. CMIS Retrieval Flow GPs Clinic Management System E-Service Private Hospitals CMIS Patient Arrives MINDEF Public Hospital Cluster EMRX Retrieve & EMR System Report Interface Component Ministry of Health 6/7/2012 Singapore 14
- 15. 2nd Wave (2008 – 2011) National EHR – Architecture Approach (1) Top Down Strategy Focus on Develop iN2015 Healthcare Governance Artefact and Biomedical & Control Library Sciences Report ? Future Focus on Planning & Delivery Innovation 6/7/2012 15
- 16. Proactive Vs. Passive Architecture Passive Architecture Proactive Architecture Build the EA Balancing Goals and Objectives Organization Build the Principles Passion Meaningful & Explore Involvement and Blue Prints Credible Business “The Art of Excite and Analysts, Architecture Possible” Encourage Develop Gover- Solution Analysis nance Blue Prints Architects, Enterprise Mandate Architects Uptake Committees and You may make a mistake, but don’t make the Boards same mistake twice 6/7/2012 16
- 17. 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 6/7/2012 17
- 18. 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 • Reputation for providing • Exceeded expectations of information required to deliver outstanding service to patients & consumers & staff the best possible care families • Value for investment meets / • Streamlined interaction with high • Culture of wanting to share clinical exceeds the promise calibre providers across the information with partners in care • Pre-eminence in Health IT and healthcare sector delivery clinical research • Encouragement to seek answers • Support to deliver the highest level • Innovative, evidence based systems to clinical questions of clinical care outcomes • Satisfaction from the knowledge that • Empowerment delivered by self- • Streamlined transfer of care the health system is sustainable management capabilities • More time for direct patient care • Belief that the future population will • Minimise inconvenience from due to less manual / paper based be healthier than before unplanned encounters with the processes • Able to attract, develop and retain health system • Trust in data analysis and entry of high quality clinicians • Confidence that personal data is other clinicians • Confidence that health policy is protected • Confidence in the quality of data based on decisions and insights from robust operational data 6/7/2012 18
- 19. To Enable Transformation and Innovation Planned Components 6/7/2012 19
- 20. In the last 4 years… 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q ‘08 ’08 ’09 ’09 ’09 ’09 ’10 ‘10 ‘10 ’10 ’11 ’11 ’11 ’11 Value Value NEHR NEHRA NEHR POC NEHR RFP detailed design NEHR Value NHIS Design Live From NHISA Scoping Assurance Strategy to Program ESB focus From problem to innovation: Value Work Deep dive into a Repository Packages tricky problem space NEHRA & take opportunity to Data/Doc next iteration innovate. Service Catalog IIA Interop Specs Extending to new CIC & PHM Business Areas Architecture EA Ops & Implementing operation Tooling: EA Content & governance only Gov & Operation Repository population Gov when needed. 6/7/2012 20
- 21. Solving wicked problems: Source Data and Operations 6/7/2012 21
- 22. Current: Planning for Phase 2 Continue to Leverage and Extend Gap analysis Look at Current of current vs Goal State NEHR system Integration Identify new analysis of business services current systems and capabilities Options analysis Goal state architecture 6/7/2012 22
- 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 6/7/2012 23
- 24. Reference Architecture example: Goal State EMR cmp ABC-026-JHS Cross (cluster) EMR communication «goal state» «goal state» out of cluster :EMR EMR A conceptual goal state EMR system has been modeled to add context to the application getOTNotes architecture and integration putReconciledMedications getEDNotes putDischargeSummaryMetadata putReconciledProblems getDischargeSummaryMetadata putDispensedMedications resolveRecordLocation getReconciledAllergies getReconciledMedications pattern. putOTNotesMetaData putEDNotesMetaData getDischargeSummary putReconciledAllergies putOrderedMedications getOTNotesMetaData getRadiologyReport getEDNotesMetaData getReconciledProblems putReferralLetter putRadiologyReport getImmunisations resolveEndpoint getReferralLetter addImmunisation putLabResult getLabResult sendMessage getEvent putEvent getSCR Used to resolve the Required to recieve The conceptual goal state address of documents and document / referral and deliver communications from EMR’s capabilities are: recipients other care providers / • Integration systems NEHR • Clinical data sharing «OSB» • Reconciliation NEHR-ESB «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 6/7/2012 24
- 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 6/7/2012 25
- 26. Goal State Architecture operationalized in repository Business Application Data EArepository manages indexes of the major entities, physical and Business logical, within the MOHH enterprise. Organization Info flow (appln. srv.) Appln Svs Service • Business Data Inventory • Application Inventory Info Information srv.) Business Svs vs Appln Svs(appln. Flow • Organisation Inventory • Business Svs Inventory • Appln Svs Inventory • Information Flow flow • Info flow (appln. srv.) • Appln vs Appln Svs • Business Svs vs Appln Svs 6/7/2012 26
