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Why National Digital Health Mission (NDHM) is seminal to transforming India’s medical care ecosystem and fighting pandemic emergency situations

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Why NDHM Now?

The recent survey by ICMR on COVID19 situation, records a peculiar observation for Maharashtra, currently the epicenter of COVID19 pandemic– although not entirely unknown– i.e. 70% of COVID19 deaths in Pune and 87% in Maharashtra were due to co-morbidity. With comorbidity — most of it lifestyle diseases like diabetes, hypertension etc that Indians in the past few decades or so have become increasingly prone to— emerging as one of the main causes of mortality in the ongoing COVID-19 pandemic, the importance of a repository holding patients’ health records centrally that can be used to alert the physician to a patient’s medical history at the click of a button would be a huge help.

Migrant population of India especially those moving across locations/cities due to economic and other reasons as well as those wanting to seek second opinion from a doctor could be greatly benefited by allowing the doctor to see the complete diagnosis and previous care provided through sharing / consenting access for the electronic health records (EHRs).

Looking back at how different cities responded to pandemic crisis and the strategies that the successful ones adopted to deal with the situation reveals a big gap that India has on our health and wellness front. India’s Integrated Digital Health Infrastructure is supposed to have two distinct yet interoperable layers—one, the underlying physical infrastructure layer and two, digital /data/ information layer. On physical infrastructure i.e. hospitals, pharmacies, number of doctors, paramedics staff admittedly we do have gaps and there is a massive work afoot to bridge those gaps (e.g. strengthening district hospitals for multi-specialty care. 75 new medical colleges being built adding 15700 new MBBS seats over the next 3 years, Ayushman Bharat health insurance for insuring 50 crore Indians etc). However the biggest gap where even the basic framework is lacking is around the digital/ data / information harnessing layer on top of physical health infrastructure layer. Starting with basics, we don’t yet have a common repository of Indian citizens’ medical records which could be accessed using unique ID from anywhere (with proper access and security protocols) for the quick, efficient and effective diagnostics and medical care. The Govt though NDHM is attempting to build a digital stack on top of physical infrastructure leveraging digital technologies such as cloud, big data, analytics, Block-chain etc. Learnings from the successful experience of COVID19 containment and suppression by Hangzhou, the capital of Zhejiang Province in China using big data and information technology, like QR codes, to track and stop the spread of the corona virus has provided necessary impetus for acceleration of NDHM.

Every patient having a health ID on the lines of AADHAR has been central to the new National Digital Health Mission (NDHM) that Prime Minister Narendra Modi announced from the ramparts of Red Fort in his 15th August independence speech. National Health Mission (NHM) which is primarily about the underlying physical infrastructure has been in discussion since Modi first came to power in 2014 but the recent COVID19 pandemic has starkly brought out the gaps and limitations in the NHM and forced the Govt to prioritize digitization of healthcare system on war footing. The possible and a robust answer to the challenge could be digitization of the entire health care ecosystem to the extent possible, which will essentially be an icing on the cake as far as physical infrastructure like more hospitals, more doctors, cheaper generic medicine stores, health and medical coverage through Ayushman Bharat etc

What are the Key Ecosystem Building Blocks for NDHM?

As per GOI 2017 National Health Policy (NHP), different building blocks have been identified for creating a National Health stack. A few fundamental components are as below:

National Digital Health ID: every Indian citizen will have a unique Digital Health ID, which will be on the lines of AADHAR ID (AADHAR linkage will be necessary for the people availing Govt scheme related benefits) and uniquely identify the individual. This unique patient ID will not only help save costs and time on the redundant testing for the individuals by way of having all health records tied to it but also help migrant’s workers and those availing Ayushman Bharat scheme who need to travel to different cities for work and other economic reasons. The health ID for every Indian citizen will work as their health account.
The citizen’s health ID will enable rule based access to comprehensive database of the individual’s medical records from anywhere in the world. This will of course be preceded by proper validation, access control and consent mechanism by the citizen to the user. The health ID would enable access to every test, disease and diagnosis, and medical reports together with medicine details in it for an individual.
The mission has been rolled out on pilot mode in six Union Territories. Chandigarh has already enrolled 4000 citizens and is moving ahead with full enrollment targets.

National Health Registry (NHR): This is a common register with two separate modules: the register for provider of health services and register for consumer of health services. The registry will hold an authentic, standardized and updated geo-spatial data of all public and private healthcare. The Indian Space Research Organisation (ISRO) is the project technology partner for providing data security. Govt estimates that more than 20 lakh healthcare establishments such as hospitals, individual doctors, clinics, diagnostic labs, pharmacies and nursing homes would be enumerated from the provider side.
This resource repository shall also be leveraged by public health professionals and policy makers to assess trends and enable advanced research towards ongoing and forthcoming healthcare challenges arising from other determinants of health such as disease and the environment. Approximately 4,000 trained professionals have been engaged to approach every healthcare establishment to collect information. This repository for the first time will bring providers and consumers of the health services on the same platform.

