Digital health has emerged as a breakout concept for responding to the Covid-19 outbreak and its implications. This is leading the Indian health sector stakeholders to create and strengthen building blocks for a resilient digital health ecosystem, writes Mrinmoy Bhattacharjee, Assistant Editor, Elets Technomedia Pvt Ltd.
The digital health ecosystem is rapidly evolving in India. The concept that lies at the intersection of ICT technology and healthcare is witnessing an unprecedented adoption as the country’s healthcare providers, policy-makers and patients are seeking efficient means to provide and access healthcare services amidst the Covid-19 pandemic.
‘Covid-19 Accelerated Technology Adoption’
Neeraj Lal, Group Sr VP for Medicover Hospitals’ India Operations, says that healthcare was the slowest adopter of technology. But, thanks to the Covid-19 pandemic that has accelerated the tech adoption and penetration of digital health. The pandemic has taught that to stay in business, organisations will need continuous innovation and adaptation to the rapidly changing environment.
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“Due to the pandemic, the count of consultations, planned surgeries and procedures took a dip augmented by fear of people visiting the hospitals, thereby slumping revenue. Besides, the surge of operating costs due to stringent infection control protocols impacted the worldwide healthcare sector. The hospitals which used new technologies and evolved continuously are the only ones who managed to stay in the market.”
Lal adds that hospitals started using tele consultation technologies, remote monitoring, paperless systems such as EMR, E-prescriptions, online feedbacks, virtual training, conferences, ANCs and committee meetings, social robots and robots for material movement, cleaning, Artificial Intelligence (AI) in diagnostics and pathology and Aadhaar linked E-health card. “Enterprise-wide digital transformation is the key strategy to stay updated in today’s healthcare scenario and the new reality for healthcare will require hospitals to redefine the existing process and bring digitalisation.”
‘Digitalisation Momentum will not stop after Covid-19’
The pandemic has “truly” come as a blessing in the disguise, says JP Dwivedi, Chief Information Officer, Rajiv Gandhi Cancer Institute & Research Centre (RGCIRC). “It was in everyone’s interest to avoid crowding in the hospitals. Doctors became much more receptive to the idea of telemedicine. At the same time, patients also tried to use mobile devices to upload reports and obtain prior prescriptions on mobile apps for ready reference to the physician during teleconsultation.”
Even inside the hospital, Dwivedi recalls, paper files became a potential carrier of the virus. Doctors preferred to look at EMR or EHR rather than referring to paper files. IT product and service companies, he says, accelerated their pace of developing an increased count of user-friendly applications integrated with EMR systems. “The momentum that has been generated will not stop even after the fear of the Covid-19 subsides, as people will become used to the comfort, convenience and efficiency brought in by digital health.
‘All Have Realised the Winds of Time’
Anurag Khosla, CEO, Aetna India observes that digital health has emerged as a “critical” component of the modern-day healthcare system during the pandemic. Due to the Covid-19 enforced restrictions and limited infrastructure for general consultation, many hospitals either halted or suspended their services for non-Covid patients which mounted the stress on those seeking medical consultations other than the pandemic.
“One such powerful catalyst that manifests silver lining to the entire healthcare industry is the use of technology in delivering healthcare services. The acceptance of digital healthcare services among both ends of the value chain – healthcare providers and patients – have been phenomenal. This has led to a rapid supply of digital healthcare and a huge surge in the demand for virtual medical assistance by the public. The government authorities, healthcare providers, corporates, and social organisations have realised the winds of time and they have started delivery of care at home through telemedicine and virtual consultation.”
‘Telemedicine’s Moment Finally Arrived’
Omni Hospitals Group CIO Abdullah Saleem, says, “The pandemic has changed the mindsets of the patients and doctors, especially for the primary care treatment, which is taking almost 50-60% remotely or virtually. The pandemic has brought Information Technology fiction down to the ground. We live it, we breathe it, and to move forward we also need to take it up it, too. Upon the first news of a certain virus in China, we quickly started talking about the right use of digital health technologies and plenty of technologies were suddenly widely adopted, and interestingly not only by the medical professionals but the general public as well.
