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.

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)

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

1.      The Innovator’s Prescription: A Disruptive Solution for Healthcare

2.      EHR Standards

3.      National Health Policy 2017