Monday, June 8, 2020
Saturday, June 6, 2020
A registry is an organized system or database that collects, stores uniformed data or information about an entity like patient, person , or facility etc and is kept updated at all times to act as “Single Source of Truth” for the entity in question. The data facilitated by the registry can be accessed as service by information technology applications or by the government for planning initiatives and governance.
How a Registry is different from a Directory?
A registry is an official record keeping database which not only identifies an entity uniquely but also proves its existence in the ecosystem in question. E.g.: ADHAAR- A person must be listed in AADHAAR registry to be able to verify his/her identification as an Indian Citizen with authentic demographic details.
Directory on the other hand does not required to be an official or comprehensive, but mere a collection of data without uniquely identifying entities listed in it and do not serve as “single source of truth”. Example- A telephone directory.
What is a National Health Facility Registry?
A National Health Facility Registry is a centrally maintained registry that stores and facilitates uniform minimum required data or information about both public and private health facilities in the country. It is a building block that is essential to enable nationwide health information exchange. It will do so by identifying each health facility uniquely and creating a unique Identifier for every registered facility. This unique identifier then becomes available to be utilized by states and IT systems as a pointer or primary key to store more facility related data in directories maintained at state/district level, providing comprehensive data on all private and public health establishments
Indian healthcare has been trying to overcome the problem of interoperability and siloed systems to enable continuum of care. This requires a standard driven health information exchange (HIE), and to enable a HIE, it is essential to uniquely identify each stakeholder and resource (Patient, Provider, facility, health worker) involved in an episode of care.
Also, from a quality of care and governance perspective a facility registry becomes very critical for resource planning to create a reliable, unified registry of country’s healthcare infrastructure & associated resources through associated state or national level repositories like NHRR to show their distribution pattern of health facilities and services areas across the country. This assumes even greater significance in emergencies like Pandemics and disasters.
Several initiatives have been made by the Indian Government in the past to enable a centrally maintained facility registry for India.
Key initiatives undertaken in India for facility registry includes:
- National Identification Number (NIN) project that was undertaken by National Health System Resource Centre (NHSRC) in 2016 where data pertaining to approximately 1,11,990 health facilities was cleaned and validated by 25 states including longitude-Latitude details. A 10-digit unique National Identification Number (NIN) was allocated to the identified public health facilities. A NIN portal was also developed for missing facilities or new facility registrations and states were provided trainings on the same to keep the NIN facility data updated.
- National Health Resource Repository (NHRR) project by Ministry of Health and Family Welfare (MoHFW)- In NHRRa Healthcare establishment Census was conducted which included on ground physical survey to enlist all the health facilities as well as resources. NHRR database has listed approximately 8.5 lakhs+ facilities and provides around 7000+ attributes withspatialinformation maintained by the technology partner ISRO.
- ROHINI (Registry of Hospitals in Network of Insurance)– Dubbed as the AADHAAR of Hospitals by Insurance Information Bureau of India (IIB)- ROHINI is a PAN India registry of hospitals/day care centers that are empanelled with health insurance payers/Third Party Administrators(TPAs) for service delivery to the beneficiaries. It has approximately 35,000 facilities listed so far. Each registered facility is allotted a 13-digit Global unique GS1 identifier, along with geo coding of facility address. ROHINI also has self service portal for registration/inactivation /deletion or amendment of registered facilities. All network hospitals and hospitals involved in cashless reimbursement claims or those that wish to provide this facility, are registered on ROHINI.
All the initiatives as mentioned above had common goals, one to act as single source of truth and second to become single point of reference for facility information as per their identified scope.
Since a lot of effort has gone into each of these initiatives, they should be brought together and harmonized to enable a National Facility Registry that can identify both public and private health facilities uniquely. The data collected under each mentioned initiative can be consumed or exposed as service to get/retrieve additional data about a facility using the same National Unique Facility Identifier that can be allotted by the National facility registry and act as a primary key to stitch the different databases together.
