RESEARCH ArchitectingforBusinessInsightandStrategicForesight:ASystems ApproachtoManagementofChronicDiseasesinSingapore

PallabSaha NationalUniversityofSingapore InstituteofSystemsScience pallab@nus.edu.sg

ExecutiveSummary
Business leaders operate in the realm of confounding uncertainties and astounding complexities. These lead to incomplete and often nonactionable information that makes business decisions increasingly speculative. The advent and diffusion of Enterprise Architecture (EA) as a metadiscipline provides organizations and business leaders the means to address the twin challenges of business dynamism and complexity. However, this necessitates the inclusion of strategic (systems) thinking within the EA approach, requiring with it a complete transformation of the architects mental models pertaining to the development and utility of EA. As organizations become increasingly hyperconnected they oughttobeviewedandexaminedassystems,whereintheholisticapproachand the interrelationships between the organizational elements play a crucial factor in ensuring overall business coherency. This paper demonstrates the value of adopting the systems approach to addressing chronic disease management in Singapore, and provides insights to advance the impact of EA by integrating creativethinkingtotacklecomplexproblems.

Keywords
Healthcare Systems; Public Health Transformation; Connected Health; eHealth; Coherency Management; Chronic Disease Management; Policy Resistance; Management Agility; OrganizationalChange;BusinessModelInnovation.

2011NUSInstituteofSystemsScience.NUSInstituteofSystemsSciencegrantspermissiontoreprintthisdocument providedthiscoverpageisincluded.

Introduction
Structured enterprise architecture (EA) approach is often used to plan and implement efficient and effective transformationefforts.However,thestrongestdriverforEAistoimproveservicedeliveryandoverallperformance within the organization's business segments. The principal challenge faced by chief architects today is to institute an EA program that is able to coordinate sustainable changes throughout the organization, while simultaneously mentoring the specific transformation planning that is needed to support the mission. In a nutshell, EA is a robust planning function which helps organizations to understand the process by which business strategies turn into operational reality. Hence, establishing a standard methodology for conducting architecture planning and implementationisvital.Metaphorically,anEAistoanorganizationsoperationsandsystemsasasetofblueprints is to a city and its buildings. However, EA comes with additional challenges given that the primary frame of reference, the organization, is a complex adaptive system. Even as architecture teams are architecting, the organizations that are being architected continue to function and as a result remain dynamic and everchanging. Traditionally, by following an architecturebased approach, organizations usually aim to address issues pertaining to: (1) strategic alignment; (2) information accuracy and integrity; (3) infrastructure management; (4) security; (5) technology compatibility; (6) business value of IT; (7) corporate governance; (8) business collaboration; and (8) procurement among others. Though EA is often assumed to follow an organizations strategy and to align IT with business objectives, increasingly, evidence of the reverse is also surfacing. In other words, organization strategies arebeinginfluencedbyITcapabilities. In the book Coherency ManagementArchitecting the Enterprise for Alignment, Agility and Assurance, authors Doucet,Gotze,SahaandBernardpresentanddiscusstheextendedandembeddedmodesofEAinadditiontothe traditional mode. They assert that as organizations start embracing the more advanced extended and embedded modes, the need for synergy and consistency amplifies, thus facilitating the attainment of organizational coherence, the ultimate goal of EA. They define EA as the inherent design and management approach essential fororganizationalcoherenceleadingtoalignment,agilityandassurance". This paper starts with a brief discussion on the key emerging trends in the discipline of EA. This is important because it delineates the way in which the growth and adoption of EA as a management discipline will take place. The purpose of this section is to set the context for the next section, which elaborates the role of strategic (systems)thinkinginEA,primarilyfromawholeoforganizationperspective.Thissectionalsoexplicitlyshowshow adoption of IT leads to national productivity and prosperity. The author believes this linkage is important because theoperational,product,serviceandbusinessmodelinnovationsthatEAbringsinlendingthemselvestoadoption of technology given its ubiquity. Moving forward, the subsequent sections present a case study of the use of strategic (systems) thinking as an integral part of architectural analysis through a detailed elaboration of its adoption in the management of long term health conditions (also called chronic disease management) in Singapore. It is important to note that though the case study pertains to Singapore, the issue of chronic disease management is the foremost healthcare challenge in several countries, hence the lessons and experiences are easily generalizable to other countries and jurisdictions. The author has directly been involved in this journey as a leadingexpertandadvisortoahealthcareclusterinSingapore.TheprimaryobjectiveofthispaperistoelevateEA as a management and leadership metadiscipline. Given the authors own experiences in delivering several keynotesessionsinconferencesandseminarsworldwide,withoutdoubtthishasalreadybeenachieved.

EmergingTrendsinEnterpriseArchitecture
The emerging trends in enterprise architecture stems from key misconceptions that are currently evidenced. Authors Gary Doucet, John Gotze, Pallab Saha and Scott Bernard provide the first glimpse of the imminent mega trends in EA in their book. This has been followed by research reports by Gartner, the two notable ones being Introducing Hybrid Thinking for Transformation, Innovation and Strategy and From Hierarchy to PanarchyHybrid Thinkings Resilient Network of Renewal. Additionally, Gartners Hype Cycle for Government Transformation 2009 and Hype Cycle for Enterprise Architecture 2010 provide partial insights. Presented below are the trends and characteristics,whicharetransformingthedisciplineandpracticeofEA:

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1.

ThetransitionfromEAbeingequatedtotheEnterpriseITArchitecturetothearchitectureofenterprise demands that it be viewed as a complete holistic metadiscipline that has the potential to link other management discipline and bring in business model innovation. The next generation of EA will form the backbone of all successful organizations, and the misconception that organizations do not have architecture until they initiate a formal project and a team tasked with managing the project will start to fade.Theunderlyingprinciplethateveryfunctioningorganizationhasarchitecturewilltakehold. The emphasis of architecture development will shift from designing the various architectural views and viewpoints to designing the interconnections between various views and viewpoints so as to achieve organizationalcoherence.Doucet et. al have identified the dimensionsof organizational coherencewhich are:(1)designed;(2)organized;(c)consistent;(d)connected;and(e)Institutionalized.Withinthecontext of these dimensions, organizations will be characterized by three primary modes of EA, all operating concurrently.

2.

Organizations are complex adaptive systems and success in the contemporary operating environment requires innovative ways of thinking about business problems and organizations. There will be an increased drive to integrate strategic (systems) thinking as a core capability within enterprise architecture. As organizations become more hyperconnected and as the wider environment (political, economic, social and technological) becomes uncertain and unpredictable, the ability of organizations to sense and respond will become as important as the abilitytoplanandexecute.Insuchachangingscenario,openloop(straightline)thinkingtobusinessissueswillbe inadequate to address them. Closedloop (systems) thinking will allow organizations the ability to think about the whole,whereinsynthesistakesprecedenceoveranalysis.

