Sunday, March 29, 2020

Terminology Standards for Health Information Exchange in the times of SARS-Cov2


To provide better and cost effective patient care, one needs to exchange healthcare information. For this to happen seamlessly, there is a dire need of Standards that facilitate this interoperability.

A Standard denotes the ability of two or more systems or components to exchange information (structural or syntactic interoperability) and to (meaningfully) use the information that has been exchanged (functional or semantic interoperability).

The EHR Standards, 2nd edition, were notified by the Ministry of Health and Family Welfare, Government of India (MoHFW) in December 2016.

Subsequently, to give a boost to implementation of digital health in India, the National Digital Health Blueprint (NDHB) has been finally notified, and it also mentions a minimal set of standards to be used. It tries to define the standards required for ensuring interoperability within the National Digital Health Eco-system.

Also, now the Telemedicine Practice Guidelines have been notified by the MoHFW and NITI Aayog.

Categories of Standards for exchange of Health Information
The broad categories for Standards mentioned in the NDHB are those for Consent, (Clinical) Content, Privacy and Security, Patient Safety and Data Quality.

Currently for epidemiological purposes, all countries send reports to the WHO using the ICD classification system (current version is ICD-10, while ICD-11 has been formally released last year and will be applicable from January 2022). However, for getting better insights into the clinical data, SNOMED CT (a clinical terminology system) is the globally preferred standard and India has been a country member of SNOMED International since 2014. The basic differences of these two systems are summarized below.

     ICD (International Statistical Classification of Diseases) codes, from the WHO, have limited scope and granularity, summarizes and aggregates data into broad categories (for epidemiological purposes), and are mono-hierarchical (Each code is grouped into a single grouping) –
        No links to body sites or causes
        Groups multiple clinical meanings  together using a single code
        Does not always represent sufficient detail for clinical purposes

      SNOMED CT is broader in scope, more granular, allows data to be grouped and aggregated in different ways (poly-hierarchical), and to be queried, based on Relationships between the Concepts. Also, since it is inherently logical, developing Clinical Decision Support Systems (CDSS) is also relatively easier with SNOMED-CT enabled systems.

Presently mappings are available from to SNOMED CT to ICD-10 and its various adaptations. Therefore, if any system is SNOMED CT enabled, it is possible to report according to ICD-10 or 11 as may be the statutory requirement for epidemiological and public health purposes.

Updating for SARS-Cov2

Now, with the world being gripped by a new Pandemic, the SDOs (Standards Development Organizations) have also geared up and come up with pertinent standards for this novel Corona virus or Covid-19 (Corona virus Disease 2019) or SARS-Cov2 (Severe Acute Respiratory Syndrome Coronavirus-2). The World Health Organization (WHO) has named the syndrome caused by this coronavirus “COVID-19”, and the International Committee on Taxonomy of Viruses (ICTV) has named the virus SARS-CoV-2.

The COVID-19 disease outbreak has been declared a public health emergency of international concern. The WHO has included it into the ICD system:
o    An emergency ICD-10 code of ‘U07.1 COVID-19, virus identified’ is assigned to a disease diagnosis of COVID-19 confirmed by laboratory testing.
o    An emergency ICD-10 code of ‘U07.2 COVID-19, virus not identified’ is assigned to a clinical or epidemiological diagnosis of COVID-19 where laboratory confirmation is inconclusive or not available.
o    Both U07.1 and U07.2 may be used for mortality coding as cause of death
o    In ICD-11, the code for the confirmed diagnosis of COVID-19 is RA01.0 and the code for the clinical diagnosis (suspected or probable) of COVID-19 is RA01.1.

