Wednesday, March 28, 2018

How can Digital Health be Implemented as envisaged in the National Health Policy 2017?

The National Health Policy 2017 (NHP-2017) of India correctly identified the need for creating many new institutions like the National Digital Health Authority (NDHA).  However, the ground realities don’t appear to have been considered well enough. Early setting up of a functional NDHA is essential for India to avoid a digital health mess in future. The first job for the proposed NDHA will be to formulate a robust National Digital Health Strategy / Policy, in consultation with all the stakeholders. Caution needs to be exercised before cross referrals and sharing disparate information among different systems of medicine. Health informatics education must be embedded as an integral part for health and hospital management. It may be prudent to include Health in the Concurrent list of the Constitution of India. That will ensure a smooth adoption of digital health in India. Seeking comments on the Draft Bill DISHA (Digital Information Security in Healthcare Act) is a good start.

It has been now more than a year that the (third edition of the) National Health Policy 2017 (NHP-2017) of India has been notified. While the accompanying Situation Analysis didn’t mention anything about Digital Health, the Policy correctly identified the need for creating many new institutions like the National Digital Health Authority (NDHA).

Now, let us look at where do we stand one year later, regarding the ushering in of Digital Health in India.

First let us glance at some of the key provisions of the NHP-2017 as mentioned in the various sections. Just beneath the quotes from the relevant sections of the NHP-2017, I’m commenting on certain issues for thought.

2.4.3.3 Health Management Information
a. Ensure district-level electronic database of information on health system components by 2020.
b. Strengthen the health surveillance system and establish registries for diseases of public health importance by 2020.
c. Establish federated integrated health information architecture, Health Information Exchanges and National Health Information Network by 2025.

Comments: The NHP-2017 focuses on Digital technology, right from the beginning. Some timelines are also proposed here. However, while some states have been doing very well, some others are lagging. We would further elaborate on this aspect towards the end.

3.3 Organization of Public Health Care Delivery: For effectively handling medical disasters and health security, the policy recommends that the public healthcare system retain a certain excess capacity in terms of health infrastructure, human resources, and technology which can be mobilized in times of crisis.
In order to leverage the pluralistic health care legacy, the policy recommends mainstreaming the different health systems. This would involve increasing the validation, evidence and research of the different health care systems as a part of the common pool of knowledge. It would also involve providing access and informed choice to the patients, providing an enabling environment for practice of different systems of medicine, an enabling regulatory framework and encouraging cross referrals across these systems.
Comments: Here there is a need for more caution since the other streams of medicine – viz., Ayurveda, Yoga and Naturopathy, Siddha, Unani and Homeopathy, follow entirely different principles from those followed by modern medicine. Therefore, cross referrals may add to the complexity and confusion, ultimately harming the patient.

11.1 Medical Education: The policy recognizes the need to revise the under graduate and post graduate medical curriculum keeping in view the changing needs, technology and the newer emerging disease trends.
Comments: There have been a lot of issues regarding the Medical Council of India and the National Board of Examinations in the past, followed by a proposed revamping through the National Medical Commission. Despite all the proposed changes, one of the essential features that is amiss is the incorporation of health informatics essentials in all branches of health professional education. Without doing that, a smooth adoption of digital health is extremely difficult.

11.8 Public Health Management Cadre: The policy proposes creation of Public Health Management Cadre in all States based on public health or related disciplines, as an entry criteria.
Comments: In continuation of the previous section, health information management must be embedded as an integral part for health and hospital management. Health Informatics weds both health information technology and health information management. Scaling up, public health informatics combines health informatics and population demographics.

13.12: Health Information System: The objective of an integrated health information system necessitates private sector participation in developing and linking systems into a common network/grid which can be accessed by both public and private healthcare providers. Collaboration with private sector consistent with Meta Data and Data Standards and Electronic Health Records would lead to developing a seamless health information system. The private sector could help in creation of registries of patients and in documenting diseases and health events.
Comments: Most of the times various health information systems don’t talk to each other and therefore there is a dire need of Standards for interoperability. I would discuss this issue in greater details this issue towards the end, where I would talk about the Clinical Establishments Act.

14.2: Regulation of Clinical Establishments: A few States have adopted the Clinical Establishments Act 2010. Advocacy with the other States would be made for adoption of the Act. Grading of clinical establishments and active promotion and adoption of standard treatment guidelines would be one starting point. Protection of patient rights in clinical establishments (such as rights to information, access to medical records and reports, informed consent, second opinion, confidentiality and privacy) as key process standards, would be an important step. Policy recommends the setting up of a separate, empowered medical tribunal for speedy resolution to address disputes /complaints regarding standards of care, prices of services, negligence and unfair practices. Standard Regulatory framework for laboratories and imaging centers, specialized emerging services such as assisted reproductive techniques, surrogacy, stem cell banking, organ and tissue transplantation and Nano Medicine will be created as appropriate.
Comments: Discussed below separately.

