Thursday, April 16, 2020

Health Systems for a New India: eObjects Building Blocks

eObjects were first written by Prof Dennis Streveler and Dr Pankaj Gupta in a white paper in Nov 2018 that was published by Niti Aayog in the book Health Systems for New India, Chapter 5 - Reimagining India's Digital Health Landscape Wiring the Indian Health Sector in Nov 2019.

ACCESS Health Digital Strategy Council defined the details of the National Digital Health Blueprint building blocks - Minimum viable products including the eObjects and microservices architecture to comply with the NDHB Standards. ACCESS Health Digital runs a Social Entrepreneurship Accelerator to accelerate the implementation of the NDHB Standards through these building blocks. 

The eObjects have now been adopted by Joint working Group of National Health Authority NHA and Insurance Regulatory Development Authority IRDAI Sub group on common IT infrastructure, in its report published on 11 Sep 2019 and will be built into the India’s national Health Claims platform.

The eObjects were designed for interoperability across the healthcare ecosystem on a federated architecture. eEncounter, eDischarge Summary Objects are for Provider-to-Provider interoperability; such that the data can flow across healthcare facilities, State HIE and National Data Lake. Whereas the eClaims Object creates a Financial Lever for the market. If the providers submit the claims in standard eClaims Object format then the turnaround time for their payments can be expected to be faster. Clearly eObjects are an innovative breakthrough.

This is very similar to what happened in the FinTech revolution in India where Government of India created the Unified Payment Interface UPI platform and then created the BHIM App and released the related Application Programming Interface APIs to the market. Later the Market used the API’s and built the hugely successful Paytm, Googlepay, Phonepe wallets. In 3 years the UPI transactions went from negligible to 1 Billion transactions per month.

Financial lever and strong governance for digital health transformation, plays a vital role in ensuring successful outcomes of such undertakings. India would do well to heed this truth. 

Provider eObjects Published

Immediate usecases: 
  • ePrescription and eEncounter FHIR based Objects for Telemedicine interoperability. 
  • The same eObjects can also be used for Referral across Primary, Secondary and Tertiary care.
  • Epidemiological Surveillance is the next big thing. We will need eEncounter, ePrescription and eDischarge Objects to fetch the data from disparate OPD/IPD HIS/EMR systems.
  • eObjects act as a Standard Output Format in these use cases.

The need for the eObjects arose because most of the Healthcare-IT applications are being developed without any standards by different agencies and vendors in the public and private sector in India. Each application is developed for standalone use without much attention to semantic interoperability. Later when the thought of interoperability emerges – it becomes difficult to connect the systems and make them talk to each other because they were never designed for that purpose.
Even if technical and organizational interoperability is done the semantic interoperability may remain a challenge. For example – all applications must have the same Facility master. When Application A sends the ANC data for Facility 123, the receiving Application B should understand ANC and uniquely identify Facility 123. Another example is if a hospital application sends the insurance reimbursement bill to the insurance company/government, the recipient application should be able to understand and re-present the same meaning of bill information.

Interoperability among e-Governance applications for the health sector requires exchange of information across applications. There is a need for commonly accepted data definitions for the various data elements used in e-Governance systems in Healthcare. Hence, standardization of data elements is the prerequisite for systematic development of e-Governance applications in the health sector.

The old HIS and EMR systems or even the new breed Digital Health Apps lack credible Global Digital Health Standards. Hence, they exist in silos and don’t interact with each other or the larger Healthcare ecosystem. The data cannot be referred for any meaningful analysis. For example, we still don’t know clearly the size, scale and depth of the Dengue, Chikungunya and H1N1, Flu epidemics that strike us every year. Hence, we are always left gasping for breath when the seasonal spike starts. 

India is already the Diabetes capital of the world with 70 million cases and counting. We still don’t have standard protocols based on the Digital Disease Management Platform.

The HMIS/HIS/EMR market in India requires Digital Health Standards based FHIR/JSON eObjects that can help the existing systems to communicate with the external world in a Standardized format. 

These Provider eObjects were first published in Health Systems for New India book by Niti Aayog and comply with NDHB, EHR and Meta Data standards, guidelines provided by Medical Council of India, Clinic Establishment Act and as per the latest Telemedicine guidelines released by the Government of India.

We have published the details of the eObjects on the To facilitate standard value sets for the entire ecosystem, we have also provided all the required value sets/code directories/master in an excel format.
  • eEncounter Note
  • ePrescription and
  • eDischarge Summary

Please follow the link provided here to access the e-provider objects and related documents:

Your respective Healthcare Delivery Systems should be able to generate the Provider eObjects formats. You can use the eObjects as input forms i.e. if you are building a new system. Legacy systems will use eObjects as Standard Output format.

The provider e-object can also facilitate capturing of signs, symptoms, vitals and procedures data during an active surveillance, which would in turn be useful in studying and analysing a disease outbreak.

We request you to kindly use these eObjects to collect data in your respective health delivery systems, that we can together facilitate Government with valuable clinical data for analysis and planning.

eObjects are evolving, check with us for the latest versions. Reach out to us for any help to understand or implement the e-objects. We can set up a group call with all of you to explain these eObjects in detail or even can set up one to one calls.