TheRoleofStrategic(Systems)ThinkinginEnterpriseArchitecture
EA has gained the center stage as an essential discipline to enable and even drive business transformation. To be consideredasthearchitectureoftheenterprise,itisthusanimperativetounderstandtheorganizationthatisto bearchitected,anunderstandingthatpermeatestheentireorganization.Yet,almostallcurrentEAactivitiesfocus primarily on the operational aspects, completely ignoring the more important strategic aspects. In order for business leaders and policy makers to comprehend the role and intended outcomes from EA programs, it is essential that they view such programs from a strategic viewpoint in the way these are planned, designed, embraced, managed andgoverned. It would beanunderstatementto say that organizations arecomplex. Going a step further, governments are even more complex and at times paradoxical. This stems from the fact that governmentsarebyfarthelargestorganizationsandwithsizecomescomplexity.Complexitiesinorganizationsare of both typescombinatorial complexity and dynamic complexity. Complexity arising due to sheer number of componentsandelementsthatareinterconnectedreferstocombinatorialcomplexity.Dynamiccomplexity,onthe other hand, arises due to the velocity of change and the quantum of interactions between the components and elements. In addition, unpredictable delays between decisions and their effects (and countereffects) completes the picture of what constitutes, according to Gartner, wicked problems. In short, organizations are excellent examples of complex dynamic systems. A system here is defined as a set of interrelated things encompassed by a well defined and permeable boundary, interacting with one another and an external environment, forming a complexbutunitarywholeandworkingtowardacommonoverallgoal. Organizationsfaceseveralchallenges,andalotofthemareverystubborninnature(i.e.,wickedproblems),andare thereforeunder pressure toaddress thesechallenges ina more open,accountable and transparentways. Inorder for organizations to transform, it is critical that they are understood as complex dynamic systems. Organizations characterizedbytheabove,requiremuchmorethanconventionalthinkinginordertocomprehendtheunderlying system and the challenges that the system faces. The success of business transformation programs thus becomes dependent on comprehending the underlying system. For instance, ambiguity in understanding the system is one of the primary reasons for public sector transformation showing less than satisfactory results and success rates. It is amply evident that countries adopt wholeoforganization EA as t he metadiscipline to trigger, design and realize government transformation. However, in the past decade or so the focus of EA programs have been on developing frameworks, methodologies, languages, guidelines, best practices, reference architectures and other
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capacity building activities. On the government side, it is to be noted that countries are using egovernment as a means to achieve public sector reforms and government transformation. This is clearly articulated in the periodic global egovernment surveys undertaken by the United Nations. Adoption of IT for government services and programmes plays an important role in crafting and furthering the egovernment initiatives. Robert Atkinson and Andrew Mackay, in their report titled Digital ProsperityUnderstanding the Economic Benefits of Information Technology Revolution, clearly demonstrate the role and influence of IT adoption on national productivity and overall economic prosperity. This is not surprisinggiven the ability of ITto enable nearly everyaspect of a modern knowledge based economy that countries increasingly aspire to be. The ubiquity of the IT makes it even more compellingtoembraceandderivebenefitsoutof.Exhibit1depictsthesystemicviewofthisphenomenon.

Exhibit1:TheEconomicBenefitsofInformationTechnologyAdoption The report, without any ambiguity, spells out the need to consider IT adoption in a coherent manner and with a long term view in mind. Understanding the above phenomenon is impressive for countries to design and execute their EA. Despite all these seemingly impressive benefits, the adoption of wholeofgovernment (WOG) EA has been less than expected. This is evidenced by Gartners Hype Cycle for Government Transformation 2009, wherein WOG EA would require another 5 to 10 years before reaching full maturity and delivering benefits justifying its immense potential. On the upside, however, Gartners Hype Cycle for Enterprise Architecture 2010 does state that WOG EA is past the bottom of the trough of disillusionment. There is no dearth of literature and
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other enabling resources for countries to build their enterprise architectures. Yet, after the initial enthusiasm, things are difficult to sustain with questions often being raised regarding the efficacy of government EA efforts. This is not surprising at all. Without fully understanding the underlying system, the success achieved and benefits derived through the adoption of EA has been limited. This leads to two logically explainable reactions: (1) frantic efforts to improve the frameworks, methodologies, guidelines, principles, bestpractices and tool support; and (2) discontinuingtheEAaltogetherbytermingittoodifficultandtoocomplex. The need of the moment is not better solutions, but better thinking about the problems. Gary Hamel in his book TheFutureofManagementstatesthatsolvingasystemicproblemrequiresunderstandingitssystemicrootsandit is the first of the ten rules of management innovation. It is in this context that conventional openloop thinking to solvingbusinessproblemsneedstobereplacedwithsystems(closedloop)holisticthinking.Asystemicperspective isusedtounderstandhowthenumerouscomponentsoftheorganizationact,reactandinteractwithoneanother with the intent of improving the adoption of EA for a coherent organization. This provides a comprehensive, holistic and a more coherent way of anticipating synergies and mitigating negative emergent behaviors, which wouldfacilitatedevelopmentofpoliciesandotherrelevantinterventionmechanisms.Usingasystemicperspective encouragesstrategicthinking.Exhibit2showsacomparisonofsystemsthinkingoverconventionalthinking.

ComparingConventionalandSystemsThinking Conventional(OpenLoop)Thinking Staticthinking

Focusingonparticularevents.

Systems(ClosedLoop)Thinking Dynamicthinking
Framingaproblemintermsofpatternsofbehaviorover time.

Systemsaseffect
Viewingbehaviorgeneratedbyasystemasdrivenby externalforces.

Systemascause
Placingresponsibilityforabehavioroninternalfactorsand actors.

Fragmented
Believingthatreallyknowingsomethingmeansfocusingon thedetails.

Holistic
Believingthattoknowsomethingrequiresunderstanding thecontextofrelationships.

Factorsthinking
Listingfactorsthatinfluenceorcorrelatewithsomeresults.

Operationalthinking
Concentratingoncausalityandunderstandinghowa behaviorisgenerated.

Straightlinethinking
Viewingcausalityasrunninginonedirection,ignoringthe interdependenceandinteractionbetweenandamongthe causes.

Loopthinking
Viewingcausalityasanongoingprocess,witheffectfeeding backtoinfluencethecausesandthecausesaffectingone another.