1. Identify Minimum required data elements for Centrally maintained Registry
A central or nationally maintained registry that can be self-sustainable and easy to maintain should not have a long list of data elements or attributes. It should consist of only a set of minimum required data elements that helps to identify the facility uniquely and can be kept updated at all times. The recommended data elements should follow Metadata and Data standards for India (MDDS) which is a standard notified by Ministry of Electronics and Information Technology (MeITY). It is essential to use data standards to collect and store information in a registry, so that if states want to maintain their own facility directories/state registry/database they can use the same standard MDDS elements to define the local registry structure and will be able to push data seamlessly to the National facility registry.
The recommended minimum viable data elements are listed in the Annexure.
2. Map NHRR-NIN-ROHINI Facilities& State verification and updation
Facilities listed in all the three mentioned databases can be mapped using Machine Logic/AI and manual interventions by making use of the key attributes like name, address and longitude-latitude details.
Following steps are recommended to harmonize and enable a National Health Facility Registry
- Map ROHINI, NIN and NHRR facilities. The facility data from NHRR, NIN and ROHINI data sources will be harmonized by employing Fuzzy logic-based matching of facility data from each of these different sources. Facility data (NHRR, NIN and ROHINI) shall be matched by deploying fuzzy algorithms like Soundex or levenshtein distance matching etc. The unique minimum required attributes as described in appendix 1 shall be loaded in the facility registry database.
- Develop standard definitions for attributes using MDDS elements as provided in the Annexure I.
- Identify & publish mismatches and duplicates in the standard definition template and suggests standard process of verification with district and health state departments.
- State can filter facilities district wise and get the data verified through the respective district health department.
- Districts can update information in excel format and request corrections if any to the state.
- State after verification and validation can push the cleaned facility data to the centre.
3. Convert the clean, verified data using a technology partner like NIC into a registry.
The first step towards digitalizing the National Facility Registry after receiving clean and validated data is to load the cleaned facility data into the National Facility Registry. The facility registry shall store the source ID of each system (NHRR ID, NIN ID and ROHINI ID) against the set of data attributes loaded from each of these three data sources to facilitate the facility data set retrieval from registry based on different identifiers (e.g. based on ROHINI ID or NHRR ID) and thus it shall not disrupt the design of existing systems which are using this data.
The loading process of facility data into facility registry shall ensure the uniqueness and deduplication of facility data by using validation/data deduplication engine. A National unique facility Identifier shall be generated for each facility populated in the facility registry (the algorithm to generate the unique facility identifier should be decided by the authority implementing the design of facility registry), The facility unique Identifier will be a 10 digit unique Integer value and should not contain any data attribute based logic in the design of identifier code due to volatile nature of the facility data attributes as that may change in future e.g. if facility identifier contains the logic built based on the location of facility e.g. state and district code, the same may change due to administrative change of the location of facility due to addition or deletion of state or district by the respective state government in future. It is recommended that facility identifier should be a running serial number generated based on a selected algorithm like generation of AADHAR NUMBER which generate a unique number which is unique across the lifetime.
4. Develop a central portal with standard operating procedures on deletion, updation or addition of facilities.
- Portal for enrolling new public and private facilities into National Facility Registry.
- Public Portal for access to National Facility Registry data as part of e-governance.
5. Develop a roadmap for training & updation of National Facility database by state users.
6. Maintenance of National Health Facility Registry
For maintenance of Facility data in Facility Registry. openAPI/web service standards can be used to add/update or delete facility data. After Initial load of facility in facility registry any new facility shall be added in the Registry by use of openAPIs/webservices. The updation of facility registry shall follow the design principles for registries as laid out in National Health Stack document and will ensure the single source of truth and non repudiablity of facility data in registry.
Advantages of a harmonized facility registry using NHRR, NIN and ROHINI
- The National Facility Registry will be a single source of truth for all the clinical establishments or healthcare facilities in India and can be a single point of reference for health infrastructure planning.
- The Facility registry will always also help the Government to plan emergency responses and predict healthcare expenditure by making operational status of facilities available.
- Harmonizing the different initiatives like NHRR, NIN and ROHINI will help in collating authentic data for facilities which are already recorded under respective initiatives while the initiatives coexist in harmony and expose the data as a service.
- A repository like NHRR and state repositories if linked with the National Facility Registry can provide more information about a facility’s resources like Doctors, Nurses, equipment etc which will help a state to plan optimized utilization of available resources.