- 27. What We’ve Learned 01. Focus on solving 02. problems, not Build just delivering relationships/ 05. artefacts trust Evolve from where you are 04. 03. Be pragmatic, Be a servant not dogmatic first, policeman later Revolutionaries make good Martyrs! 6/7/2012 27
- 28. A happy occasion 6/7/2012 28
- 29. Thank you! Peter Tan peter.tan@mohh.com.sg 6/7/2012 29 29
Notes de l'éditeur
- - small country, but big city- but even in this small place, we have great diversityAnd I think the greatest advantage that Singapore has is “It will be done”
- As for the Health care services, - we have the full spectrum of health sectors: Primary, acute & intermediate, and Long term care. moreover, in each sector, the ownership is divided between numerous independent institutionsThusthe challesges for EA, What we have is quite a fragmented IT landscape - For example Multiple EMR systems in place at Hospitals, Polyclinics and Specialist Clinics , Minimal EMRs at GP and across Community Hospitals We have regional hospital partnering step down care institution,
- At present, Singapore is organized into a 3 tiers pyramid With Tertiary Care be supported by the two local university, NUS, and Duke NUS..At the secondary care, each of the 4 zone, West, east, North and central will be anchored by a regional hospital, …A new model being employed in the recent time… 4 region….And finally at the Primary care , it is supported by Polyclinics, GPs, Community hospital and nursing home.This is where our jobs become interesting. For example, when KTPH was build, and under the new regional hub model, KTPH has a choice, and the path they choose is a mix from both cluster….And as we look across there are some interesting development… for example the paperless system uniquely developed….So as the healthcare eco-system and the model of care evolve, EA will face a bigger challenges with the 4 hubs continuous to evolve and the expected silver tsunami and still support the national driver to manage cost and information exchange between hospitals.
- Singapore do have an over arching strategy going back to 2006, …
- Adaptive Architecture – is this an oxymoron? Some will say that architecture does not adapt, technology does. However our experience is that architecting with an ‘ability to adapt’ mind set brings different principles to the fore that influences the nature of the final architecture deliverable.
- We’ve introduced a passionate architecting style outside of the comfort zone of traditional enterprise architects. There is an art to mixing passion and architectural analytics skills to produce meaningful and credible results. The passionate style is also useful when engaging stakeholders, being able to vocalize and sell “the art of the possible” excites people, encouraging them to be involved and have a say.By it’s very nature innovation attracts risk. To address this we try to continue to evolve an environment that tolerates high risk, accepts the potential impacts of taking on risk and encourages brave decision making.
- Our architecture team extends from one providing traditional architecting services into a more hybrid model that provides the skills needed to understand and create business transformation, innovation and strategy, and integrate them into architecture.
- Our architecture team extends from one providing traditional architecting services into a more hybrid model that provides the skills needed to understand and create business transformation, innovation and strategy, and integrate them into architecture.
- Our objective has been to provide meaningful supporting infrastructure and services that enable transformation and innovation.
- The primary objective was never to develop a single, comprehensive target goal state – but to address future vulnerability and be adaptable to future requirements.
- Solving Wicked ProblemsWe have entered a ‘VUCA’ world: Volatility, Uncertainty, Complexity and Ambiguity, and it’s becoming the norm for highly complex integrated eHealth programs. In response, we have actively established “problem solving” working groups, bringing together those who rise to the challenge of solving wicked problems.We strive to not only solve the EHR problem, but also consider the broader national connectivity, workflow and access problems that must be solved to enable true integrated health care.
- Going forward we will continue to leverage on and extend the foundations delivered with NEHR phase 1. As I am presenting this, our teams in Singapore are planning future phases of NEHR implementation focusing on business intelligence, research, personalized healthcare and the extension of integrated care. Building a national information exchange capability that ensures access anywhere anytime in a flexible way to support changing models of care continues to be paramount.
- We will be ‘brave’ going forward supporting innovative initiatives that make our clinicians lives easier, provide better outcomes for patients, continuously ensuring Singapore is at the forefront of eHealth.