A more detailed breakup for ICD-10 is available at: https://www.who.int/classifications/icd/COVID-19-coding-icd10.pdf?ua=1

SNOMED International has come out by placing the concept under the parent Human Coronavirus (Organism): Severe acute respiratory syndrome coronavirus 2 (organism) – SCTID: 840533007

840533007 | Severe acute respiratory syndrome coronavirus 2 (organism) |
  en   Severe acute respiratory syndrome coronavirus 2 (organism)
  en   2019-nCoV
  en   Severe acute respiratory syndrome coronavirus 2
  en   SARS-CoV-2
  en   2019 novel coronavirus

And, under Coronavirus infection (Disorder): Disease caused by severe acute respiratory syndrome coronavirus 2 (disorder) – SCTID: 840539006
840539006 | Disease caused by severe acute respiratory syndrome coronavirus 2 (disorder) |
  en   Disease caused by severe acute respiratory syndrome coronavirus 2
  en   COVID-19
  en   Disease caused by 2019 novel coronavirus
  en   Disease caused by 2019-nCoV
  en   Disease caused by severe acute respiratory syndrome coronavirus 2 (disorder)

The Regenstrief Institute that develops the LOINC codes, is developing Special Use codes in response to an urgent or emergent situation. These codes are based on the most up to date information available at the time of their creation. They have undergone the normal QA terminology process. LOINC supports their use in the unique situation that resulted in their rapid creation. However, be aware that downstream users may not be ready to handle prerelease codes until they are published in an official release. The emerging codes for Covid-19 are available at: https://loinc.org/sars-coronavirus-2/

Conclusion

The pandemic of SARS-Cov2 is evolving, and, so are the Standards related to the exchange of health information because of the disorder and / or organism. Once the situation stabilizes a bit, the unambiguity in the semantic exchange of such information will also become clear.

References
  1. .      National Health Portal, Ministry of Health and Family Welfare, Government of India, EHR Standards. Available from: https://www.nhp.gov.in/ehr-standards-helpdesk_ms
  2. .      Ministry of Health and Family Welfare, Government of India, National Digital Health Blueprint, 2019, Available from: https://main.mohfw.gov.in/sites/default/files/Final%20NDHB%20report_0.pdf (A compressed version is available at: https://main.mohfw.gov.in/sites/default/files/Final%20Report%20-%20Lite%20Version.pdf )
  3. .      Ministry of Health and Family Welfare, Government of India, Telemedicine Practice Guidelines: https://www.mohfw.gov.in/pdf/Telemedicine.pdf
  4. .      Sarbadhikari SN, The Role of Standards for Digital Health and Health Information Management, JBCR, 2019, 6(1):1: https://jbcr.net.in/JBCR-VOL-6-issue-1-2019-20/current-issues-volume-VI-issue-1-1.html

  1. Sarbadhikari SN, Digital Health in India - as envisaged by the National Health Policy (2017), Guest Editorial, BLDE University Journal of Health Sciences, 2019, 4: 1-6.
  2. SNOMED International, SNOMED CT Basics: https://confluence.ihtsdotools.org/display/DOCSTART/4.+SNOMED+CT+Basics
  3. WHO, ICD-10: https://www.who.int/classifications/icd/covid19/en/
  4. SNOMED International: http://www.snomed.org/news-and-events/articles/snomed-loinc-coronavirus-collaboration
  5. SNOMED International: https://browser.ihtsdotools.org/
  6. Regenstrief Institute, LOINC codes: https://loinc.org/prerelease/

Sunday, February 9, 2020

Health Data Analytics and clinical terminology systems like SNOMED CT

Healthcare, with its inherent complexity, deals with large volumes of data coming in. Well designed and used EMRs (Electronic Medical Records) can collect huge amounts of data. However, neither the volume nor the velocity of data in traditional modern healthcare may qualify as big data now. Only a small fraction of the tables in an EMR database may be relevant to the current practice of medicine and its corresponding analytics use cases.

Certainly there will be variety in the data, but most of the EMR systems collect very similar data objects and models. However, new use cases supporting genomics and Internet of Medical Things (IoMT) will certainly require a big data approach.

Healthcare (data) analytics describes healthcare analysis activities that can be undertaken as a result of data collected from four areas within healthcare:

  • Claims and cost data
  • Pharmaceutical and research and development (R&D) data
  • Clinical data (collected from electronic medical records (EMRs))
  • Patient behavior and sentiment data (patient behaviors and preferences)

In health information management (HIM) — and in coding, specifically — the HIM professional must understand the importance of their role in interpreting and abstracting the data to be collected and analyzed. In other words, (health) data literacy is essential. While this data is used primarily in reimbursement and claims activities, it also plays a much larger role in clinical data analysis performed in facilities for quality of care reporting, disease management, and best care practices.