Thank You for your continuous association with us.

-- ACCESS Health Digital --

Contact for Clarifications:
Access Health Digital

Wednesday, April 15, 2020

ACCESS Health India Perspectives: Digital Will Drive Access to Healthcare

India’s Healthcare system is fragmented, the country is too diverse and large for a single unified system. Each state has its own healthcare programs. The central government provides the majority of the funds but the implementation largely rests with the states. States that are better off are independent in their decision making and show better outcomes. However, India can still aim for standardized protocols and interoperability across states. Interestingly, digital technology is proving to be a binding force between the three important stakeholders of healthcare namely, payer, provider and people. The new Ayushman Bharat national health insurance program is becoming the melting pot for public and private healthcare and emerging as the biggest driver for digital health.
Healthcare in India has lagged in adoption of technologies, but digital technologies are now pushing the country in the right direction. Technology driven transformation has happened in many sectors like Mobile and Telecom, Aadhaar based eGovernance, Fintech and Banking. Healthcare is likely to go through a digital transformation now.
Technology has already taken its toll on the Hospital Information Systems [HIS] market. Large HIS vendors have exited the market. Either they have lost interest and exited or have been acquired. On the other hand, many tier-II incumbent players are not able to shift out to cloud because of their long term negotiated contracts in client-server model. The newer cloud-based players are comparatively smaller in size and yet to reach size and scale. The HIS market is ready for complete disruption by Digital Health!
Now is the Era of Mobile-First Apps. Small Data ^ = Big Data. The time has come when you don’t need big monolithic HIS software to run hospitals. Now you can do a lot with small mobile based Apps for every function. Clinical evidence-based medicine has got a new meaning with Digital devices run on Artificial Intelligence being introduced. These devices can automate Laboratory Reports, read Radiology reports better, do accurate differential Diagnosis, pin point relevant Order sets, send Referrals, drug refill alerts and follow-up reminders. Disease management has gone Digital and the devices are learning fast and outcomes getting better with every new patient.
However, the old HIS and EMR systems or even the new breed Digital Health Apps lack credible Global Digital Health Standards. Hence, they exist in silos and don’t interact with each other or the larger Healthcare ecosystem. The data cannot be referred for any meaningful analysis. For example, we still don’t know clearly the size, scale and depth of the Dengue, Chikungunya and H1N1, Flu epidemics that strike us every year. Hence, we are always left gasping for breath when the seasonal spike starts. India is already the Diabetes capital of the world with 70 million cases and counting. We still don’t have standard protocols based Digital Disease Management Platform.
The HIS/EMR market in India requires EHR and Meta Data Standards based XML/JSON wrapper/objects that can help the existing systems to communicate with the external world in a Standardized format.
We need centralized Registries for uniquely identifying the Patient, Provider and the Facility where the treatment was carried out. We need Reference data dictionaries for standardizing the Diagnosis, Prognosis, Procedures, Laboratory tests, Radiological examinations, Drug prescriptions. This should be the common lookup so that everyone can be interoperable. The need for such Central Registries and Lookup Dictionaries is of paramount importance. Though the vital question remains, as to who will build and manage it. Should it be privately owned and controlled or publicly funded and managed.
Health Insurance sector has similar challenges. Private Health Insurance covers about 3% of India Population. There are 17+ Private Insurance companies that also do business in Health Insurance. 4 Public Sector Companies also cover Health Insurance. Four Private Insurance companies whose core business is only Health Insurance.
Public Health insurance covers about 10-17% of India Population. 80+% is Out of Pocket expenses. About 2% of India’s population falls below the poverty line every year due to unaffordable hospitalization expenses. Now the Central Government Pradhan Mantri Jan Arogya Yojana (PMJAY) has come to the rescue of most of the uninsured population. PMJAY is set to cover 40-50% of India’s Population. In absolute numbers the market is set to expand from the current 150 million people and go up to 500 million people.
Obviously, the TPA business which has been servicing only the private health insurance i.e. 3% of India’s population, must gear up to support PMJAY covering over 40% of India’s population. Hence TPA business is ready for disruption. The number of daily claims is set to go up by multiple times.
All these claims pipelines cannot be processed manually. We need to use high end technology to process the claims. We need a Standardized Claims format. The TPA market in India requires XML/JSON based standard Claims wrapper/object that can help the existing systems to communicate with the Hospital HIS/EMR world and the Health Insurance world in a Standardized format.
Globally, winds of change are evident. Digital is totally changing the way Health Insurance business has been run in the past. CVS has been building retail Primary Care centers and Diagnostics in its Pharmacies. Now with CVS Purchasing Aetna! John Hancock is shifting from traditional Life Insurance model to incentivize longer, healthier lives. In brief, they will move away from Life insurance model to Disease management and Precision medicine. Blockchain based Unique Identifiers are emerging. AI based start-ups are working on meta data driven Discharge Summary, Hospital Billing and Claims, Intelligent Claims Adjudication and Fraud detections. The Digital Tech Giants are becoming Healthcare companies. The lines are beginning to blur.
Is India far behind? Not really, India has a habit of leapfrogging stages, specifically with regard to Telecom and FinTech sectors. It will now happen to Healthcare. A Digital Healthcare Ecosystem is already taking shape.