Exhibit2:ComparingConventionalandSystemsThinking This paper uses causalloop diagrams to capture nonlinear cause and effect relationships in order to realize the systems thinking described earlier. The conventions of causalloop diagrams are not described here, as excellent literatureisalreadyavailableinthisarea.Inordertodemonstratetheabove,thehealthcaresegmentisusedasan illustration. This is deliberate because the health care issues are complex, dynamic, timely and relevant to many countries. Developed countries around the world are said to face five critical healthcare challenges in the years to come.Theseare:(1)patientsafety;(2)longtermconditions;(3)outcomebasedmodels;(4)costcontainment;and (5) service delivery reforms. These apply to Singapore as well. The sheer complexity of the health care system is mindboggling. This segment is huge, multifaceted, and selfcontained. For these purposes, management of long term conditions(also known as chronic disease management) is selected and examined. As would be evident over the course of the next few sections, the management of chronic diseases exhibits all of the complexities and nuances described in the previous. This makes it an excellent illustration for demonstrating the potential of embracing strategic (systems) thinking. A note of caution here for all readers the content and approach described in this paper represents the leadingedge in EA discipline, hence it is meant for organizations who have
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the maturity to adopt the emerging by going beyond what is already established. In a reasoned way, the paper does not emphasize on the technological aspects of EA. This is deliberate because at the level that the business concernhasbeendescribedandexamined,technologylooksoutofplace.

TheHealthcareConundrum Health care is a complex adaptive system with a strong social focus. Exhibit 3 shows the key stakeholders in the healthcareecosystemasidentifiedbytheWorldHealthOrganization(WHO).Further,theWHOalsohighlightsthe interconnectednessthatisbothexistinganddesirabletoensurehighqualityhealthcareataffordablecosts.

Exhibit3:StakeholdersintheHealthCareEcosystem(Source:WHO)

Health care systems operate in a heterogeneous environment of public and private services, with numerous business operating models that make a coherent design, implementation and operation of integrated health care systems challenging. In general, health care systems around the world are on a troublesome and dangerous path with a combination of high costs, uneven quality, frequent errors, and limited access to care. The situation is further exacerbated by changing demographics that bring forth issues that have hitherto never been analyzed in totality. Michael Porter and Elizabeth Teisberg in their book Redefining HealthcareCreating Value Based Competition on Results list out key causes of the ills that afflict the health care industry. Broadly, these are : (1) prevalence of the commodity mindset; (2) focus on reducing shortterm costs; (3) variation in quality and costs based on geographical location; (4) incentives to the the health care providers to blend in and follow standard procedures; (5) continued practice of academic specialties replicated in health care providers; (6) questionable patient attitudes and motivations; (7) patient care cenetered on medical conditions; and (8) incentives to health planandhealthcareproviderstoaimforshorttermgoalsandperformancemetrics. Furthermore,theoverallhealthcaresystemsgetevenmoremuddledwiththeadventofnewandemergingissues that get amplified due the ever changing demographics. The disease profile of the world is changing ever so rapidly, and long held notions about health care systems are no longer true and at most times even misleading. A health care phenomenon that is confounding governments across the world is the ever growing issue of management of long term conditions (or chronic disease management). Chronic diseases have emerged as the
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largest cause of death and source of health care costs in developed countries. In many countries, deaths from chronic diseases now outstrip mortality for traditional health concerns such as injuries and communicable diseases. While the primary purpose of this paper is not to present a detailed review of chronic diseases and their management. The next section discusses the trends and information pertaining to chronic diseases. These trends andinformationarepresentedastheyarecriticaltounderstandingthebusinessdomainwiththeaimofproviding critical inputs to the systems models presented in the subsequent sections. The quantum of background information on chronic diseases provided is deemed to set the context and fulfill the objective of this paper i.e., to demonstrate the use and value of strategic (systems) thinking as an integral element of the EA discipline, therebymakingEAmoreforwardthinkingandbusinesseffectivenessorientedratherthanfocusingonoperational efficiencies. This change in the way EA itself is viewed is neccesitated to support the massive shifts that are being observed.

UnderstandingChronicDiseases
To set the context for the rest of the paper, Exhibit 4 shows a comparison of chronic and acute illnesses. As is evident, the characteristics of chronic conditions are all too different when compared to acute illnesses. In fact, theyareastudyincontrastandistheprimaryrootcauseofamajorityofthehealthcarechallengesthatcountries today face. It is clearly evident from Exhibit 4 that policies, procedures, processes, systems and other supporting mechanisms established for acute illnesses would be grossly inadequate and even incorrect when applied to chronic illnesses. The WHO lists heart disease, stroke, cancer, asthma and chronic obstructive pulmonary diseases anddiabetesasthemajorones.Thispaperdoesnotexamineanyspecificchronicdisease.Instead,itviewschronic diseases in a collective aggregated manner. It is sufficient for the objective of the paper as the lessons learnt and otherfindingscanbegeneralized.

Exhibit4:ComparingAcuteandChronicIllness With the above information as context, the following are the megatrends in chronic diseases that are currently underway.Theyareexaminedsincetheyprovidearichsourceoffactorsandvariablestobeusedasinputsforthe
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systems models elaborated in subsequent sections. It is to be noted that the purpose of these megatrends is to understand and gain adequate insights into the phenomenon so as to derive sufficient information to effectuate strategic (systems) thinking. The intent is not to provide a detailed discourse about chronic disease management perse.ThesefactsandfiguresarelargelytakenfromrelevantliteraturemadeavailablebytheWHO. 1. Anestimated388millionpeoplewilldiefromchronicdiseasesinthenext10years.Withincreasedinvestment in the prevention or delay of chronic disease onset, it will be possible to prevent 36 million premature deaths inthesametimehorizon.Withoutactiontoaddressthecauses,deathsfromchronicdiseaseswithincreaseby 17%between2005and2015. The macroeconomic impact of chronic diseases will be substantial. Large countries will likely forego in excess of$500billioninnationalincomeoverthe next10years.Averteddeathswithbettermanagementofchronic diseaseswouldtranslateintosubstantialgainsinthenationaleconomicgrowth. Globally, a misconception that chronic diseases mainly affect high income countries is widely prevalent. Furthermore, there is also a belief that low and middle income countries must focus on infectious diseases before chronic diseases. These misconceptions are contrasted by the fact that 80% of all chronic disease deathsoccuronlowandmiddleincomecountries. Globalization, urbanization and population ageing are the key underlying socioeconomic, cultural, political and environmental determinants contributing to modifiable and nonmodifiable risk factors. The most common modifiable risk factors leading to chronic diseases include unhealthy diet, physical inactivity and tobaccouse.Thenonmodifiableriskfactorsincludeageandgenetics. Chronic diseases and poverty are interconnected in a vicious cycle. On one hand, poor people are more vulnerable for several reasons, including increased exposure to risks and limited access to health services. Whileontheotherhand,chronicdiseasescanleadtopovertyinindividualsandtheirfamilies.Together,these two have the potential to lead to a downward spiral of worsening disease and poverty. This phenomenon directlybringsdowntheindividualandnationalproductivities. In general, health care services and systems are primarily designed for acute care. Services and systems for chroniccareareusuallycarvedoutbytweakingthemfromtheacutecare.This,despitethefactthatchronic diseases constitute 70% of the disease burden, thus creating a massive mismatch between supply and demand. Thedifferentchronicdiseasesthemselveshavesomedegreeofinterconnectedness,thatis,theincidencesof comorbidities which usually worsens with age, plays an important role in complicating treatments and interventions.ThisisdepictedinExhibit5. The total number of people aged 70 years and above worldwide is expected to increase from 269 million in 2000 to 1 billion by 2050. Age is an important factor in the accumulation of modifiable risks for chronic diseases; that is the impact of risk factors increases over the life course. Exhibit 6 shows the age pyramids for Singaporein2008and2025,andthedemographictransitioncurrentlyunderwayistrulydramatic.Thatsaid,it isimportanttonotethatmostdevelopedcountrieshavearapidlyageingpopulation,primarilyduetothedual affectsofincreasinglifeexpectancyanddangerouslylowbirthrates.ForexamplecountriesinEastAsiahavea total fertility rate of under 1.2. This compares very unfavorably, given that a country requires a total fertility rate of 2.1 just replace its population. Another negative impact of an ageing population is that it leads to a shrinkingpoolofpotentialcaregivers,thusaffectingtheveryqualityofchroniccare,pushingthewholehealth systemtoafurtherdownwardspiral.