HIM Professionals are implementing coding data analytics to continually monitor their coding teams and cost-justify ongoing educational investments. Coding data analytics is a long-term commitment to improve coding performance for productivity and accuracy.

Elements that impact coding productivity data include: the type of electronic health record (EHR) used, the number of systems accessed during the coding process, clinical documentation improvement (CDI) initiatives, turnaround time (TAT) for physician queries, and the volume of non-coding tasks assigned to coding teams.

Accuracy should never be compromised for productivity. That may lead to denied claims, payer scrutiny, reimbursement issues, and other negative financial impacts. Instead, a careful balance between coding productivity and accuracy is considered best practice. Both data sets must be assessed simultaneously. The most common way to collect coding accuracy data is through coding audits and a thorough analysis of coding denials.

The fully-electronic 11th edition of the International Statistical Classification of Diseases (ICD-11) from World Health Organization (WHO) contains (epidemiological or morbidity and mortality causes) 55,000 codes, compared to the 14,400 in ICD-10.

SNOMED CT (India is a member of SNOMED CT and therefore it is available for use by anyone in India, free of cost) from SNOMED International contains 311,000 clinical concepts (including anatomical sites, disease diagnosis and procedures), with their descriptions, and more importantly, poly-hierarchical relationships.

To quote SNOMED CT:
"SNOMED CT is a clinically validated, semantically rich, controlled terminology designed to enable effective representation of clinical information. SNOMED CT is widely recognized as the leading global clinical terminology for use in Electronic Health Records (EHRs). SNOMED CT enables the full benefits of EHRs to be achieved by supporting both clinical data capture, and the effective retrieval and reuse of clinical information.

The term 'analytics' is used to describe the discovery of meaningful information from healthcare data. Analytics may be used to describe, predict or improve clinical and business performance, and to recommend action or guide decision making.

Using SNOMED CT to support analytics services can enable a range of benefits, including:

  • Enhancing the care of individual patients by supporting:
    • Retrieval of appropriate information for clinical care
    • Guideline and decision support integration
    • Retrospective searches for patterns requiring follow-up
  • Enhancing the care of populations by supporting:
    • Epidemiology monitoring and reporting
    • Research into the causes and management of diseases
    • Identification of patient groups for clinical research or specialized healthcare programs
  • Providing cost-effective delivery of care by supporting:
    • Guidelines to minimize risk of costly errors
    • Reducing duplication of investigations and interventions
    • Auditing the delivery of clinical services
    • Planning service delivery based on emerging health trends

SNOMED CT has a number of features, which makes it uniquely capable of supporting a range of powerful analytics functions. These features enable clinical records to be queried by:

  • Grouping detailed clinical concepts together into broader categories (at various levels of detail);
  • Using the formal meaning of the clinical information recorded;
  • Testing for membership of predefined subsets of clinical concepts; and
  • Using terms from the clinician's local dialect.

SNOMED CT also enables:

  • Clinical queries over heterogeneous data (using SNOMED CT as a common reference terminology to which different code systems can be mapped);
  • Analysis of patient records containing no original SNOMED CT content (e.g. free text);
  • Powerful logic-based inferencing using Description Logic reasoners;
  • Linking clinical concepts recorded in a health record to clinical guidelines and rules for clinical decision support; and
  • Mapping to classifications, such as ICD-9 or ICD-10, to utilize the additional features that these provide.

Analytics tasks, which may be enabled or enhanced by the use of SNOMED CT techniques, can be considered in three broad categories:

  1. Point-of-care analytics, which benefits individual patients and clinicians. This includes historical summaries, decision support and reporting.
  2. Population-based analytics, which benefits populations. This includes trend analysis, public health surveillance, pharmacovigilance, care delivery audits and healthcare service planning, and
  3. Clinical research, which is used to improve clinical assessment and treatment guidelines. This includes identification of clinical trial candidates, predictive medicine and semantic searching of clinical knowledge. 