14.5: Medical Devices Regulation: The policy recommends strengthening regulation of medical devices and establishing a regulatory body for medical devices to unleash innovation and the entrepreneurial spirit for manufacture of medical device in India. The policy supports harmonization of domestic regulatory standards with international standards. Building capacities in line with international practices in our regulatory personnel and institutions, would have the highest priority. Post market surveillance program for drugs, blood products and medical devices shall be strengthened to ensure high degree of reliability and to prevent adverse outcomes due to low quality and/or refurbished devices/health products.
Comments:  Medical Devices Rules, 2017 that has come into force with effect from 1st day of January, 2018, has included in the Part-I of the first schedule Parameters for classification of medical devices other than in vitro diagnostic medical devices. There, Software as Medical Device (SaMD) is defined as: (iii) Software, which drives a device or influences the use of a device, falls automatically in the same class. This is indeed a very forward looking and welcome legislation, ahead of the times in our country.

22: Health Technology Assessment: Health Technology assessment is required to ensure that technology choice is participatory and is guided by considerations of scientific evidence, safety, consideration on cost effectiveness and social values. The National Health Policy commits to the development of institutional framework and capacity for Health Technology Assessment and adoption.
Comments: We can combine these aspects with the digital health technology, described in the next section.

23: Digital Health Technology Eco - System: Recognising the integral role of technology(eHealth, mHealth, Cloud, Internet of things, wearables, etc) in the healthcare delivery, a National Digital Health Authority (NDHA) will be set up to regulate, develop and deploy digital health across the continuum of care. The policy advocates extensive deployment of digital tools for improving the efficiency and outcome of the healthcare system. The policy aims at an integrated health information system which serves the needs of all stake-holders and improves efficiency, transparency, and citizen experience. Delivery of better health outcomes in terms of access, quality, affordability, lowering of disease burden and efficient monitoring of health entitlements to citizens, is the goal. Establishing federated national health information architecture, to roll-out and link systems across public and private health providers at State and national levels consistent with Metadata and Data Standards (MDDS) & Electronic Health Record (EHR), will be supported by this policy. The policy suggests exploring the use of “Aadhaar” (Unique ID) for identification. Creation of registries (i.e. patients, provider, service, diseases, document and event) for enhanced public health/big data analytics, creation of health information exchange platform and national health information network, use of National Optical Fibre Network, use of smartphones/tablets for capturing real time data, are key strategies of the National Health Information Architecture.

23.1 Application of Digital Health: The policy advocates scaling of various initiatives in the area of tele-consultation which will entail linking tertiary care institutions (medical colleges) to District and Sub-district hospitals which provide secondary care facilities, for the purpose of specialist consultations. The policy will promote utilization of National Knowledge Network for Tele-education, Tele-CME, Tele-consultations and access to digital library.
23.2 Leveraging Digital Tools for AYUSH: Digital tools would be used for generation and sharing of information about AYUSH services and AYUSH practitioners, for traditional community level healthcare providers and for household level preventive, promotive and curative practices.

Comments: This is a very correct decision and the first job for the proposed NDHA will be to formulate a robust National Digital Health Strategy / Policy, in consultation with all the stakeholders. The first constituents of the Authority will lay down the rules of the game as to how will digital health be adopted in India. The earlier the NDHA is set up and functional, the better it will be for India to avoid a digital health mess in future. Any delay in the process might make us deal with non-interoperable legacy systems, as has been the case in many developed nations. However, cross referrals and sharing disparate information among different systems of medicine may add to the complexity and confusion, ultimately harming the patient. Currently, the MoHFW is seeking comments on the proposed DISHA (Digital Information Security in Healthcare Act) that will be the Bill setting up the NDHA / NeHA.

25. Health Research: The National Health Policy recognizes the key role that health research plays in the development of a nation’s health. In knowledge based sector like health, where advances happen daily, it is important to increase investment in health research.

25.1 Strengthening Knowledge for Health: The policy envisages strengthening the publicly funded health research institutes under the Department of Health Research, the apex public health institutions under the Department of Health & Family Welfare, as well as those in the Government and private medical colleges. The policy supports strengthening health research in India in the following fronts- health systems and services research, medical product innovation (including point of care diagnostics and related technologies and internet of things) and fundamental research in all areas relevant to health- such as Physiology, Biochemistry, Pharmacology, Microbiology, Pathology, Molecular Sciences and Cell Sciences. Policy aims to promote innovation, discovery and translational research on drugs in AUSH and allocate adequate funds towards it. Research on social determinants of health along with neglected health issues such as disability and transgender health will be promoted. For drug and devices discovery and innovation, both from Allopathy and traditional medicines systems would be supported. Creation of a Common Sector Innovation Council for the Health Ministry that brings together various regulatory bodies for drug research, the Department of Pharmaceuticals, the Department of Biotechnology, the Department of Industrial Policy and Promotion, the Department of Science and Technology, etc. would be desirable. Innovative strategies of public financing and careful leveraging of public procurement can help generate the sort of innovations that are required for Indian public health priorities. Drug research on critical diseases such as TB, HIV/AIDS, and Malaria may be incentivized, to address them on priority. For making full use of all research capacity in the nation, grant- in- aid mechanisms which provide extramural funding to research efforts is envisaged to be scaled up.