2.

3.

4.

5.

6.

7.

8.

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Exhibit5:PotentialCoMorbiditiesAssociatedwithMainChronicDiseases Alloftheabovefactsandfiguresinsomesensecapturethesymptomsailingthemanagementofchronicdiseases. The most natural reaction would be to address these symptoms through short term quickfix type of solutions. Such an approach would be conventional (openloop) thinking demonstrating the characterisctics are shown in Exhibit2 earlier. There is substantial literature elaborating thedangersof openloop thinking. Incontrast, bringing in the closedloop thinking provides the ability to look at the big picture in a unified collective manner, understand the interconnectedness and interdependencies between the various elements and parameters involved.Inotherwords,inthecontextofthechronicdiseases,alloftheabovefactsandfigureswouldhavetobe looked at collectively in a systemic perspective. There is no doubt that management of chronic diseases is a wicked problem that requires deeper holistic thinking. It is to be noted that the megatrends above look at chronic diseases collectively in a generic manner, and do not granularize it in terms of individual disease types or patterns.

Exhibit6:SingaporePopulationPyramidsin2008and2025
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EmbracingStrategic(Systems)Thinking
According to Edward Deming, 94% of all organizational issues are systemic in nature. Usually, leaders and managers do not fully understand the systemic issues. This is absolutely true with regard to management of chronic diseases. The work presented in this paper was carried out for a healthcare cluster in Singapore. The cluster consists of a group of polyclinics, large hospitals, specialist centers and other provider entities looking at community and home care services. The cluster is also supported by a group of enlisted general practitioners and otherbusinesspartners.Insummary,alltheelementsofthehealthcareecosystemshownearlierinExhibit3exist in this cluster. Some of these elements of the ecosystem are in their own right large and complex organizations, having their own strategy, management and operations. The business areas within the purview of the healthcare cluster are depcited in Exhibit 7. This represents the clusters business reference model (BRM). The BRM depicts the outsidein perspective of the health care cluster. It only shows the business areas and business functions without depicting which provider entity (organization) within the cluster provides the service. This perspective is important as it organizes the cluster business in a way that makes sense to the service recipients (i.e. citizens and patients). The service recipients do not need to be aware of the health care clusters internal administrative structure. This makes the cluster more enduser (patient) centric without cluttering them with administrative details. The implication of viewing the business from a patient centric perspective includes disintermediation of individual provider entities and assumes seamless integration between them. In short, to the patients and citizens the cluster appears as one, the manifestation of connected health paradigm. This is absolutely essential for countries aiming to reform their public health sector. Though not central to this paper, an interesting sidenote is that such a connected paradigm in the health care sector is an essential precursor to the success of electronic healthrecord(eHR)programsthatmanycountrieshaveenthusiasticallyinitiated. Purely from a technology perspective, the BRM needs to supported and enabled by other reference models (e.g. the Data Reference Model (DRM), Application Reference Model (ARM) and Technical Reference Model (TRM)). However,thispaperdoesnotdiscusstheDRM,ARMandTRManyfurther. Despite each individual provider entity tasked with different aspects of the care delivery value chain, it was very clear upfront that tackling chronic disease management required a holistic and integrated approach, because it had bothclusterwide and nationwide ramifications. Chronic diseasemanagement touched every business area shown in Exhibit 6, thus the integrated approach is an imperative. The care delivery value chain (CDVC) proposed byMichaelPorterandElizabethTeisbergintheirbookRedefiningHealthcareCreatingValueBasedCompetitionon Results, is a powerful technique to capture the integrated view. The CDVC provides an excellent technique to identify and sequence the care functions and subfunctions in an integrated manner working through the care journey that a patient traverses via the different stages. The CDVC also depicts the various participating provider entities in the delivery of the care. This highlights the collaborative aspects in the care delivery which is essential for better andeffective care. However, in order for us to understand and dissect a complex problem, not only is it important to understand the interactions between the various provider entities and the functions they perform, but also to capture and fully understand the interactions between the various factors and variables that form the core and contribute to the complexity and dynamism. This is achieved through adopting strategic (systems) thinking. The subsequent paragraphs elaborate the adoption of strategic (systems) thinking factoring in the mega trends that have already been presented earlier. This contrasts very well with the usual approach, wherein the approachwouldbetoidentifyafewkeybusinessfunctionsfromtheBRM,sometimescalledhotspots,prioritze them and analyze them to address the issues in consideration. This analytical approach characterized by its divideandrule mindset is reductionist in nature and put forths all the ingredients that usually tend to make organizations microsmart and macrodumb. The underlying rationale for adoption of strategic (systems) thinking is that any assumption that the effectiveness of the whole will be achieved automatically, as long as the parts are optimal, can no longer be sustained with the systemic paradigm. Strategic (systems) thinking is able to capture the wisdom of diverse stakeholders. This notion is strengthened by the WHO World Health Report which states that the responses of many health systems so far have been generally considered inadequate and nave. Inadequate, insofar as they not only fail to anticipate, but also to respond appropriately too often with too little, too late or too much in the wrong place. Nave insofar as a systems failure requires a systems solution not a temporaryremedy.
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That said, strategic (systems) thinking is not a silver bullet. Its adoption does not automatically mean that addressingcomplexbusinessissuesbecomeseasierwithoutchangingthemindsetthatcausedtheproblemtostart andaggravate.