While the use of SNOMED CT for analytics does not dictate a particular data architecture, there are a few key options to consider, including:

  • Analytics directly over patient records;
  • Analytics over data exported to a data warehouse;
  • Analytics over a Virtual Health Record (VHR);
  • Analytics using distributed storage and processing; and
  • A combination of the above approaches.

Practically all analytical processes are driven by database queries. To get the most benefit from using SNOMED CT in patient records, record-based queries and terminology-based queries must work together to perform integrated queries over SNOMED CT enabled data. To this end, SNOMED International is developing a consistent family of languages to support a variety of ways in which SNOMED CT is used. Clinical user interfaces can also be designed to harness the capabilities of SNOMED CT, and to make powerful clinical querying more accessible. Innovative data visualization and analysis tools are becoming more widespread as the capabilities of SNOMED CT content are increasingly utilized."

Therefore, now it is possible to make every kind of analytics and reporting results much more detailed than it used to be. Billing and coding companies that have adopted predictive analysis tools have received a considerably higher value return from mining their data.

HIM professionals must encourage the administration and policymakers to adopt SNOMED-CT enabled systems to get better informed and analyzed outcomes.

References:

1. https://www.healthcatalyst.com/big-data-in-healthcare-made-simple
2. https://www.healthcareittoday.com/2017/11/15/opening-the-door-to-data-analytics-in-medical-coding-him-scene/
3. https://www.osplabs.com/insights/data-mining-in-medical-coding-and-billing/
4. https://bok.ahima.org/doc?oid=302591#.Xj-2xvkzbDc
5. https://confluence.ihtsdotools.org/display/DOCANLYT/Data+Analytics+with+SNOMED+CT
6. https://confluence.ihtsdotools.org/display/DOC
7. https://jbcr.net.in/JBCR-VOL-6-issue-1-2019-20/current-issues-volume-VI-issue-1-1.html
8. https://www.healthcatalyst.com/the-case-for-healthcare-data-literacy
9. https://nnlm.gov/data/guides/data-literacy/course-materials
10. https://confluence.ihtsdotools.org/display/DOCANLYT/1+Executive+Summary

Tuesday, June 4, 2019

Professional Education for Digital Health


The term digital health is rooted in eHealth, which is defined as “the use of information and communications technology in support of health and health-related fields”. Mobile health (mHealth) is a subset of eHealth and is defined as “the use of mobile wireless technologies for public health”.
The newly proposed Global Strategy for Digital Health from the WHO is trying to define Digital Health as “the field of knowledge and practice associated with any aspect of adopting digital technologies to improve health, from inception to operation.”
Digital health interventions are applied within a country context and a health system, and their implementation is made possible by a number of factors. These include:

     (i)            the health domain area and associated content;
   (ii)            the digital intervention itself (i.e. the functionality provided);
 (iii)            the hardware, software and communication channels for delivering the digital health intervention; and, mediated within
 (iv)            a foundational layer of the ICT and enabling environment, characterized by the country infrastructure, leadership and governance, strategy and investment, legislation and policy compliance, workforce, standards and interoperability, and common services and other applications.

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). Also, Health informatics education must be embedded as an integral part for health and hospital management. That will ensure a smooth adoption of digital health in India. India will then be recognized as a significant global player in digital health.
India has hosted the 4th Global Digital Health Partnership Summit and the International Digital Health Symposium in the last week of February 2019. This also shows the commitment of India towards strengthening Digital Health Globally. Here the “Delhi Declaration” was adopted to accelerate and implement the appropriate Digital Health interventions to improve health of the population at national and sub-national levels, as appropriate according to national context.

Soon after, on 16th April 2019, the World Health Organization (WHO) has released its recommendations of ten ways that countries can use digital technologies that people can improve their lives and essential services. Therefore, there is an imminent need for people, trained in digital health management, who can confidently handle a multitude of software services and help medical professionals, hospitals, healthcare organizations and common people. Courses on digital health are very new even globally and the career opportunities for early entrants are enormous.

Here I propose a 2-day or 12-hour interactive modular course for initiating health professional educators and administrators to the concepts and practice of digital health. I have been offering this course on-site, with suitable customization according to the needs of the institutes.