25.2 Drug Innovation & Discovery: Government policy would be to both stimulate innovation and new drug discovery as required, to meet health needs as well as ensure that new drugs discovered and brought into the market are affordable to those who need them most. Similar policies are required for discovering more affordable, more frugal and appropriate point of care diagnostics as also robust medical equipment for use in our rural and remote areas. Public procurement policies and public investment in priority research areas with greater coordination and convergence between drug research institutions, drug manufacturers and premier medical institutions must also be aligned to drug discovery.

25.3 Development of Information Databases: There is also a need to develop information data-bases on a wide variety of areas that researchers can share. This includes ensuring that all unit data of major publicly funded surveys related to health, are available in public domain in a research friendly format.

25.4 Research Collaboration: The policy on international health and health diplomacy should leverage India’s strength in cost effective innovations in the areas of pharmaceuticals, medical devices, health care delivery and information technology. Additionally leveraging international cooperation, especially involving nations of the Global South, to build domestic institutional capacity in green-field innovation and for knowledge and skill generation could be explored.
Comments: For health research and innovation the government’s role of encouraging Standards for interoperability and allowing open data for analysis will go a long way.
Apart from the NHP-2017, there are certain existing legislations that affects the adoption of digital health in India. The first and foremost is the 2012 Amendments of the Clinical Establishments Act 2010. The other guidance comes from the Constitution of India. Both of these are discussed below.

Clinical Establishments (Registration and Regulation) Act (CEA): In 2012, the MoHFW amended the CEA (2010) and added Clause “9 (iv): the clinical establishments shall maintain and provide Electronic Medical Records (EMR) or Electronic Health Records (EHR) of every patient as may be determined and issued by the Central Government or the State Government as the case may be, from time to time”.
Comments: The Act has taken effect in the four states namely, Arunachal Pradesh, Himachal Pradesh, Mizoram, Sikkim, and all Union Territories since 1st March, 2012 vide Gazette notification dated 28th February, 2012. The states of Uttar Pradesh, Uttarakhand, Rajasthan, Jharkhand, Bihar and Assam have adopted the Act under clause (1) of article 252 of the Constitution. 
The Ministry has notified the National Council for Clinical Establishments and the Clinical Establishments (Central Government) Rules, 2012 under this Act vide Gazette notifications dated 19th March, 2012 and 23rd May, 2012 respectively.

The Act is applicable to all kinds of clinical establishments from the public and private sectors, of all recognized systems of medicine including single doctor clinics. The only exception will be establishments run by the Armed forces.

The good point is the enactment of the necessity for EMR / EHR. The Ministry of Health and Family Welfare has been notifying Standards for EHR since August 2013 and the second edition of the Guidelines were notified in December 2016. That is the right way to move forward. However, Health being a State subject, not all the states are equally keen to adopt it.

Concurrent List: The seventh schedule of the Constitution of India lists “Health” (Public health and sanitation; hospitals and dispensaries) under the Item 6 of List-II (State list). As expected, like the Union ministry, health ministers of various states have also agreed to equipping PHCs and CHCs with latest technology.
Comments: However, as seen in the previous section, the CEA has not yet been adopted by most of the states of India. Therefore, although the CEA mandates EMR / EHR, most of the states are not yet bound to follow it. Since Health is neither in the Union list, nor in the Concurrent list, it may be prudent to include it in the Concurrent list. In that case adoption of digital health would be much smoother.

Conclusions:
While the NHP-2017 is bold in its thoughts and foresight, for facilitating digital health, the ground realities don’t appear to have been considered well enough. Early setting up of a functional NDHA is essential for India to avoid a digital health mess in future. Inordinate delays might make us deal with non-interoperable legacy systems. The first job for the proposed NDHA will be to formulate a robust National Digital Health Strategy / Policy, in consultation with all the stakeholders. Caution needs to be exercised before cross referrals and sharing disparate information among different systems of medicine. Health informatics education must be embedded as an integral part for health and hospital management. Since Health is neither in the Union list, nor in the Concurrent list of the Constitution of India, it may be prudent to include it in the Concurrent list. In that case adoption of digital health would be much smoother. Seeking comments on the Draft Bill DISHA (Digital Information Security in Healthcare Act) is a good start.