A harmonized National facility registry can be one shot solution, which can support the Government to manage and optimize healthcare infrastructure & resources effectively and predict the unmet needs to design an effective risk mitigation plans in advance to combat a future pandemic. It can identify key areas of improvement by upgrading existing health facilities or establishing new health facilities keeping in view the population density, geographic nature, health condition, distance.
For Annexures please read the full Health Facility Registry document on slideshare.
Reach out to us for clarifications:
Department of Digital Health, ACCESS Health
With a proactive concern for patient safety and quality of care, The Indian Medical Council Act 1956 prohibits a person other than a medical practitioner enrolled on a State Medical Register or the Indian Medical Register (IMR) to practice in India. Every New Medical Graduate must Register with the respective State Medical Council Register and is then allocated a registration number. With that Registration Number, the Doctor can Practice anywhere in India.
As it works Currently, apart from MCI’s National level Indian Medical Register (IMR), different state councils have their own medical Registers. The MCI then compiles data received from state medical councils.
Healthcare being a State Subject, a degree of latency creeps into the system. However, when a Doctor migrates to any other part of India, he/she often overlook to update the State Register and also similarly about recent Qualifications, Degrees, Certifications, etc.
This makes for high chances of duplication of data of Registered Doctors between the various registers. This makes the compilation and de-duplication exceedingly difficult because of the administrative dependencies which are beyond the MCI’s control.
There are also then, several unqualified or fake Doctors working in the country without proper qualifications and/or registration with IMR or State Registers. MCI has no way of tracing, tracking, and weeding out such practitioners from a wide variety of genuine Doctors working in the Country.
On the other hand, the patient also has no way of differentiating between genuine and fake doctors.
With the adoption of Universal Healthcare as a Policy in 2017, increasingly healthcare services are going to be paid for by Insurance or state programs. From a Health Insurance perspective, it becomes exceedingly difficult to establish the veracity of the Claim. The liability lies on the payer whereas there is no authentic single source of truth.
Similarly, in the event of medico-legal cases, it is hard to trace back from the prescription to build a legal case. A wide variety of degrees appear on Doctors’ Prescription pads. MCI lacks a master list of accepted Qualifications including Indian and International Degrees/Diplomas/Certificates. Hence there is no way of finding out if these Degrees are genuine, equivalent international qualifications, derecognized, or even completely fake!
There are many use cases where the sanctity and harmonization of the Registers come into question. These are some of the practical detractors to the authenticity of data on the Medical registers.
Doctor has Migrated/Died or left the practice:
- Migrated Doctor may Re-Register in the other State Register at the time of Renewal. Though a procedure exists about taking a No-Objection-Certificate from the previous State Register; but it is not very strictly followed. There is a possibility of Doctor getting counted in both Registers.
- When a Doctor dies, the Register is usually not updated with a Death Certificate.
- When a Doctor has Left the country, the Register is usually not updated because usually it is not known if the migration is temporary or long-term or permanent.
- When the Doctor has left Practice due to any reason e.g. Administrative job, Higher Education, Change of Sector, etc.
Name Change or Mismatch:
- The Register is usually not updated when Doctor Changes Name E.g. Marriage, Religious reasons, etc. This results in a Name mismatch between IMR Register and the changed Government IDs.
- The Register is usually not updated when Doctor Name Spellings is changed e.g. Family, Social or Numerology reasons, etc. This results in a Name mismatch between IMR Register and the changed Government IDs.
- Name Mismatch between Degree, Internship Certificate, and Registration. Only possible to check at the time of first Registration, later it is very difficult to harmonize.
- Demographics Mismatch between Degree, Internship Certificate and Registration. Only possible to check at the time of first Registration, later it is very difficult to harmonize.
Degrees and Specialisations
- When a Doctor attains a Specialized/ Super Specialized Degree or Certificate, it is usually not updated in the Register because there is no real mandate to do so.
- Equation of Foreign Degrees with Indian Medical Degrees e.g. MD from US equivalent to MBBS or MD or DM? DNB equated to MD or DM? Exceedingly difficult for MCI to decide if the Registration should be granted or not.
