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/

Monday, November 16, 2015

Workshop on e-Learning for Health Professional Education

Here is a sample outlay:

Time
Activity
Logistics
13.30 to 15.00
Demonstration of some e-Learning platforms, followed by    activities on
      (a)  How to design an online Course?
      (b)  State the principles used

Laptop, LCD projector, Internet connectivity

Group Activity on flip charts
15.00 to 16.00  
Defining Netiquette, followed by activities on
     (a)  How to facilitate learning?
     (b)  How to enforce Netiquette?
Laptop, LCD projector, Internet connectivity

Group Activity on flip charts
16.00 to 17.00
Asking participants to look at the sample online discussions, then asking them to list the advantages and disadvantages of online discussion forums
Q&A Session for clearing doubts
Laptop, LCD projector, Internet connectivity

Group Activity on flip charts


Some platforms:
1. Moodle: https://moodle.org/
https://docs.moodle.org/29/en/Main_page
2. https://en.wikipedia.org/wiki/List_of_learning_management_systems

Examples of an online presentations:
1. http://www.pitt.edu/~super1/lecture/lec35331/
2. http://www.pitt.edu/~super1/lecture/lec43331/index.htm
3. Links to presntations in Youtube: https://sites.google.com/site/supten/

ADDIE Model: https://elearning.net/addie-instructional-design-model-overview-2/

Netiquette:
1. http://www.ncbi.nlm.nih.gov/pubmed/17425016
2. http://www.ncbi.nlm.nih.gov/pubmed/17614893

Some examples of online interactions:
1. http://www.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=1066
2. http://www.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=1732


Wednesday, March 18, 2015

Stakeholder Consultations for NeHA Concept Note

India is planning to move towards “Digital India” and Technology for Health – e-Healthcare is mentioned in the proposed 5th Pillar of eKranti. The stress is on pan-India healthcare information exchange and services, like online medical consultation and medicine supply with a focus on electronic health / medical records (EHR / EMR).
The Ministry of Health and Family Welfare (MoHFW), Government of India, had notified the Guidelines for EHR Standards in September 2013, and had also become a Country Member of IHTSDO for using SNOMED-CT (a global standard for medical vocabulary) in April 2014. However, India is yet to have a National eHealth Strategy or Policy.

Currently the MoHFW is in the process of setting up the National eHealth Authority (NeHA). Once the NeHA is set up, the first priority for it should be to formulate a National eHealth Strategy or Policy, in consultation with all the stakeholders – the general public, state governments, healthcare providers, health information technology vendors, and academicians. It will be prudent to have a robust National eHealth Strategy to facilitate smooth adoption of eHealth in India. Presently (by 20th April 2015) the MoHFW is inviting comments from all the stakeholders on the Concept Note of NeHA. Let us hope that everyone sends in adequate inputs to formalize the concept and to quickly make the NeHA a necessary and useful reality. The earlier the NeHA is set up, the better it will be for integrating the diverse ICT efforts (by the Central and State governments, as well as the various private players) for delivering healthcare to all.
UPDATES (AUG 2017):

The MoHFW has come out with the second edition of the EHR Standards in December 2016: https://www.nhp.gov.in/NHPfiles/EHR-Standards-2016-MoHFW.pdf
Also, The National Digital Health Authority of India Act 2017 is being drafted and is likely to be placed soon in the public domain for comments.



Thursday, December 11, 2014

Proper way to implement ICT tools for the National Health Assurance Mission (NHAM)


What practical steps can a country take to begin to develop a NeSF (National eHealth Standards Framework) that supports health care delivery and UHC initiatives? The following are recommended by Ritz, Althauser and Wilson [2014] as useful, actionable steps:

1. Storyboard: Develop a set of characteristic user stories that illustrate both the care workflows and the health insurance workflows common to the country. These stories should be aligned with the country’s health strategic goals (e.g., if improving maternal health outcomes is a strategic goal for the health ministry, draft stories describing maternal care delivery activities).

2. Stack: Based on the requirements and the constraints in the country, choose a “stack of standards.” [MoHFW, Government of India has already notified the Standards for EHR in India in August 2013. The National Health Portal also offers a Help Desk for that.]

3. Scope: Narrow the initial implementation scope and grow the scope over time. Any country embarking on a national-scale eHealth infrastructure effort will be well served by focusing on a few key areas. [A “crawl, walk, run” strategy “from the essential to the optimal” is more practical.]

Keeping the above recommendations in mind, India needs to incorporate the NeSF within its National eHealth Strategy / Policy (NeHS/NeHP) that has to be formulated by the Proposed National eHealth Authority (NeHA). It will be good if the NeHA is set up immediately so that the NeHS/NeHP for India can be outlined, in consultation with all the stakeholders, especially the state governments, as Health is a State subject in India. India’s NeHS/NeHP has to be aligned with the National Health Policy, Digital India initiatives, as well as the proposed National Health Assurance Mission (NHAM) policies, so that a focused and judicious use of ICT can make the healthcare delivery systems more efficient and transparent. It will be good to build the ICT policies of NHAM upon the existing ICT mechanisms of the National Health Mission (NHM) and the Rashtriya Swasthya Bima Yojana (RSBY) instead of reinventing the wheels.