Exhibit7:HealthCareClusterBusinessReferenceModel(Level0View) Taking the chronic disease facts and figures presented earlier, the problem framing process starts with the common modifiable risk factors (like unhealthy diet, physical inactivity and use of tobacco) triggered by the underlying determinants of globalization, urbanization and ageing population; this increases the overall risk of chronicdiseases,whichleadstotheeventualonsetofchronicdiseases.Theonsetofthediseaserequiresfinancial resources to provide for adequate care and treatments, thus increasing the overal economic burden for the individual.Thesituationisfurtherexacerbatedbythefactthatthepopulationwithchronicdiseasesarelikelytobe lessproductive(ascomparedtohealthypopulation),leadingtoforegoneincome.Thisleadstoadropinresources andfinancialcapabilitytoaffordpropercare,furtherincreasingthenegativeimpactofthechronicdiseases.Thisis depictedinExhibit8,andcollectivelytermedastheavoidableburdenloop.Thisisapositiveloopasitrepresentsa downward spiral and clearly demonstrates the long term negative consequences of chronic diseases both on the individuals and countries. The loop is deliberately named so because it implicitly captures a phenomenon that is largelyaviodableifindividualsandcountriesfocusonreducingthecommonmodifiablerisks.Thisthinkingisinline withtheWHOrecommendations.Theavoidableburdenloopthusbecomesthecentralcoreoftheproblemframe, around which other chronic disease factors and variables are progressively added in the form of more loops. This processiselaboratedinthesubsequentparagraphsofthissection.

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Exhibit8:UnderlyingFactorsandtheChronicDiseaseOnset

As the incidences of chronic disease care becomes more prevalent and expensive duethe downward spiral shown inExhibit7,thereisincreasedpressurebythecitizensandthecivilsocietyonthegovernmenttosubsidizedisease care. Being a political hotbed, most governments provide subsidy enmasse, i.e. there is a great likelihood that the sectionofthesocietythatnotneedthesubsidyarealsosubsidized.Toaddressthis,theconceptofmeanstesting isrightlybeingintroducedinSingapore.Thissubsidyisrealizedthroughvariousmeans,forinstancethepatientcan directlybesubsidized,orthehealthcareproviderscanbecompensatedfortreatingpatientswithchronicdiseases. Usuallygovernmentsadoptamultiprongedapproachtodeliverthesubsidiesasitprovidesthemgreaterleverage. Irrespective of the means of providing the subsidy, the impact on the national income and the economy is inevitable. This is the shown in the subsidy response loop. This leads to further negative impact on the resources availableforthehealthcaresectoringeneral(andchronicdiseasemanagementinspecific).Hencethesubsidyhas the potential to become a national burden, if it is not carefully targeted as shown in the national cost loop. These two loops together work in tandem and have the potential to create serious shortcomings in the healthcare ecosystem by constraining the availability of resources and opportunities to manage chronic diseases. This then feeds into the core downward spiral depicted by the previously described avoidable burden loop. The foregone national income has direct negative impact on the available resources and leads to the deterioration of overall qualityoflife,eventuallyleadingtohigherrisksofchronicdiseases.Inotherwords,individualandnationalpoverty aggravates the problem of chronic diseases even further. On top of this, increasing life expectancy actually worsens the problem even further. This is depicted in the life expectancy matters loop. Exhibit 9 shows the three new loops and also amply demonstrates how these three loops actually worsen the downward spiral. This is an interestingphenomenonwhereinonedownwardspiralisstrengthenedbyaseriesofotherinterconnectedloops, via common factors and variables. Strategic (systems) thinking makes this behavior explicit and apparent. This is precisely how whole systems thinking propagates and makes the approach more amenable to effective interventionsbyanticipatingandyetformallystructuring. Longtermevidenceprovesthatwithtimelyandeffectiveinterventionsandpropermedicationmanagement,most patients with chronic diseases can actually lead nearnormal lives with minimal interruptions. This is further made possible with recent advancements made in medical sciences. This means that most patients can actually drasticallyreducetheirvisitstospecialists.Inotherwords,inmostsituationsgeneralpractionersandpolyclincsare sufficient to continue to treatments and keep the diseases at bay. Reducing interactions with specialists directly leads to lower costs for payers and also ensures that specialists, who are always in short supply, do not become bottleneckinthewholeecosystem.
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Exhibit9:RoleofSubsidies,ForegoneNationalIncomeandLifeExpectancy With the previous notions in mind, there is also empirical evidence to prove that as subsidy is increased (by the government),itbecomesmoreattractivetoreferaspecialistandtheusualinclinationistoreferaspecialistasthe first level intervention, irrespective of whether it is needed or not. This demonstrates normal human behavior which is driven by incomplete and misconceived mental models on part of the patients. This behavior is the evidence of questionable patient attitudes and motivations that Michael Porter and Elizabeth Teisberg have identifiedandhighlightedintheirbook.Thisbehaviorleadstocrowdedhospitalsandspecialistcenters,elongating queues and waiting times. This has an impact on the national productivity and eventually the gross national income.Thisphenomenoniscapturedintheinvolvingspecialistsloop. Building up from the life expectancy matters loop, and ageing population leads to a drop in working (and productive) adults, which has a negative impact on the gross national income; an eventual drop in investments available for healthcare occurs as it erodes the tax base over time. Typically governments respond to this by increasing the retirement age limits, as is currently being seen in many countries. However, the downside is an older working population would also be more prone to chronic diseases. An erosion in the tax base results in governmentsearninglowerrevenuesthroughtaxesandotherlevies.In otherwords,astheproportionofworking adults drop there are less people to contribute into the countrys financial system, and an increasing number who require financial assistance during their nonproductive years. In addition, a dropping birthrate also ensures that not adequate number of working adults come into the system in the decades to come, further eroding future tax base. This effectively has long term negative implications on the national economy and resources available for healthcare, thereby increasing the chronic disease morbidity and mortality, further strengthening avoidable burdenloopdescribedearlier.Thisbehavioriscapturedinthechronicdiseasedeathsloop.Thisaffectsthequality of life and eventually leads to greater risks of chronic disease onset. There is evidence that as gross national income falls, the proportion of the population in the lower income category bulges and usually tends to be most badly affected. In other words, the poorer sections of the society become even poorer, thus enlarging the chasm between the rich and the poor, primarily because of inequal distribution of wealth. The inequality (measured as theGINIindex)increasestheintensityandthespreadofpoverty.This,withoutdoubt,leadstoincreasesinchronic disease morbidity and mortality as shown in the poverty hurts loop. The WHO has clearly demonstrated the
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existence of adownward spiral betweenchronic diseases and poverty.Exhibit 10 depicts the involving specialists, chronicdiseasedeaths,healthcareinvestmentsandpovertyhurtsloops.