- Equation of Degrees in India e.g. Ph.D. Clinical Pathology without MBBS, or MD Pathology? MCI usually does not grant Registration for such cases. Though they may be equated Internationally. Will the documents signed by such professionals be recognized e.g. Genetic Testing Reports.
- University Mismatch – e.g. Individual Universities in Maharashtra no longer gives Medical Degrees. Nasik University has taken over that function and gives Degrees across all Medical Colleges in Maharashtra. Only possible to check at the time of first Registration, later it is exceedingly difficult to harmonize.
- If the Doctor has lost the Graduate Medical Degree. It is hard to justify the details mentioned in the IMR Register. The only way is to ask for a Duplicate Degree from the University, which is also a very long process and is usually not pursued.
- Medical Graduates of States having special status were given Provisional Registration to Practice pending the legal decision on the State – e.g. J&K, Arunachal, Sikkim, Pondicherry, Goa. Later there is no way of revalidating the data before regularizing the Registration. So the old Registrations continue to languish.
- How do you split the Medical Graduates between States that were split or newly carved out – e.g. Goa, Uttarakhand, Chhattisgarh, Jharkhand, Telangana. Later there is no way of revalidating the data before regularizing the Registration for the New State. So the old Registrations continue to languish.
- Medical College recognized by the State but not by MCI Govt of India. State Register gives the Registration, but MCI does not recognize it.
- Medical College derecognized by MCI Govt of India. State Register gives the Registration, but MCI does not recognize it.
- Provisional Registration is granted in cases of Emergency e.g. Disasters and Epidemics. This should be withdrawn after the Emergency. However, no clear process has been defined for this purpose.
Foreign Degrees and Passports:
- Foreign Passport but studied from Medical College in India. State Register gives the Registration though the foreign national will not practice in India e.g. Nepal, Bhutan, Sri Lanka, ASEAN, Africa, West Asian countries.
- Indian Citizen but studied from Foreign Medical College e.g. Russia, China. MCI Register gives the Registration after an examination. Though many of these Indian nationals migrate out and do not practice in India.
As per newspaper reports, In 2017 the Medical Council of India had directed all states to provide a unique permanent registration number (UPRN) to every Doctor Registered in their jurisdiction.
MCI had envisaged a digital platform. The MCI initiated the process of implementing e-governance through digital mission mode project (DMMP); one of the ambitious modules under DMMP project is the implementation of new IMR through unique permanent registration number generation for each Registered Doctor in India, the MCI said in a letter sent to the Indian Medical Association (IMA).
On implementation of the system, the existing registration numbers of the Doctors shall be migrated to a standard system of UPRN. Doctors shall also apply online for additional qualification registration in IMR like Postgraduate, super-specialty etc. After commissioning, Doctors can use the system to make online applications for services like issue of certificates etc.
The initiative will put an end to the duplication of Doctors Registered by various state medical councils as well as the Indian Medical Register under the MCI and provide a clear picture of how many Doctors are practicing in India. A UPRN number is to be generated for the over one million Doctors recorded in the IMR.
We will get to know about the actual number of Doctors and the list of medical specialists practicing in the country. We will have all the details about a Doctor, ranging from addresses to personal details, and Specializations. Currently, we seek information about Doctors from the state medical council. Once all the Doctors are given a separate code or UPRN, it will become amazingly easy to trace them in a case of medical emergency, epidemics, disasters, negligence, or second opinions for their expertise.
However, from 2019 the MCI role has now been taken over by the National Medical Commission [NMC]. The handover of charge by MCI BoG to the NMC is awaited.
Para 31 of The NMC act of 2019, mandates it to ensure electronic synchronization of National and State register in such a manner that any change in one register is automatically reflected in the other register 
Fortunately, this can easily be accomplished by leveraging the MDDS recognized in the National Digital Health Blueprint, 2019. This would make it possible for the IMR to evolve into a single-source-of-truth and be looked up appropriate stakeholders.
Recent events like the COVID 19 Pandemic have brought the vital role that Telemedicine and similar technologies can play sharply into focus. Para 32 of the NMC act also conceives a role for a limited number of Community Health Providers to work under the supervision of a medical practitioner.