References:
  1. Ministry of Health and Family Welfare, Government of India, National Health Policy 2017: https://www.nhp.gov.in//NHPfiles/national_health_policy_2017.pdf (Accessed 19th February 2018)
  2. Ministry of Health and Family Welfare, Government of India. Situation Analyses: Backdrop to the National Health Policy – 2017, New Delhi. Available from : https://mohfw.gov.in/sites/default/files/71275472221489753307.pdf
  3. Sundararaman T, National Health Policy 2017: A Cautions Welcome, Indian J Med Ethics. 2017 Apr-Jun;2(2):69-71
  4. Sarbadhikari SN. A farce called the National Board of Examinations. Indian J Med Ethics. 2010 Jan-Mar;7(1):20-2
  5. Thomas G, Medical education in India – the way forward, Indian J Med Ethics. 2016 Oct-Dec;1(4):200
  6.  Government of India, The Gazette of India, dated 31/01/2017: http://www.cdsco.nic.in/writereaddata/Medical%20Device%20Rule%20gsr78E(1).pdf (Accessed 19th February 2018)
  7. Government of India, The Gazette of India, dated 19/8/2010, Clinical Establishments (Registration and Regulation) Act 2010:  http://clinicalestablishments.nic.in/WriteReadData/969.pdf  (Accessed 19th February 2018)
  8. Government of India, The Gazette of India, dated 23/5/2012, Clinical Establishments (Registration and Regulation) Act, (Amendments) 2012:   http://clinicalestablishments.nic.in/WriteReadData/386.pdf (Accessed 19th February 2018)
  9. Ministry of Health and Family Welfare, Government of India.  http://clinicalestablishmentstraining.nic.in/cms/Home.aspx (Accessed 19th February 2018)
  10. National Health Portal, Ministry of Health and Family Welfare, Government of India, EHR Standards: https://www.nhp.gov.in/electronic-health-record-standards-for-india-helpdesk_mty (Accessed 19th February 2018)
  11. Government of India, The Constitution of India  http://lawmin.nic.in/olwing/coi/coi-english/coi-4March2016.pdf  (Accessed 19th February 2018)
  12. Press Information Bureau, Government of India, Shri J P Nadda chairs 12th Conference of the Central Council of Health and Family Welfare to discuss Draft National Health Policy, dated 27/02/2016: http://pib.nic.in/newsite/PrintRelease.aspx?relid=136961 (Accessed 19th February 2018)
  13. Ministry of Health and Family Welfare, Government of India. https://mohfw.gov.in/newshighlights/comments-draft-digital-information-security-health-care-actdisha (Accessed 28th March 2018)
  14. National Health Portal, Ministry of Health and Family Welfare, Government of India, EHR Standards: https://www.nhp.gov.in/ehr-standards-helpdesk_ms (Accessed 28th March 2018)

Thursday, January 11, 2018

The Role of Change Management and Capacity Building for the smooth adoption of Digital Health in India

Digital health electronically connects the points of care so that health information can be shared securely to help deliver safer, better quality healthcare.
The broad scope of Digital Health includes categories such as mobile health (mHealth), health information technology (IT), wearable devices, telehealth and telemedicine, and personalized medicine. Digital health is about electronically connecting the points of care so that health information can be shared securely. This is the first step to understanding how digital health can help deliver safer, better quality healthcare.
Health Information Management (HIM) professionals are well trained in the latest information management technology applications and understand the workflow in any health care provider organization. Health Information Managers are vital to the daily operations management of health information and electronic health records (EHRs). They ensure that Data Quality is maintained, by applying the principles of Change Management and continuous capacity building through education and training. They ensure that the health information and records of a patient are complete, accurate, protected and meet the desired and stipulated medical, legal and ethical standards. Therefore, it must be made mandatory to appoint an adequate number of health information managers, according to the size of the healthcare organization, to ensure safe and smooth adoption of digital health in India, leading to informed healthcare delivery.
These professionals affect the quality of patient information and patient care at every point in the health care delivery cycle. They work on the classification of diseases and treatments to ensure they are standardized for clinical, financial, and legal uses in health care. HIM professionals care for patients by caring for their medical data. This, in turn, leads to informed healthcare delivery, especially when and where the information is translated into actionable outputs.
I have been tracing the evolution of health informatics and health information managers in making healthcare delivery more informed. Further they also show the role of unlearning and relearning in effectively assimilating information for better healthcare delivery.
As the Indian government aims for Universal Health Coverage (UHC), the lack of skilled human resource may prove to be the biggest impediment in its path to achieve targeted goals. Therefore, the model curriculum handbook on health information management has been designed with a focus on performance-based outcomes pertaining to different levels. The learning goals and objectives of the undergraduate and graduate education program are based on the performance expectations. These are articulated as learning goals and learning objectives. Using this framework, students will learn to integrate their knowledge, skills and abilities in a hands-on manner in a professional healthcare setting. These learning goals are divided into nine key areas, though the degree of required involvement may differ across various levels of qualification and professional cadres:

1. Clinical care
2. Communication
3. Membership of a multidisciplinary health team
4. Ethics and accountability at all levels (clinical, professional, personal and social)
5. Commitment to professional excellence
6. Leadership and mentorship
7. Social accountability and responsibility
8. Scientific attitude and scholarship (only at higher level- PhD)
9. Lifelong learning