Exhibit10:MacroeconomicConsequencesofChronicDiseases Chronic diseases constitute 70% of the disease burden. The supplydemand mismatch between acute and chronic careisalreadyanobservedphenomenon.Wrongpatientattitudesandmotivationsleadingtocrowdedhospitalsis a result of the involving specialists loop, examined earlier. This is further worsened by the fact that crowded hospitalshaveagreatertendencytofocusonthewrongpriorities(i.e.focusonimmediatepriorities)attimeseven hurting the long term effectiveness. Given the immediacy of needs and other operational pressures, healthcare providersusuallytendtospendgreaterproportionoftheirtimeandresourcesinprovidingacutecareandtreating patients with infectious diseases. This is captured in the unclear priorities and priority for acute care loops in Exhibit11. AccordingtoasurveydonebytheWHO,thecostofchronicdiseasecareisbyfarthemostsignificantchallengefor both individuals and governments. In general, the escalation in the cost of healthcare far outstrips the broader inflation. The situation is even more acute when viewed from the chronic disease perspective. As cost of chronic care treatments escalate, people attempt to cover through insurance (wherever possible). With wrong patient attitudes and motivations, the typical behavior is for patients to prefer specialists over general practitioners (already discussed earlier). This inflates the overall costs in the whole of the healthcare ecosystem. As costs rise, insurance firms are forced to become more stringent in their checks and approvals. Given that insurance firms have a profit making motive, this worsens the situation even further. This increases the incidents of noncoverage for existing customers and lengthens the list of exclusions for potential new customer, leading to insurance becoming less attractive. As insurance becomes less attractive, the insured tend to opt out of the programs and potential new customers not finding insurance attractive are not inclined to insure themselves or their families. This creates twin headwinds for the insurance sector as existing customers optout and new customer base expansion slows down. The overall collective insurance base gets severely restricted. For the population who stay back as part of the insurance programs, the premiums go up because there are not enough healthy people to pay into the programs and plans. All of these happen, even as the whole ecosystem is plagued by increasing life expectancies and falling birth rates. The paradox is in the fact that insurance firms want to insure the healthy, whereasthehealthydonotwanttogetinsuredbecauseoftheoverallunattractivenessoftheprogramsandplans. This death spiral is depicted in Exhibit 12, through the costs of treatment, questionable insurance effectiveness andgapsinqualityofhealthcareloops.
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Exhibit11:AmplificationoftheSupplyDemandMismatchandUnclearPriorities The loops in Exhibit 11 also amplify the mismatch between supply and demand. The current insurance plans and programs are designed for acute care, and then tweaked to work for chronic care. In addition, upwards trend in the GNI provide the fodder for socioeconomic, cultural, political and environment determinants, magnifying the globalizationandurbanizationprefactorsthatleadtoincreaseinrisksofchronicdiseases.Thisis showninExhibit 11inthepriceofgrowthloop.

Exhibit12:TheHealthInsuranceDeathSpiral
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Exhibits8throughto12examinedthevariousfactorsrelevantinthecontextofchronicdiseases.Thevariousloops that were discussed aimed to link these factors in a series of causal connections. Exhibit 13 depicts the complete businesssystemsmodelforchronicdiseasemanagement.Thesynthesizedview: 1. Enables capturing and understanding the forest before digging into the trees. This is an essential perspective that allows for discovery and understanding of both combinatorial and dynamic complexities. AccordingtotheIBMGlobalCEOStudy2010,publicsectorleadersbelieveescalationofcomplexityisthemost important issue confronting organizations. Strategic (systems) thinking facilitates creative thinking that is essentialtoaddresschallengesofcomplexity. Does not clutter the holistic perspective as the individual organizational entities (in this case provider entities like general practitioners, polyclinics, hospitals, specialist centers, community and home care providers) take the backseat, and instead the focus on the common underlying concern or issue that is being examined. This enables theconnected view. In other words, the focus is on the interactions rather than the entities involved. This is essential for architects to become designers of coherence rather than designers of components and layers. Framestheproblemspaceinawaythatallowsfororganizationalleaderstodesignstrategicinterventionsand toenvisiontheimpactoftheseinterventionsbothupstreamanddownstream.Thestrategicinterventionscan then be examined, prioritized and effectuated through smaller more tactical action items. This creates a cultureofandacapabilityforoperatingdexterity,providingbothinsightandforesight. Encourages collaboration and cocreation as the key stakeholders are now able to view the problem in an integrated manner and also realize that addressing the issue requires these stakeholders to think collectively and holistically. It also discourages piecemeal and stovepipe approach. Multidisciplinary and multi stakeholderinvolvementisessentialsuccessfactorforeffectiveenterprisearchitectureandleadership. Catalyzes business design and innovation by taking benefit of all of the above current and emergent perspectives, thereby providing relatively sustained advantage. This is supported by a survey done by the BostonConsultingGroup(BCG).
Globalization& Urbanization + Socioeconomic,Cultural, Political&Environmental Determinants + RiskofChronic Diseases + NonModifiable RiskFactors EconomicBurdenof ChronicDisease Management + Pressureto Subsidize Treatments + + Gross National Income(GNI) + + PRICEOFGROWTH

2.

3.

4.

5.

+ + Numberof Insured ChronicDisease Onset

Common,Modifiable RiskFactors AVOIDABLEBURDEN Proportionof AgedPopulation +

+ OverallPublic HealthSpending

IncomeInequality (GINIIndex)

Attractiveness of Insurance

+ InabilitytoCover MedicalCosts

+ Foregone IndividualIncome Resources & Opportunities to Manage

+ LIFEEXPECTANCYMATTERS Population Longevity + HEALTHCAREINVESTMENTS Resources for HealthcareResearch& Innovations

+ Intensityof Poverty

COSTSOFTREATMENT + StringentChecks by InsuranceFirms + + QUESTIONABLEINSURANCEEFFECTIVENESS CostEscalationto InsuranceFirms + Likelihoodof Seeking Insurance

SUBSIDYRESPONSE

+ Likelihoodof Involving Specialists +

NATIONALCOST ForegoneNational Income + + +

+ QualityofLife + + Resources for ChronicDiseases CHRONIC DISEASEDEATHS ChronicDisease Morbidity&Mortality + Availabilityof Care

POVERTYHURTS

INVOLVINGSPECIALISTS

Patient Compliance

Crowding at Hospital Facilities

PRIORITYFORACUTECARE +

UNCLEARPRIORITIES

GAPSINQUALITYOFHEALTHCARE

Quality ofCare

Focus onAcute& Infectious Diseases + <StringentChecks by InsuranceFirms>

Exhibit13:SynthesizedViewoftheChronicDiseaseManagementPandemic
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DesigningStrategicInterventions
Peter Senge in The Fifth Discipline argues that to solve difficult problems one needs to understand the inter relationships rather than things, for seeing patterns of change rather than static snapshots. To design effective intervention strategies, it is critical to diagnose the issues correctly and frame the problem space. Insight and foresight are both crucial. Exhibit 12 depicts problem space in a synthesized view. It captures several factors and connects them via series of loops, all of which have been discussed earlier. It is important to note that the factors and the loops are specific to the local conditions in Singapore. They need to be suitably adapted prior to use in othersituations.Needlesstomention,thespecificinterventionswoulddependonthecontextofspecificnuances. Designing the right interventions are as important as the location these interventions would be applied. However, part of the strategic intervention design should also include uncovering and understanding the inherent delays in thesystem,forthesystemwithlongtermdelaycannotrespondtoshorttermchanges.Inacomplexsystem,there are places where a small shift in one thing can produce large changes in (almost) everything. The places are termedleveragepointsthepointsofpower.DonellaMeadowsinherarticleLeveragePointsPlacestoIntervene in a System identifies and elaborates generic leverage points where interventions are most likely to be impactful and results bearing. Moving forward, the next logical step from an architectural perspective is to propose steps that could be taken to address the chronic disease pandemic. These steps are called strategic interventions, as they tend to be long term in nature and often require series of action items to be executed and operationalized. The WHO recommends ten steps to applying systems perspective in the design and evaluation of strategic interventions. Exhibit 14 depicts the synthesized view with the strategic interventions (as arrows) and the significantdelaysarealsoshown.