Online Pharmacy
An online pharmacy, is a pharmacy that operates over the Internet and sends orders to customers through their logistics partners i.e. mail, shipping companies, or online pharmacy web portal. Although the draft guidelines for online pharmacies have been created by the Govt, they have still not being released and hence there is a haziness on when e-Pharmacy Rules will get finalized. This is one of the impediments in the sector attracting investments and innovations. For the success of NDHM, the Govt will have to address this issue on priority. From an online pharmacy platform perspective (e.g. Netmeds, now owned by Reliance), the customer journey goes as below:

Customers (patients) get their e-prescriptions uploaded to central patients records databases, and are able to order fulfillment online (via web or app), either for home delivery or for pickup at a nearby pharmacy via click & collect.

There are 3 different models which are likely to emerge/have emerged in online pharmacy
1) Customers browse about the product online but buys it via brick and mortar stores 2) Customers browse the product online, order online but pick up from nearby brick and mortar store 3) Customers browse the product online, order online and receive the home delivery of the products via logistic partner of the pharmacy.
Full integration of generic drug stores (Jan aushadhalaya-the low cost generic medicine pharmacies started by GOI) into NDHM will need to be undertaken on priority.

Coverage and Claims Platform (CnCP):
CnCP provides the building blocks required to implement any large-scale health insurance program, in particular, any government-funded healthcare programs. The single biggest problem with the current healthcare services in India pertains to coverage and claims procedures. More so with Ayushman Bharat scheme additional 50 crore citizens have been enrolled for health insurance. Normally it takes anything between average 3-4 hours for completing paperwork of a simple claim and more than that for a complex claim in hospitals. Besides involvement of the multiple entities (patients, insurance co, third party administrators (TPAs) and hospital), the process is also complicated due to lack of automation wherein the patient and their relatives are expected to furnish every bill, every invoice in a manual manner. 50 crore Indians who are already a part of Ayushman Bharat would be hugely benefited by this platform. But for 80 crore Indian who are outside Ayushman Bharat will need their Insurance services provides and TPAs seamlessly integrated (though open APIs) with the

Digital Health Stack. This would also necessitate an efficient and effective fraud management system a la Income Tax department.

Centralized Health Records & Analytics Framework

Aimed to bring a holistic view combining information on multiple health initiatives (including apps like Aarogya Setu) and feed into smart policy making, for instance, through improved predictive analytics; Heath analytics is expected to provide decision support to stakeholders on multiple “themes”, like quality of care and quality of data, by analyzing aggregated data from providers.
The framework design must ensure that analytics data is collected or created at the source i.e. when a medical record is being prepared for the EHR. o Analytics data can be aggregated by using either a subscription model or a push model where the data is sent mandatorily to one or more government controlled analytics systems.

NDHM Operating Model and Nodal Agency:

The National Health Authority (NHA), the apex agency responsible for the implementation of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (ABPMJAY), has been given the mandate by the govt. to plan, design, build, and roll-out and implement the NDHM within the country.

A new entity, National Digital Health Mission (NDHM), will be charged with the responsibility of implementation.

The core building blocks of NDHM such as Health ID, Digi-Doctor and Health Facility Registry shall be owned, operated and maintained by the Government of India. Private stakeholders will have an equal opportunity to integrate with these building blocks and create their own products for the market.

NDHM will be a government owned body, so as to ensure control within central and state governments o It will have two arms – one for policy & regulation, and another for operations & service delivery

Key components of NDHM Operating Model

National Health Electronic Registries: Electronic registries will hold a single source of truth for all patients’ health data and manage master health data of the nation.

A Federated Personal Health Records (PHR) Framework: to solve twin challenges of access to their own health data by patients and to healthcare service providers for treatment, and availability of health data for medical research – critical for advancing our understanding of human health.

A National Health Analytics Platform: health analytics platform is expected to generate a holistic view combining information on multiple health initiatives, derive trends and feed into smart policy making, for instance, through improved predictive analytics.

Other Horizontal Components: Including, and not restricted to, Unique Digital Health ID, Health Data Dictionaries and Supply Chain Management for Drugs, payment gateways. Shared across all health programs.

The services offered by NDHM can be categorized as

 Client/Patient services- These include secure health ID for all Indian citizen, personal health record, national health portal etc

 Services for healthcare providers. These include summary care records, digital pharmacy and pharmacy supply chain, digital diagnostics, hospital digitization

 Technical services includes data and cyber security, information governance, defining service standards etc

Applications Building Block

Following Public/Government Apps such as Reproductive and Child Health (RCH), NIKSHAY (Online TB Patients monitoring application), e-Raktkosh, Health Management Information System (HMIS), among others are expected form a key part of building block applications. Telemedicine ought to be given a high priority given the low Doctor-Population ratio, especially in rural areas.