Among these nine core competencies, the third one (Membership of a multidisciplinary health team) is perhaps the most important. The student will learn to put a high value on effective communication within the team, including transparency about aims, decisions, uncertainty and mistakes. Team-based health care is the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively to accomplish shared goals within and across settings to achieve coordinated, high quality care. Program objectives will aim at making the students being able to:
Ø  Recognize, clearly articulate, understand and support shared goals in the team that reflect patient and family priorities
Ø  Possess distinct roles within the team; to have clear expectations for each member’s functions, responsibilities, and accountabilities, which in turn optimizes the team’s efficiency and makes it possible for them to use division of labor advantageously, and accomplish more than the sum of its parts
Ø  Develop mutual trust within the team to create strong norms of reciprocity and greater opportunities for shared achievement
Ø  Communicate effectively so that the team prioritizes and continuously refines its communication channels creating an environment of general and specific understanding
Ø  Recognize measurable processes and outcomes, so that the individual and team can agree on and implement reliable and timely feedback on successes and failures in both the team’s functioning and the achievement of their goals. These can then be used to track and improve performance immediately and over time.

As this model curriculum is competency-based, it connects the dots between the ‘know what’ and ‘do how’ for HIM professionals.
The National Health Policy-2017 advocates extensive deployment of digital tools for improving the efficiency and outcome of the healthcare system. The policy aims at an integrated health information platform or system which serves the needs of all stake-holders and improves efficiency, transparency, and citizen experience. Delivery of better health outcomes in terms of access, quality, affordability, lowering of disease burden and efficient monitoring of health entitlements to citizens, is the goal. Establishing federated national health information architecture, to roll-out and link systems across public and private health providers at State and national levels consistent with Metadata and Data Standards (MDDS) and Electronic Health Record (EHR) Standards, will be supported by this policy. The policy suggests exploring the use of “Aadhaar” (Unique ID or UID) for identification. Creation of registries (i.e. patients, provider, service, diseases, document and event) for enhanced public health/big data analytics, creation of health information exchange platform and national health information network, use of National Optical Fiber Network (NOFN), use of smart phones/tablets for capturing real time data, are key strategies of the National Health Information Architecture. The policy advocates scaling of various initiatives in the area of tele-consultation which will entail linking tertiary care institutions (medical colleges) to District and Sub-district hospitals which provide secondary care facilities, for the purpose of specialist consultations. The policy will promote utilization of National Knowledge Network (NKN) for Tele-education, Tele-CME, Tele-consultations and access to digital library.
The National Health Policy 2017 of India states that recognizing the integral role of technology (eHealth, mHealth, Cloud, Internet of Things or IoT, wearables) in the healthcare delivery, a National Digital Health Authority (NDHA) will be set up to regulate, develop and deploy digital health across the continuum of care.
Currently, in the International Institute of Health Management Research, New Delhi,  I am involved in training such professionals through a regular 2-year PGDHM (Post Graduate Diploma in Health and Hospital Management) course that is equivalent to MBA, as per the Association of Indian Universities (AIU), and also through short-term Management Development Programs (MDP) for in-service professionals.
To conclude, HIM professionals are very well trained and suited to ensure that the health information and records (EHRs) of a patient are complete, accurate, protected and meet the desired and stipulated medical, legal and ethical standards. Therefore, it must be made mandatory to appoint an adequate number of health information managers, according to the size of the healthcare organization, to ensure safe and smooth adoption of digital health in India, leading to informed and safer healthcare delivery. 

Saturday, November 4, 2017

How to successfully Implement Digital Health in India

The first chief clinical information officer (CCIO) of NHS England, Keith McNeil, has resigned from his role in August 2017, being barely 13 months in the job. NHS England has now hired Odgers Berndtson to help find a replacement, who should be a "Visionary leader with a track record of leading the development and implementation of national information and data strategies to transform health services." The Health and Care system in England is seeking an outstanding CCIO to lead this exciting agenda, commissioning and delivering data and technology services that will achieve the ambitions of the NHS Five Year Forward View and the Department of Health’s shared delivery plan. The CCIO has to provide clinical leadership to a team of strategy, technology and policy specialists, driving the national information and technology agenda for healthcare delivery.


One of the roles to be played by the CCIO is to chair the National Information Board and to be a member of the Digital Delivery Board, the governance body for the technology investment program, ensuring the effective delivery of information and technology programs and live services across the portfolio.

The basic qualifications, for the post, have to be a registered nurse, medical professional or allied health professional with significant senior clinical experience and a substantial track record of management of multi-disciplinary teams.

The Digital Delivery Board, which replaced the Department of Health’s (DoH) Informatics Portfolio Management Board, is the new governing body for the government’s technology investment program. Former CCIO Keith McNeil was appointed chair of the board in September 2016.


Let us look at similar efforts in India.