Exhibit14:SynthesizedViewoftheChronicDiseaseManagementPhenomenonwithSuggestedInterventions Management of chronic diseases is a national priority in Singapore, as in many other countries. This is evidenced by the fact that the Singapore Government has always been viewing this from a long term perspective and designing policies and programs to suit current and emerging needs. Healthcare services in Singapore are one of the most advanced and arguably one of the best in the world. With regard to chronic diseases the government
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clearly demonstrates long term vision, which is achieved by a series of small yet focussed and progressive action items. In the national budget announcement for 2011, made in March 2011, the government announced a series of action items that are intended to tackle this gigantic public health issue of chronic disease management. The actionitemsannouncedinclude: 1. 2. 3. 4. 5. 6. 7. EstablishingtheGeriatricEducationandResearchInstitute. ExpandingtheHomeNursingFoundation. ScalingupoperationsoftheAgencyforIntegratedCare. ContributingtotheCommunitySilverTrust. ExpandingtheMedifundbudget. ExtendingtheMedicationAssistanceScheme. EncouragingstepdowncarewiththeexpandedPrimaryCarePartnershipScheme.

Theseactionitemshavenotbeenelaboratedindetailasthatisnottheintentofthispaper.

LeveragingthePowerofStrategic(Systems)Thinking
It is obviouslyclear from theabove that the action items are targeted tomeet specificneeds andaddress some of the strategic interventions depicted in Exhibit 14 earlier. Comparing the strategic interventions and the action itemsshowsthatthestrategicinterventionsaremorelongterminnature,whiletheactionitemstendtobemore tactical and executable in nature. The strategic interventions are excellent inputs for governments to develop policy enablers. Furthermore, strategic thinking also facilitates deeper understanding of policy resistance that is oftendisplayedbystubbornproblems. Exhibit 15 shows the authors own assessment of the strategic interventions covered with the announced action items. It is clearly seen that the action items put forth reflect the preemptive anticipatory thinking on part of the government.Theproblemathand,chronicdiseasemanagement,isacomplexandstubbornone.Hencetheaction items demonstrate the progressive series of tasks that are being planned and performed to tackle it. It is to be noted that the Singapore government already has existing plans and schemes for management of long term conditions, example policies and programs pertaining to: (1) ageing workforce; (2) chronic disease care costs; (3) programs mitigating modifiable risk factors; (4) preemptive screening; and (5) GNI / GDP growth and economic wellbeing. In Exhibit 15 the action items are limited to ones specifically announced in the March 2011 national budget. In summary, a great start has been made and it is comforting to see that progress is being made in the rightdirection.Thisishoweffectivestrategic(systems)thinkingisintendedtobe.Itisimperativethatthecomplex effects, synergies and emergent behavior of system interventions are fully understood in order to take benefit. Additionally, any intervention with systemwide implications cannot be considered simple and allows organizationstocapitalizeoncomplexity.

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Exhibit15:MappingtheStrategicInterventionstotheAnnouncedActionItems

Strategic thinking establishes the vision, while action items realize the vision. This is an essential element for enhancing the effectiveness of the EA, as often EA is perceived of being overly skewed towards housekeeping typeofactivities,ratherthanfacilitatingtheorganizationstothinkforwardandenablethevisioningprocess.The perception is not entirely incorrect and current EA frameworks reinforce this even further. Organizations find the current frameworks intimidating as they tend to quickly take them into a journey of deep and granular analysis, without spending adequate time for future thinking. Organizations overly focus on improving the operational enablers at the cost of strategic wisdom and direction. Ignorance, complexity and capability gaps are cited most frequently as the primary reasons. Operational enablers mean: (1) frameworks; (2) methodologies; (3) reference architectures and models; (4) tool capabilities; (5) competency building activities; (5) guidelines and standards; (6) best practices and the like. The skewness in favor of operational enablers is hard to miss. Though operational enablers are important, they, by no means have the ability to supplant the strategic perspective. Their role is primarly in supplementing strategic wisdom and direction. In the absence of the strategic perspective, the EA program virtually navigates partblind leading to cynicism, lack of persistence, erosion of confidence and loss of attention by the organizationleaders. It almost takesa crisis to makedeep change.Andwhen it is time to address the crisis, the focus is on symptoms, not causes. Embracing strategic (systems) thinking as part of the EA process notonlyaddressestheperception,butalsoelevatestheroleofEAasamanagementandleadershipdiscipline.This ups the innovation stakes, moving up from operational innovation to business model innovation, which goes to the very core of business design. This factors in and influences the value proposition and the operating model of theorganization.Becausethisinvolvesamultidimensionalandcoherentsetofactivities,innovationatthislevelis bothchallengingtoexecuteanddifficulttoimitate.Thereisempiricalevidencethatprofitoutperformersfocuson business model innovation by a substantial margin. The author has personally been involved in guiding such a
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mindsetchange,hencebeingabletovouchforit.Thatsaid,itwouldbeawhileforcurrentEAframeworkstomake strategic(systems)thinkingasanintegralpartoftheirmethodologiesandapproaches. In the current state of practice, EA programs and initiatives are often conceived and driven by the IT department. In this context, there already are substantial literature and other supporting evidence that the IT department, more often than not, finds it challenging to deeply engage the business or the domain side of the organization. According to the IBM Global CIO study, realizing business innovation has been identified as the first and foremost activity as being increasingly expected from CIOs. Questionable credibility on part of the IT department exacerbatesthelackofcommunication,leadingtodisengagementandeventuallossofmomentumandinterestin EA. It gets relegated as an IT project. Embracing strategic (systems) thinking allows for: (1) a business understandingofbusinessconcerns/problems;(2)synthesistotakeprecedenceoveranalysiswhichisessentialto manifest the organizationwide view of the architecture; (3) triangulation of emergent strategy development with the more traditional topdown strategic planning; (4) identification of leverage points wherein the interventions tend to be most impactful; (5) framing the problems space in a way that is comprehensible by the senior executive leadership in the organization; (6) deemphasizing on the siloed mindset; (7) establishment of collective strategic priorities; and (7) designing for coherence (consistent, collaborative, connected). Once the above are achieved, identifying the most relevant business services, business functions and processes to execute theactionitemsbecomesthenextlogicalstep,followedbytheotherdownstreamstepsinthedevelopmentofthe IT architecture. This paperdoes not attempt to elaborate the downstream IT architecture steps asthere is already a plethora of literature available that covers the topic. Exhibit 16 summarizes the phases and steps that are typically required to effectuate the business transformation that is driven by EA. The phases, steps, sequence and theotherelementsdepictedinExhibit16areindicativeinnatureandthereisnofurtherelaborationinthispaper.

