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)