The National Health Policy 2017 of India  states that recognizing the integral role of technology (eHealth, mHealth, Cloud, Internet of Things or IoT, wearables) in the healthcare delivery, a National Digital Health Authority (NDHA) will be set up to regulate, develop and deploy digital health across the continuum of care. The first task that the proposed NDHA will need to carry out is the formulation of a robust National Digital Health Strategy, in consultation with all the stakeholders, for smooth adoption of digital health throughout India.

The National Health Policy-2017 advocates extensive deployment of digital tools for improving the efficiency and outcome of the healthcare system. The policy aims at an integrated health information platform or system which serves the needs of all stake-holders and improves efficiency, transparency, and citizen experience. Delivery of better health outcomes in terms of access, quality, affordability, lowering of disease burden and efficient monitoring of health entitlements to citizens, is the goal. Establishing federated national health information architecture, to roll-out and link systems across public and private health providers at State and national levels consistent with Metadata and Data Standards (MDDS) and Electronic Health Record (EHR) Standards, will be supported by this policy.


Hopefully successful and well trained healthcare delivery professionals with clinical, informatics and management skills will be entrusted to lead and coordinate such efforts to usher in Digital Health in India.

Sunday, July 16, 2017

Health Informatics and the Role of Standards for exchanging Health Information


Public health informatics is the systematic application of information and computer science and technology to public health practice, research, and learning (1). It is an interdisciplinary profession that applies mathematics, engineering, information science, and related social sciences (e.g., cognitive psychology and analysis) to public health problems and processes. Public health informatics is a subdomain of the larger field known as biomedical or health informatics. Health informatics is not synonymous with the term health information technology (IT). Though the concept of health IT encompasses the use of technology in the field of health care, health informatics is defining the science, the how and why, behind health IT (2). For example, health IT professionals should be able to resolve infrastructure problems with a network connection, whereas trained public health informaticians should be able to support public health decisions by facilitating the availability of timely, relevant, and high-quality information. Health informaticians should always be able to provide advice on methods for achieving a public health goal faster, better, or at a lower cost by leveraging computer science, information science, or technology. The field covers the art and science of healthcare data and information analytics.

For the adoption and uptake of health information technology and digital health, the technical standards and specifications have to be in place to support this technology and is critical to the development and success of a fully functional nationwide health IT ecosystem. Interoperable health information exchange is not a “one-size-fits-all” solution like many other domains. Different providers will have different uses, and the standards and specifications supporting those needs areusually notified by the respective governments.

In India, the Ministry of Health and Family Welfare had notified the Standards for EHR in August 2013, and the second revised version was notified in December 2016 (4). These guidelines provides a set of
recommendations relevant to adoption of electronic health informatics standards in EHR/EMR and other similar clinical information systems. The scope is limited to identifying the standards, their intended purposes
in such systems, followed by a short guideline for implementation approach. With the adoption of these standards properly,the data capture, storage, view, presentation, and transmission will be standardized to levels that will achieve interoperability of both meaning and data contained in the records.
.While earlier hopes were not fulfilled (5-10), now, with Digital India becoming a reality and the National Digital Authority to be set up as an action item included in the National Health Policy - 2017 (11), the importance of Standards in Health Informatics are being recognized gradually. The industry (12) is also looking forward to the establishment of the NDHA, as proposed in the NHP-2017.

Once the NDHA of India is in place, a robust National Digital Health Strategy / Policy, in consultation with all the stakeholders, will ensure the smooth adoption of Digital Health in India.


References:
1. O'Carroll PW, et al. Public health informatics and information systems, Springer, 2002.
2. Savel TG and Foldy S, The Role of Public Health Informatics in Enhancing Public Health Surveillance
https://www.cdc.gov/mmwr/preview/mmwrhtml/su6103a5.htm (Accessed July 17, 2017)
3.  HealthIT.gov, Standards and Interoperability: https://www.healthit.gov/providers-professionals/standards-interoperability (Accessed July 17, 2017)
4. NHP, EHR Standards Helpdesk: https://www.nhp.gov.in/ehr-standards-helpdesk_ms  (Accessed July 17, 2017)
5.Sarbadhikari SN, Gogia SB. An overview of education and training of medical informatics in India. Yearb Med Inform. 2010:106-8. 
6: Sarbadhikari SN. How to make healthcare delivery in India more "informed". Educ Health (Abingdon). 2010 Aug;23(2):456. Epub 2010 Aug 3.
7. Sarbadhikari SN. Applying health care informatics to improve student learning. Med Educ. 2008 Nov;42(11):1117-8. doi: 10.1111/j.1365-2923.2008.03190.x.
8. Sarbadhikari SN. The state of medical informatics in India: a roadmap foroptimal organization. J Med Syst. 2005 Apr;29(2):125-41.
9. Sarbadhikari SN. Health care delivery--the roads not taken. J Indian MedAssoc. 1995 Sep;93(9):329-30. 
10.  Sarbadhikari SN. Medical informatics--are the doctors ready? J Indian MedAssoc. 1995 May;93(5):165-6.
11. MoHFW,  National Health Policy 2017: https://www.nhp.gov.in//NHPfiles/national_health_policy_2017.pdf (Accessed July 17, 2017)
12. NHP-2017 - Industry gives a thumbs up: https://www.cytecare.com/media/national-health-policy-2017-industry-gives-a-thumps-up (Accessed July 17, 2017)