Course Objectives and Competencies


References
  1.  Sarbadhikari SN, Sood JM. Gamification for nurturing healthy habits. Natl Med J India 2018; 31: 253-4 / Sarbadhikari SN, Sood JM. Gamification for nurturing healthy habits. Natl Med J India Available from: http://www.nmji.in/text.asp?2018/31/4/253/258236
  2. Sarbadhikari SN, Will Health Informatics gain its rightful place for ushering in Digital India?, Indian Journal of Community Medicine, 2018, 43 (2): 126–127.
  3. Sarbadhikari SN & Srinivas M, Health Informatics and Health Information Management, In, Gyani G & Thomas A, Eds, Handbook of Healthcare Quality and Patient Safety, Jaypee, New Delhi, 2nded, 2016, Sec. 4, Ch. 17: 206-216.
  4. 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.
  5. Balsari S, Fortenko A, Blaya JA, Gropper A, Jayaram M, Matthan R, Sahasranam R, Shankar M, Sarbadhikari SN, Bierer BE, Mandl KD, Mehendale S and Khanna T. Re-imagining health data exchange: An API-enabled roadmap for India. J Med Internet Res [Impact Factor 4.7], 2018. doi:10.2196/10725.
  6. Ministry of Health and Family Welfare, Government of India, National Health Policy 2017. Available from: https://www.nhp.gov.in//NHPfiles/national_health_policy_2017.pdf
  7. Sarbadhikari SN. Digital health in India – As envisaged by the National Health Policy (2017). BLDE Univ J Health Sci 2019;4: [In Press]
  8. Sarbadhikari SN. Available from: https://blog.hcitexpert.com/2018/04/how-can-digital-health-be-implemented-in-NHP2017-Prof-Supten-Sarbadhikari.html - republished with permission from: http://supten.blogspot.com/2018/03/how-can-digital-health-be-implemented.html
  9. National Health Portal, Ministry of Health and Family Welfare, Government of India, EHR Standards. Available from: https://www.nhp.gov.in/ehr-standards-helpdesk_ms
  10. Ministry of Health and Family Welfare, Government of India and World Health Organization, India. Available from: https://www.gdhpindia.org/
  11. Global Digital Health Partnership, Delhi Declaration, Available from: https://s3-ap-southeast-2.amazonaws.com/ehq-production-australia/25eb0facd90ee547c03071b005807288dbeac40b/documents/attachments/000/099/429/original/GDHP-Delhi_Declaration_Final.pdf?1551307009
  12. World Health Organization; WHO guidelinerecommendations on digital interventions for health system strengthening. Geneva: 2019. Available from: https://apps.who.int/iris/bitstream/handle/10665/311941/9789241550505-eng.pdf


Saturday, January 19, 2019

“National” in my life!