These emerging trends make the authenticity of the medical register critical to healthcare delivery in a safe, accessible and equitable way.
Architectural Approach for Doctor’s Registry
1. Federated Architecture for Doctor’s Registry
As per NMC Act, the Ethics and Medical Registration Board shall maintain a central National Medical Register (aka National Doctor’s Registry) containing the set of minimum data elements for identification and credentialing of a licensed medical practitioner (aka provider) practicing anywhere across the country. To enable this a federated architecture design is recommended for the National Doctors Registry that it can be kept updated at all times and will not have a single point of failure.
The National Medical Register will be responsible for allocating a Unique National Provider Identifier (NPI) to every new provider that gets registered through a state medical council or directly through the central medical register by performing de-duplication and validation of a new provider record. This unique identifier will remain unique for the lifetime of a provider.
Every state medical council will then use this Unique Provider Identifier to maintain and regularly update the state register (aka as Provider Directory at the state level) for the providers registered within that state with not only the registration details but also with additional information about their credentials, employment, training, qualifications, CMEs attended and active status etc. There will be an electronic mechanism to update the central register with the data from the state level provider directories for new provider registration as well as for any information update through the state register. Lookup the details in ANNEXURE – 2.
Tuesday, June 2, 2020
Epidemiology Surveillance is a Lever of Change - for implementation of National Digital Health Blueprint and adoption of National Digital Health Ecosystem.
Given the vast and variable nature and quality of legacy and operational data being generated in real time which requires to be captured, any solution adopted requires to essentially ingest these disparate forms, allowing meaningful options in its use. This becomes a tall order for traditional architectures like Data Warehouses, that constrain the types of data that can be stored in them, both in terms of type and quality.
Data lakes are the leading edge and evolving architecture that can help store, share and use electronic health records and other patient data in its ever-expanding variety. Data Lakes open the possibility of taking Healthcare Analytics to its Next Level by keeping pace with the rapid growth in types and magnitude of data that needs to be harnessed and made use of. It is important here, to understand the differences between Data Lakes vs. Data Warehouses. Data Lakes store raw data on the one hand, while Warehouses store current and historical data in an organized fashion. Data warehouses are best for analyzing structured data quickly with great accuracy and transparency for managerial and regulatory purposes.
A federated data lake is essentially an architecture to store high-volume, high-velocity, high-variety, as-is, data, as it gets rolled up from State-level Health Information Exchanges. State-level Health Information Exchanges will pull in vast amounts of data — structured, semi-structured, or unstructured — in real-time, from local healthcare facilities.
Data Lakes can additionally, also ingest data from Internet-of-Things sensors, clickstream activity on public health websites, log files, social media feeds, videos and online transaction processing (OLTP) systems. Data Lakes are used for Big Data and real-time analytics. To ensure that a lake doesn’t become a mere swamp, it is very helpful to provide for a catalog that makes data visible and accessible to the business teams, as well as to IT and data-management professionals.
A healthy Data Lake requires maintenance. There are no constraints on where the data originates from, but it is a good practice to use metadata tagging, to add some level of organization to the data ingested. This will allow for relevant data to surface for queries and analysis. The value of a well-maintained data lake dealing with large volumes of disparate data, pivots on the links to metadata and ontologies. It requires consistent management of metadata, terminology management, ontology management, linked open data and modeling, and the kinds of automated algorithms that can be deployed to use these resources efficiently, to crack difficult problems such as epidemic surveillance.
The Provider eObjects can gather statistics for the appropriate authorities to allow calculation of burden of disease, epidemiological Studies for epidemic surveillance, monitor for incipient epidemics and compare outcomes across facilities. They will also play a vital role in providing epidemiological, utilization and quality data for analysis and action. Additionally, these eObjects can serve as a powerful means of recording and observing the natural history of a disease, determining the effectiveness of various clinical treatment protocols and assessing the quality of care being dispersed at different levels of care, facilitating biomedical research, while conducting analysis on disease trends.
Read the Reports:
- Data Insights Hub Report - ACCESS Health Digital
- Health Information Exchange Analytics Framework HIEAF Report - ACCESS Health Digital