Saturday, May 6, 2017

Healthcare Professional Education in the 21st Century

We need to radically change the way healthcare professional education is delivered.
Even twenty years back tertiary care hospitals were able to diagnose and treat complicated cases reasonably well, under one roof.
However, now the thrust is on wellness rather than illness. The majority of the patients suffers from NCDs (non-communicable diseases) and need long-term treatment and monitoring from home rather than in a hospital setting.
Information and Communications Technologies (ICT) is already enabling doctors, nurses, and patients to help each other. In the process, it is also facilitating primary care doctors to disrupt specialists, and for nurse practitioners to disrupt doctors.
The second role for ICT in transforming the cost and quality of health care is through the enhancement of medical records from pen and paper based to electronic forms or EMRs – ones that are portable, easily accessible, and interoperable. These can substantially reduce the costly paperwork that burdens today’s caregivers. Further, these will make it easier to avoid costly mistakes, and will enhance the involvement of patients in their own care.
In its most basic form, an electronic medical record (EMR) is simply the electronically stored version of what has always been recorded with pen and paper. However, the ability to customize and focus the personal health records or PHRs on consumer involvement may allow it to overcome many of the hurdles that have slowed the adoption of EMRs.
Unlike the US and Europe, in India, the EHRs have not yet been implemented extensively. That offers a regulatory advantage as the Health Ministry has come out with guidelines for adopting Standards. The National Health Policy 2017 has advocated a facilitating environment:

23. Digital Health Technology Eco – System: Recognising the integral role of technology(eHealth, mHealth, Cloud, Internet of things, wearables, etc) in the healthcare delivery, a National Digital Health Authority (NDHA) will be set up to regulate, develop and deploy digital health across the continuum of care. The policy advocates extensive deployment of digital tools for improving the efficiency and outcome of the healthcare system. The policy aims at an integrated health information system which serves the needs of all stake-holders and improves efficiency, transparency, and citizen experience. Delivery of better health outcomes in terms of access, quality, affordability, lowering of disease burden and efficient monitoring of health entitlements to citizens, is the goal.

The future world in which today’s health professional students will practice will be substantially different from the world for which the medical schools are preparing them. One difference is that many diseases that are in the realms of intuitive and empirical medicine today will have migrated toward the domain of precision medicine in 20 years. Therefore, many diseases will eventually be diagnosed and treated by clinical decision support systems, nurses and physician assistants. Organizing and supervising the work of allied health professionals will be a major dimension of
most of the physicians’ jobs.
Another difference can be perceived between personal versus process expertise. There will always be a need for deeply experienced, intuitively expert physicians to find complicated solutions. Many diseases will go on defying precision medicine, and new diseases will emerge. Today’s methods of preparing medical students to work as individuals is appropriate for those who will work in tertiary care hospital setups — though we will likely need fewer such physicians 30 years from now. But most of the physicians in the future will work in settings where much of the ability to deliver care will be better embedded in processes (clinical workflows) and in (smart) equipment, rather than exclusively resident in individuals’ capacities. Any medical college is yet to establish a health professional course in which students can learn how to design self-improving processes that prevent mistakes from occurring.

References
2.      EHR Standards

Thursday, May 26, 2016

Incorporation of Health Informatics in the curriculum for Healthcare Professionals