After completing my +2 from St. Lawrence High School, I got admission to Calcutta National Medical College in 1984. Our classes started on the auspicious occasion of Teachers’ Day viz., 5th September.
During my college years, I was fortunate to become the Senior Class Assistant in Physiology and Junior Class Assistant in OBG. Apart from that I also used to participate and conduct quizzes, and, conduct many perpendicular events during AGON. Along with Anindya Chaudhuri, I had represented our college in the very first Quiz Time (1985) conducted by Siddharth Basu in Door Darshan.
By the time we passed out, by July 1989, and then completed our internship, by July 1990, most of us were sure of our possible future careers.
Although I did house job (junior residency) in General (Internal) Medicine from August 1990 to July 1991, that discipline was my seventh career option! Somehow or other I felt that those twelve months were the best in my life. Later on I penned down that experience in a booklet – “হাসপাতালে একবছর” from মনফিকরা (July 2016).
Psychiatry was higher in my option list so I went to the Central Institute of Psychiatry, Kanke, Ranchi for junior residency during August – September 1991.
However, my topmost option was making a career in medical informatics. Unfortunately, in the early 90s, there was no training available for informatics in India. The foreign institutes that I wrote to wanted me to know the basics of computers. So I was thinking of getting enrolled in NIIT.
Meanwhile, the School of Biomedical Engineering, Institute of Technology, Banaras Hindu University, (then IT-BHU, now IIT-BHU), Varanasi was offering Senior Research Fellowships to MBBS graduates for pursuing PhD in Biomedical Engineering. Fortunately, I was selected to join the institute in October 1991 and got registered for the PhD from the session of March 1992. I could choose my PhD topic related to development of an (artificial neural network based) clinical decision support system for depression.
During this period (March 1992 – March 1995), I once came to visit our Alma Mater and met many of our teachers. One of the teachers whom I met, used to love me a lot, especially since Amit Behl and myself had represented our college twice – in the 4th and 5th years, in the Nestle Pediatric Quiz. He asked me that since now I am pursuing PhD in Biomedical Engineering, what will I do after that? I answered that I don’t know. I was shocked by his response to my answer. Generally a mild spoken person, he got very angry and told me that I should have never chosen a career where the future is uncertain!
I submitted my PhD thesis in March 1995 and was invited to write a Guest Editorial for JIMA (Journal of the Indian Medical Association). I wrote in May 1995 [Vol. 93(5): pp.165-6. PubMed PMID: 8834135] Medical informatics – are the doctors ready?
Meanwhile I joined the Machine Intelligence Unit of Indian Statistical Institute in Calcutta as a Research Associate in a CSIR project under Prof. Sankar K Pal. Subsequently, I also did general practice in Durgapur for about a year and half, while my better half Dr. Anindya was a Medical Officer in CRPF, posted in Durgapur. I did a couple of short term contract jobs with South Eastern Railways and Bankura Sammilani Medical College during 1998-99.
The first formal academic job that I got was in Sikkim Manipal University from January 2000 I had joined as Assistant Professor in Biophysics in the department of Physiology. I was fortunate to teach the first batches of both MBBS (2001-02) and B.Tech (1997-98) – for the latter an elective in the 8th Semester on Neuro-fuzzy computing. I was also the first Coordinator of the Distance Education Directorate there.
From there I joined as the first faculty member (Assistant Professor) of the School of Medical Science and Technology (SMST) in IIT Kharagpur in August 2002. Then I joined the Amrita University, Coimbatore in July 2004 as Associate Professor and started two courses – M.Sc. (Medical Informatics) in 2005 (the first of its kind in India) and M.Tech (BME) in 2007. In 2008 I became the Founding Chair of Biomedical Informatics in PSG Institute of Medical Sciences and Research, Coimbatore. There I started offering online courses on Health Informatics and had more students from abroad than from India.
During 2011-12 I became a Visiting Professor in Health Informatics in Bangladesh, with the support of the Rockefeller Foundation, for starting a Masters Course in Health Informatics there.
From January 2013, I joined as the first Project Director of the Centre for Health Informatics, National Health Portal, under the Ministry of Health and Family Welfare, Government of India. Apart from developing the National Health Portal from scratch, I was also instrumental in coordinating the eHealth activities. I have been a member of the EHR Standards Committee since 2010. I was also the Chairperson for revising the Concept Note on the proposed National eHealth Authority of India. Consequently, the National Health Policy of 2017 clearly mentioned the setting up of the National Digital Health Authority to facilitate the adoption of Digital Health in India. On another note I have also been associated with the inclusion Software as a Medical Device in the Medical Devices Act of 2017. I have also been actively associated with the Bureau of Indian Standards for adopting and developing Standards for Health Informatics and Active Assisted Living. In other words, the “National” of my college is still inspiring me to undertake many activities of “National” importance.
In August 2017, I briefly returned to academics as Dean (Academics and Student Affairs) and Professor (Health Informatics) in the International Institute of Health Management Research, Delhi.
I have been appointed to the Board of Governors of the Washington Medical Science Institute, Saint Lucia, English Caribbean. I am also IMA Honorary Professor (2017-20) and Distinguished Fellow, HITLAB. I am a Fellow and Faculty of PSG-FAIMER Regional Institute, and have been Chair of HL7 India (2011-13), and, President of the Indian Association for Medical Informatics (IAMI – 2016). I’m a Founder Member of HL7 FHIR Foundation.
Now I am an independent consultant on Digital Health Standards and look forward to reinforcing the Digital Health Activities in India and elsewhere.