Exhibit16:SuggestedMethodologyforArchitectureDrivenBusinessTransformation
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MovingForwardAManifestoforManagementLeadersandArchitects
Michael Porter has asserted that strategic planning in most organizations has not contributed to strategic thinking. In the case of EA this statement cannot be disputed or overstated. Strategic (systems) thinking makes it possible to translate complex information that is interconnected into simple, yet compelling explanations of not onlywhatishappening,butmoreimportantlywhy.ThereisnodearthofliteraturethatidentifypitfallstoEAand proposed solutions to avoid such pitfalls. There is also abundant guidance literature available as to how governments (and other organizations) must adopt EA. On the other hand, none of the currently available literature explain the underlying complexities of EA adoption per se. Gary Hamels contention that operational efficiency does not equate to strategic efficiency makes absolute sense in a scenario where governments are gradually transforming from a hierarchy to a lattice (both by neccessity and design). The advent of social media is hastening this transformation. And in a lattice which is more likely to characterized by collaborating nodes that form part of value networks, effective coordination and orchestration makes the difference. Moving forward, governmentsofthefuturewillembraceprinciplesofcocreation,accountability,collaborationandconnectedness. These will definitely be expolated to the healthcare sector. Innovation and personalization will trump standardization and commoditization. Driving change of any kind is challenging by itself, but at the fundamental level of business coherency, such change requires commitment, insight, foresight and leadership. All four of these distinguishing characteristics are evident in the way Singapore views it chronic disease management plans and programs. EAisaverylargeundertakingforanyorganization.EAforawholeindustrysectorisevenlarger,morecomplexand more dynamic, making it an imperative to comprehend the underlying complexities in a holistic and coherent manner. Current thinking positions EA as an ITmanagement discipline. The research this paper embodies intends to dispel this thinking and positions EA literally as the architecture of the enterprise, where knowledge is supplemented with understanding and foresight is as important as insight. It is wellknown that adopting EA requires and demands much more than just good frameworks, methodologies, tools and technical capabilities. There have been some efforts to identify distinguishing factors. However, all these efforts have looked at such distinguishing factors in a piecemeal manner and hence their proposed solutions are seldom convincing or effective. The strategic (systems) thinking approach addresses the why of EA adoption in the context of connected organization and uncovers nonobvious interdependencies between the factors such as: (1) different organization units within the enterprise; (2) corresponding actions taken by these organization units; (3) quantitative tangible variables (such as healthcare investments) and qualitative ones (such as operational diversity);(4)shortandlongtermconsequencesofmanagementdecisions;(5)uncoveringvirtuousandvicious cycles. EA for strategic leadership and advantage is a long term endeavor. The technical process of architecting is difficult enough, but understanding the underlying complexities and the interconnected dynamics that contribute to particularly intractable and difficulttosolve problems makes it intimidating for many organizations. Systems thinking, used in this paper, looks at these problems and analyzes them with the core intent of: (1) motivating peopletochange;(2)generatingcollaborationbetweengroupsthatblameeachotherforthecurrentsituation;(3) concentrate limited resources to points of greatest leverage;and (4) ensure continuous ongoing learningafter key decisionswithregardtointerventionshavebeenmade. Current EA frameworks and methodologies consider organizations as functional hierarchies, which employ the command and control paradigm, as topdown, separated from work, target and budget driven with an ethos of central control and reaction. This being the starting point, the rest of the architecture activities embed and even amplify this mindset, thus creating a biased and often incorrect view of the organization, leading to ineffective architecture.EdwardDeminghasassertedthatorganizationsneedtobeviewedandmanagedassystems.Through the integration of strategic (systems) thinking, supported with its application in the healthcare sector this paper hasattemptedtofurtherthedisciplineandpracticeofEA. The author gratefully acknowledges Singapore Healthcare Services (SingHealth) and Integrated Health Information Systems (IHiS) for their involvement and contribution to this work. Their inputs and enthusiastic participationhavebeeninvaluable.

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References
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AbouttheAuthor
Dr. Pallab Saha is with the National University of Singapore, Institute of Systems Science (NUSISS). His current research, consulting and teaching interests include Enterprise Architecture (EA) and Governance. Dr. Saha has published three books, Handbook of Enterprise Systems Architecture in Practice; Advances in Government Enterprise Architecture; and Coherency ManagementArchitecting the Enterprise for Alignment, Agility and Assurance. His books are widely referred by practitioners and researchers around the world, making it to the Top Seller list in 2008 and 2009. His papers have been translated and published inKorean,RussianandPolish. Dr. Saha is the primary author of the Methodology for AGency ENTerprise Architecture (MAGENTA) and Government EA Guidebook for the Government of Singapore and has led them to international prominence. They are available in IDS Scheers ARIS Toolset. He is a recipient of the Microsoft research grant in the area of Government EA supported by the UN and the World Bank. He consults extensively both in the public and private sectors. He has provided consulting services to the Ministry of Defence, Defence Science and Technology Agency, Infocomm Development Authority of Singapore, Integrated Health Information Systems, IP Office of Singapore, CPF Board, SingHealth, Governments of Oman and Kazakhstan, and Great Eastern Life Assurance among others. He has been invited as a keynote / distinguished speaker to the World Bank, Carnegie Mellon University, UN University, The Open Group, Microsoft, SAP Labs, Denmark IT Society, Korea Institute for IT Architecture, IEEE, SGGovCamp, Nanyang Business School, Governments of South Australia, Jordan, UAE, Macau, Korea, Kazakhstan, Colombia, BangladeshandseveralSingaporeGovernmentAgencies(AGO,WDA,MUIS,IDA,CIOForum,MHA,SPRING).Hisworkhasbeen featured and cited by the UN, WHO, United States DoD, Carlsberg and The Open Group and has contributed to the World Banks EA Guidelines for Vietnam. Featured as an Architect in the Spotlight by the Journal of EA he has been an external examiner for research degrees to the University of New South Wales, University of Indonesia, a Visiting Researcher to the UN University,andhasbeeninstrumentalinbringingAsiasfirstGovCamptoSingapore. Earlier, as Head of Development he has managed Baxter's offshore centre in Bangalore. He has had engagements in Fortune 100organizationsinvariouscapacities.Dr.SahaholdsaPh.DinManagement(InformationSystems)fromtheIndianInstituteof Science, Bangalore and has received the best research design and best thesis awards. He is an alumnus of the MIT Sloan ExecutiveProgram.Hecanbecontactedatpallab@nus.edu.sg.

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