The art and science of processing “information” is informatics, where “information” is the processed “data” (anything that is observed and recorded). Just as we get information by “data processing”, using informatics tools, we condense information into “knowledge” that can be applied to real life situations.
When the informatics tools are applied to the “biomedical” field, it is called “biomedical informatics” which is a very broad term encompassing the study and application of computer science, information science, informatics, cognitive science and human-computer interaction in the practice of biological research, biomedical science, medicine and healthcare. Other fields, including bioinformatics (proteomics, genomics, and drug design), clinical informatics (including clinical research informatics), public health informatics and medical informatics (including imaging informatics, nursing informatics, dental informatics, pharmacy informatics, consumer health informatics, healthcare management informatics and veterinary informatics) are commonly counted as sub-domains within biomedical informatics.
Health or Healthcare informatics is an alternative term that has been defined: “If physiology literally means ‘the logic of life’, and pathology is ‘the logic of disease’, then health informatics is the logic of healthcare. It is the rational study of the way we think about patients, and the way that treatments are defined, selected and evolved. It is the study of how clinical knowledge is created, shaped, shared and applied. Ultimately, it is the study of how we organize ourselves to create and run healthcare organizations.”It deals with the resources, devices, and methods necessary for optimizing the acquisition, storage, retrieval, and optimal use of information in health and biomedicine. The health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication technology (ICT).
Biomedical / Health Informatics can be applied to diagnostic procedures, imaging, decision-support systems, patient records, financial and administrative systems, educational systems (for healthcare delivery students, practicing professionals and patients), patient monitoring (e.g., anaesthesia control), and accessing health knowledge.
The National eHealth Authority is in the process of being set up through an Act of Parliament. Under such circumstances, for the smooth adoption of eHealth throughout Digital India, there would be a tremendous requirement for formally trained health informatics professionals in India very soon. It will be prudent to incorporate health informatics as a part and also as a speciality for healthcare professionals in India. Ministry of Health and Family Welfare has notified Standards for Electronic Health Records since August 2013 and India has been a country member of IHTSDO that develops and maintains a terminology standards SNOMED-CT. It is essential to make healthcare professionals at all levels aware of such initiatives and adopt standards for health information exchange.
In the USA, all ABMS (American Board of Medical Specialties) member boards have agreed to allow their diplomates to take the clinical informatics subspecialty examination if they are otherwise eligible. The ABPM (American Board of Preventive Medicine) website provides information about eligibility for the exam and online application.Certification in Clinical Informatics is a joint and equal function of the ABP (American Board of Pathology) and the American Board of Preventive Medicine (ABPM).
CDC, Atlanta, Georgia, USA, offers PHIFP (Public Health Informatics Fellowship Program) as a 2-year, competency-based training program in public health informatics. The fellowship provides a problem-based learning environment in which fellows apply information and computer sciences and information technology to solve public health problems.
They have the opportunity to:
·         learn about informatics and public health in an applied setting
·         work with teams involved in research and development of public health information systems
·         lead an informatics project
·         design, develop, implement, evaluate, and manage public health information systems
References:
1.       Sarbadhikari SN, Medical Informatics: A Key Tool to Support Clinical Research and Evidence-based Medical Practice (Ch 15), In, Babu AN, Ed, Clinical Research Methodology and Evidence-based Medicine, 2nd Ed, 2015: 179-191.
2.       Abdel-Hamid T, Ankel F,…Sarbadhikari SN, et al, Public and health professionals’ misconceptions about the dynamics of body weight gain/loss, Syst. Dyn. Rev. 30, 2014: 58–74
3.       Ahmed Z, Sarbadhikari SN, et al., Using online social networks for increasing health literacy on oral health, Intl. J User Driven Health, 2013, 3: 51-58.
4.       Karishma SH,…, and Sarbadhikari SN, Creating Awareness for Using a Wiki to Promote Collaborative Health Professional Education, Intl. J User Driven Health, 2012, 2:18-28.
5.       Sarbadhikari SN, Unlearning and relearning in online health education, (Ch 21) In, Biswas R, and Martin C M, Ed, User Driven Healthcare and Narrative Medicine, IGI Global, Hershey, USA, 2011: 294 – 309.
6.       Sarbadhikari SN, How to Make Healthcare Delivery in India More “Informed”, Education for Health, Volume 23(2), August 2010: 456.
7.       Sarbadhikari SN and Gogia SB, An Overview of Education and Training of Medical Informatics in India, IMIA Yearbook of Medical Informatics, 2010: 106-108.
8.       Sarbadhikari SN, Applying health care informatics to improve student learning, Really Good Stuff, Medical Education, 2008; 42: 1117–1118.
9.       Sarbadhikari SN, How to design an effective e-learning course for medical education, Indian Journal of Medical Informatics. 2008; 3(1): 3: http://ijmi.org/index.php/ijmi/article/view/y08i1a3/15
10.    Sarbadhikari SN, The State of Medical Informatics in India: A Roadmap for optimal organization, J. Medical Systems, 2005, 29: 125-141.
11.    Sarbadhikari SN, Basic Medical Education must include Medical Informatics, Indian J Physiol. Pharamcol., 2004, 48(4): 395-408.
12.    Sarbadhikari SN, Guest Editorial on “Medical Informatics — Are the Doctors Ready?”,J.Indian Med. Assoc. , 1995, 93: 165 – 166.
13.     Mantas J,et al, Recommendations of the International Medical Informatics Association (IMIA) on Education in Biomedical and Health Informatics - 1stRevision, IMIA, 2009
14.     Burnette MH, De Groote SL, Dorsch JL. Medical informatics in the curriculum: development and delivery of an online elective. Journal of the Medical Library Association : JMLA. 2012;100(1):61-63. doi:10.3163/1536-5050.100.1.011.
16.     NHP, EHR Standards helpdesk: http://www.nhp.gov.in/ehr-standards-helpdesk_ms
17.     IHTSDO, SNOMED-CT: http://www.ihtsdo.org/member/india
18.    American Academy of Family Physicians, Recommended Curriculum Guidelines for Family Medicine Residents on Medical Informatics: http://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint288_Informatics.pdf
19.    AMIA, ABPM, ABP, Clinical Informatics Subspecialty Board Examination: https://www.amia.org/clinical-informatics-board-review-course/board-exam
20. CDC, Public Health Informatics Fellowship Program:http://www.cdc.gov/PHIFP/