Monday, July 16, 2018

The Evolving Digital Health Landscape in India

Abstract

The journey of India towards Digital Health had begun in the right earnest, under the initiatives of the then Ministry of Information Technology, during 2002-03, with the publication of the ITIH (Information Technology Infrastructure fro Health). A major thrust has been received through the National Health Policy 2017 (NHP-2017) of India that has correctly identified the need for creating many new institutions like the National Digital Health Authority (NDHA).  The very first job for the proposed NDHA should be to formulate a robust National Digital Health Strategy / Policy, in consultation with all the stakeholders. Health informatics education must be embedded as an integral part for all health professional education, including health and hospital management. That will ensure a smooth adoption of digital health in India.
While the NHP-2017 had talked about setting up the Digital Health Ecosystem by establishing the National Digital Health Authority (NDHA), the proposed Bill, enabling the formation of NDHA, Digital Information Security in Healthcare Act (DISHA) has already sought public comments (Apr '18).
Also, pertinently, WHO, in the 71st World Health Assembly held recently (May '18), has adopted the Digital Health Resolution, initiated by India, thereby underlining the commitment of India towards Digital Health adoption.

Key Words: Digital Health; Digital India; National Health Policy 2017; Implementation; Digital Information Security in Healthcare Act (DISHA)

Twelve Landmark Steps of the Indian DH Landscape:

1. ITIH (Information Technology Infrastructure for Health) Framework published by MIT, GoI: 2003. This document stressed on the three pillars for success – regulatory / legislator framework, Standards and Education (Capacity Building).
2. National Knowledge Commission Recommendations for Digital Health (2009). Here recommendations were made for having a Health Information Network and a National Health Information Authority.
3. Formation of EHR Standards Committee by the Ministry of Health and Family Welfare, Government of India (MoHFW): September 2010. This Committee was the first to bring out comprehensive standards for health information exchange, so that electronic health records (EHRs) can be interoperable right from the beginning.
4. Setting up of the Centre for Health Informatics (National Health Portal): January 2013. This centre was responsible for developing the National Health Portal for the MoHFW and carry out all the eHealth related activities for the MoHFW.
5. 1st Edition of EHR Standards published: August 2013. This was the logical culmination of the work done by the EHR Standards Committee.
6. India takes Country Membership of SNOMED-CT: March 2014. This was a great achievement as India could foresee the importance of Clinical Terminology Systems for the exchange of health information.
7. Publication of the Core Curriculum for Health Information Management (HIM) by MoHFW, GoI: 2015. This was a very significant initiative on the part of MoHFW to develop forward-looking curricula for allied health professionals. The role and career prospects of HIM professionals have been detailed in great outline here.
8. National Level Stakeholder Consultation for the proposed National eHealth Authority: 4th April 2016
9. 2nd Edition of EHR Standards published: December 2016. This was another useful step for updating the Standards recommendations following the advances in Standards, and, also to ensure that SNOMED CT is a recommended standard as India is now a country member for SNOMED CT.
10. National Health Policy (3rd Edition): February 2017. For the first time the National Health Policy of India laid stress on eHealth and Digital Health in a formal way so as to develop a supporting ecosystem.
11. Digital Information Security in Healthcare Act (DISHA) – draft Bill put in public domain inviting comments till 21st April 2018. Currently the comments are being reconciled and the Bill is likely to be placed in the Parliament soon. The very first job for the proposed NDHA should be to formulate a robust National Digital Health Strategy / Policy, in consultation with all the stakeholders. Health informatics education must be embedded as an integral part for all health professional education, including health and hospital management. That will ensure a smooth adoption of digital health in India.
12. The adoption of the global Digital Health Resolution (initiated by India) in the 71st World Health Assembly, Geneva in May 2018. This endorsed the commitment of India towards Digital Health adoption.