Private health apps such as Hospital Management System applications, claims applications currently being used by various service providers will be an integral part of the application stack. Open Source Products for their flexibility, adaptability and cost advantages will be expected to be leveraged for the sharing of real-time patient data among the members of the medical/surgical/nursing teams for delivery of tertiary care

Benefits, Limitations and Way Forward

Through this mission GOI is aiming to achieve following:
 Easy accessibility of data/information to all the participants: The platform will be available in the form of an app and website and hence easily accessible to the participants

 Re-engineered processes with higher degree of automation leading to shorter turnaround times/cycle times and better customer experience

 Coverage and cost: With seamless integration of systems and data hub creation, NDHM aims to significantly improve operational efficiency, coverage, cost and customer experience for all the stakeholders/participants

 NDHM has proposed the creation of a National Health Stack to make both personal health records and service provider records available on cloudbased services using the internet. It has been designed along the lines of India Stack where a set of cloud-based cashless services like digital payments can use application programme interfaces or APIs to transfer information through the system.

 The NDHM still does not recognize ‘Health’ as a justiciable right. There should be a push draft at making health a right, as prescribed in the draft National Health Policy, 2015.

 One of the biggest concerns is regarding data security and privacy of patients. It must be ensured that the health records of the patients remain entirely confidential and secure. The Western countries who have implemented NDHM mission ahead of India have learned a hard way to deal with Electronic Health Records and are still struggling with the same. Privacy and confidentiality issues in fact tend to increase the cost of health. Software companies escalate the cost in order to make the system more robust- the cost is indirectly borne by the end-user (Patient) only. GOI will have to be particularly watchful of these issues with deep potential to undermine the benefits due to additional costs.

 In addition, the failure of a similar National Health Service (NHS) in the United Kingdom must be learnt lessons from and the technical and implementation-related deficiencies must be proactively addressed prior to launching the mission on a pan India scale. Digital literacy could be another concern in some parts of India (although the situation has improved a great deal due to digital payments and Direct Benefits Transfer (DBT) that Indians at large seem to have embraced in a big way).

 UK’s National Health Service (NHS) started deployment of an electronic health record systems in 2005 with an objective to have all patients with a centralised electronic health record by 2010. Several hospitals acquired electronic patient records systems as part of this process, but there was no national healthcare information exchange. The program was ultimately dismantled after a cost to the UK taxpayer was more than £10 billion, and is considered one of the most expensive healthcare IT failures. According to The Independent, the project had been beset by changing specifications, technical challenges and clashes with suppliers, which left it years behind schedule and way over cost.

 The standardisation of NDHM architecture across the country will need to find ways to accommodate state-specific rules. It also needs to be in sync with government schemes like Ayushman Bharat Yojana and other ITenabled schemes like Reproductive Child Health Care and NIKSHAY (Tuberculosis eradication by 2025) etc.

 Among its key performance measures, NHA a la its British counterpart NHS will have to look at overall patient satisfaction. This could be a complex metric build using variety of service related parameters and ultimately resulting into a single Patient Satisfaction Index (PSI) which will be useful in timely monitoring, control and correction. NHS uses plethora of 21 different electronic systems to record data on patients. These systems are not well connected and hence do not communicate well with each other. There is always a risk doctors treating a patient will not know everything they need to know to treat the patient effectively. There were roughly 10% (as many as 11 million) patient interactions out of total 121 million where information from a previous visit could not be accessed. Half the Trusts using Electronic Medical Records used one of three systems and at least those three should be able to share information. One tenth of Trusts had application/system proliferation in that they used multiple systems in the same hospital. Dr who participated in the research said, “Hospitals and General Practitioners (GP) often don’t have the right information about the right patient in the right place at the right time. This obviously has potential to lead to errors and accidents that can threaten patients’ lives. Another issue with NHS which has come to light and needs to factored in while building NDHM in India is around data security. Apparently the Information on millions of NHS patients was sold to international pharmaceutical companies, in the US and other nations for research, adding to concerns over USA ambitions to access remunerative parts of the NHS after Brexit.

The concern over lack of transparency and clarity over the data and how it is used remained paramount.

 Govt of India had drafted online pharmacy related regulation but yet to notify it. This has hindered investments in the sector. GOI will have to notify the rules for the online pharmacy. Reliance industry has acquired Chennai based online pharmacy company by name NetMeds. Amazon is also making big strides besides some other players like Apollo Pharmacy etc. Besides Jan Aushadhalaya started by GOI for low cost generic medicines will need to be integrated in the NDHM platform

 Issues due to delay in finalising online pharmacy policy

 Lack of investments: The pharma sector is expected to be $35 billion industry by 2023 as per some industry reports. Lack of clarity will always discourage entrepreneurs and investments won’t come in easily leading to slower improvement of the current infrastructure. More than 100 start-ups this year got funded in the fintech space while less than 25 start-ups got funded in the healthcare space (in-spite of fintech being much more complex in terms of execution and regulations)

 Lack of innovation: Due to fewer entrants, innovation in this space will also be quite slower than in any other category. Healthcare needs more innovation in order to improve the current standards of patient experience and lead to better outcomes.


References

1. National Health Policy 2017. Ministry of Health and Welfare, Govt of India

2. NITI Aayog, National Digital Health Blueprint, July 2019

3. Strategic Document, National Digital Health Mission (NDHM) August 2020

4. Blue print of National Health Stack (NHS) in 2018

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