India Leads the Way in Digital Health

India is in the midst of what some have dubbed the “world’s biggest healthcare overhaul.” In addition to recently launching one of the world’s largest publicly funded health insurance programs, set to cover some 500 million people living in poverty, the government has also been working diligently to develop a new digital health strategy for the nation.
The work on the strategy began more than five years ago, when the Ministry of Health and Family Welfare and the Ministry of Communication and Technologies developed a new set a metadata and data standards for health – essentially a common set of standards for the collection, creation, and coding of all health data that can be easily transferred across computers and information systems anywhere in the country. The standards were based on global best practices but adapted to better serve the local context. Previous to its work on data standards, the government also developed a system to allow it to issue a National Identification Number to all healthcare facilities in India.
These efforts have now put the government of India in a position to launch a new National Digital Health Blueprint. The blueprint, which is now open for public comments and consultations, validates the six pillar strategy that ACCESS Health has advocated for, namely:
A governance methodology and framework to help the digital health blueprint bring balance between patient privacy and scale.
Highlight the value and role of standards-based system design, including meta data and data standards for health, the health data dictionary, and registries.
A Health Delivery Information System to better manage healthcare provider operations, including software for patients medical records.
A Health Insurance Information Platform to provide better underwriting support for government schemes and to manage fraud and risks.
Electronic Health Records and a Health Information Exchange to provide citizens access to their health records and allow policy experts to understand disease burdens patterns.
Information and communications technology for infrastructure and capacity building to support digital health transformation.
A number of key members now on the ACCESS Health Digital Health team previously worked on the metadata and data standards initiative and on developing the national identification numbers. Their work was carried forward in the national blueprint.
In addition to its impact in India, the work the government has undertaken is likely to become a model for other emerging nations. The blueprint highlights some of the key points that ACCESS Health believes should be a part of any national digital health strategy. These include:
The need for federated governance and technology models to reflect the healthcare system, given that healthcare in India is a state-related subject;
The need to shift focus to more preventive medicine via a focus on strengthening the primary healthcare system and promoting alternative schools of medicine;
The importance of issuing of a personal health identification number that allows consent-based identification and portability of medical records across the continuum of care;
The importance of a mobile-first design approach that recognizes the growing penetration of telecommunication links on the back of low data tariffs;
The need for a data-driven approach to health policy making that recognizes the role of disease registries for accurate capturing of health burden; and
Recognition that there’s a need for keeping citizens healthy and productive to achieve economic growth as sick citizens become a burden on the system.
Our Digital Health team looks forward to supporting the Government of India in its ongoing efforts to develop and implement this critical new strategy to improve health in the country.

Strategy Council 1000 days Recommendations

Digital Health Strategy Council was commissioned by the Department of Digital Health, ACCESS Health International. The Theme was Digital for Universal Health Coverage for India. It brought together an Eclectic group of Healthcare and Digital Health Experts to come up with far reaching and game changing recommendations to achieve the objective over 1000 days. 

Recommendations were prepared by Digital Health Strategy Council during April 2019 to June 2019. The recommendations were released on 27th June 2019.
  1. Healthcare in Concurrent list.
  2. GST Council model - Healthcare Council.
  3. Declare Healthcare as Fundamental Right.
  4. Roadmap 60%, 80% and then 100% UHC.
  5. Portability of Healthcare like telecom. 
  6. Declare Hospital as Infrastructure Sector.
  7. AI based Health Delivery information Systems (HDIS) for Medical Colleges. Catch them young. Publish Standards based HDIS (like Android model). Let the vendors put their own skin on top.
  8. Social Media type Knowledge Management (KM) built on National Knowledge  Network  (NKN) across public sector and private sector hospitals for knowledge sharing across secondary,  tertiary.
  9. Setup 150k Jan Aushadhi stores with Telemedicine kiosk for  primary care.
  10. Health insurance Claims in Standard electronic format.
  11. Aadhaar allowed for Beneficiary Registry.
  12. Aadhaar allowed for Provider Registry.
  13. Facility Registry for Hospital Empanelment.
  14. Disease Registries for NCD.
  15. Organ Donation by default while issuing driving license, voter ID. Uncheck if person doesn't want to donate.
  16. Institutionalized Mission Mode National Digital Health Authority (NDHA).

Chaired by:
Dr. Ramachandran Balaji - Chair
Digital Health Industry Leader 
Prof. Dennis Streveler - Co-Chair
International Digital Health Evangelist
Mr. Bhavish Sood - Co-Chair
Ex-Gartner Digital Transformation Leader

Guided by:
Dr. Krishna Reddy
Country Director - India
ACCESS Health International

Sponsored by:
Dr. Pankaj Gupta
Head of Department - Digital Health
Access Health International