Some other related happenings

Another significant achievement in a related area has been Telemedicine, initially propelled by the Department of Space / ISRO through the Edusat during the turn of the millennium. However, this treatise will not elaborate on the Telemedicine / Tele-health aspects of Digital Health. Some of the aspects of telemedicine are mentioned in the MoHFW web site.
The Clinical Establishment Act (2010) has also kept provisions for eHealth. However, health being a State subject in India, many states are yet to adopt and implement the Act.
The Ministry of Electronics and Information Technology (MeITy), Government of India, is pushing the Digital India initiatives, which include – tele-consultation, online pharmacy, and, pan-India health information exchange. The MeITy and the MoHFW have been jointly involved in developing the Integrated Health Information Platform (IHIP).
In a related happening, the Gazette-notified Medical Devices Act 2017 included Software as a Medical Device (SaMD) within its ambit.
Meanwhile, the Bureau of Indian Standards (BIS) has also created a Sectional Committee for Health Informatics (MHD-17). This Committee has been collaborating with the ISO TC 215 (Health Informatics) to adopt relevant ISO Standards for Indian context.

The Adoption of the Digital Health Resolution
The Digital Health Resolution, adopted in the 71st World Health Assembly, held in Geneva in May 2018, paves the path for WHO to establish a global strategy on digital health. The resolution identifies priority areas including those where WHO should focus its efforts and engage member states to optimize their health systems in harmony with the global digital health agenda. The resolution is the first step towards mainstreaming digital interventions in health including big data and its analytics, use of deep machine learning, artificial intelligence, Internet of things (IoT) and other emerging disciplines like genomics.

Conclusions:
While the NHP-2017 is bold in its thoughts and foresight, for facilitating digital health, the ground realities need to be considered in greater details. 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 all health professional education, including health and hospital management. As an initiator of the Digital Health Resolution in the 71st World Health Assembly, India is now well poised to usher in Digital Health smoothly.

References:
Department of Information Technology, Ministry of Communications and Information Technology, Government of India, Information Technology Infrastructure for Health (ITIH), 2003.
National Knowledge Commission: Report to the Nation (21006-2009), https://www.aicte-india.org/downloads/nkc.pdf (Accessed 9th June 2018)
National Health Portal, Ministry of Health and Family Welfare, Government of India, EHR Standards: https://www.nhp.gov.in/ehr-standards-helpdesk_ms (Accessed 9th June 2018)
Sarbadhikari SN, National Health Portal and Centre for Health Informatics, Ch. 4, In, Ganapathy K, Ed, Healthcare Information Technology – The Indian Scenario, NDRF, Bengaluru, 2017: 57 – 67. 
Ministry of Health and Family Welfare, Government of India, Model Curriculum Handbook – Health Information Management, 2015-16:  http://mohfw.nic.in/sites/default/files/Model_Curriculum_Handbook_Health.pdf (Accessed 9th June 2018)
Ministry of Health and Family Welfare, Government of India, National Level Stakeholder Consultation for the proposed National eHealth Authority,  https://www.nhp.gov.in/national-consultation-on-national-ehealth-authority-(neha)_ms 
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 9th June 2018)
Ministry of Health and Family Welfare, Government of India, Draft of Digital Information Security in Healthcare Act (DISHA) )    https://www.nhp.gov.in/NHPfiles/R_4179_1521627488625_0.pdf (Accessed 9th June 2018)
World Health Assembly, Digital Health Resolution (2018): http://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_ACONF1-en.pdf (Accessed 9th June 2018)
Ministry of Health and Family Welfare, Government of India, Telemedicine and Digital Health: https://mohfw.gov.in/about-us/departments/departments-health-and-family-welfare/e-Health%20%26%20Telemedicine (Accessed 9th June 2018)
Ministry of Electronics and Information Technology (MeITy), Government of India, Digital India initiatives: http://www.digitalindia.gov.in/di-initiatives (Accessed 9th June 2018)
Bureau of Indian Standards (BIS), Ministry of Corporate Affairs, Government of India, Health Informatics Sectional Committee, MHD-17: http://www.bis.org.in/sf/mhd/MHD17(12420)_23022018.pdf (Accessed 9th June 2018)
Government of India, The Gazette of India, dated 31/01/2017: http://www.cdsco.nic.in/writereaddata/Medical%20Device%20Rule%20gsr78E(1).pdf (Accessed 9th June 2018)
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 9th June 2018)
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 9th June 2018)

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)