He adds that telemedicine solutions have been available for a long time, but its moment finally arrived due to the onset of the Covid-19 last year. “From being the far-fetched concept for the care of remote areas, the frightful need to protect medical professionals and other patients from the virus made remote technologies skyrocket.”
‘Around 60% Doctors Now Ready for Video Consultations’
The Covid may have broken the logjam as medical professionals had to adapt quickly, using telephone and online consultations by replacing patient walk-ins, says Dr K Hari Prasad, President for Hospitals Division at Apollo Hospitals Enterprises Ltd. “2 to 7% of doctors were ready to offer video consultations prior to the pandemic. But, it is now closer to 60%. The E-ICU registry to help monitor bed capacity was also implemented and set up within weeks – which would usually have taken years. At Apollo, our application 24/7 was well suited for all required needs in these difficult times.”
‘The Pandemic Exposed Dirty Underbelly of Healthcare’
The digital transformation that was to happen over 10 years has happened in the last 18 months of the pandemic, says Pankaj Gupta, Head, Access Health Digital. “The pandemic has also exposed the dirty underbelly of the healthcare system such as the gross lack of epidemiology data available in standard machine-readable formats for real-time analysis. We have failed in resource optimisation, for example, doctors and beds, supply chains of oxygen and medicines, E-governance of vaccines due to lack of machine-readable actionable epidemiological data. The hotspots should be identified on a near real-time basis and interventions should be organised as per epidemiological insights,” he adds
Developing Comprehensive Digital Health Framework
The union government had set up institutions for E-health management. It had shared a vision of digital health many years ago by spelling out its ambition to create an Electronic Health Record (EHR) of 1.3 billion people that can be exchanged in a secured manner pan-India. It had the vision to set up a national telemedicine network, use IT for surveillance and monitoring of the programs across India, use digital technology for capacity building and training, and deployment of IT tools for governance and information dissemination. In 2011, the government established a National Resource Centre for Telemedicine in Lucknow to develop and strengthen telemedicine technologies as well as provide necessary technical assistance to state governments. In 2013, it came up with a Centre for Health Informatics at the National Institute of Health and Family Welfare in Delhi for managing the national health portal and other E-health initiatives. Next year, it established National Resource Centre for HER Standards in healthcare IT applications at CDAC, Pune.
Nevertheless, there were challenges, observes Dr K Madan Gopal, Sr Consultant at NITI Aayog. “Health IT was a fragmented information system operating in silos. But we were trying to address this with the integrated health information platform, where all the programs can ride on it, or at least all the programs can talk to each other. There was no standardized format used for data collection, and therefore, not interoperable. Our efforts were on to see how we move in this direction. There was also duplication of data collection on multiple systems leading to data redundancy. Other challenges were that we had a lack of unique identifiers for patients, providers and health facilities across the system and lack of common data analytics platform.”
So, there was a clear need for a comprehensive digital health framework and the government embarked upon a journey of national health blueprint, says Dr Madan Gopal. The government brought out the National Health Policy in 2017 that envisioned a digital health technology ecosystem and recognise the integral role of technology such as E-health, M-health, Cloud, IoT, wearables, among others in healthcare delivery. In 2018, NITI Aayog released a proposal on National Health Stack or NHS that provided a framework for the country’s futuristic digital health system specifying components required health IT programs. In 2019, the government finalised the National Digital Health Blueprint (NDHB) as an architectural framework for digital health in India for the evolution of the National Digital Health Ecosystem (NDHE), he adds.
‘NDHM is a Revolutionary Reform in Healthcare’
Group Sr VP for Medicover Hospitals’ India Operations Neeraj Lal says that NDHM is a “Revolutionary” reform in healthcare that will “significantly” improve the efficiency, effectiveness, and transparency of health service delivery. It is a “major” step towards achieving the United Nations Sustainable Development Goal 3.8 of universal health coverage. The mission will bridge the existing gap amongst different stakeholders of healthcare.
“Under this initiative, a unique Health ID will be created for every Indian, and their health records will be stored in these IDs. So, as soon as a patient enters the hospital, heads to the registration desk, scans the Health ID QR code at the desk using his personal health records app on his smartphone, the hospital immediately gets detailed information about the patient. There is no waiting time for the patient and the hospital sends a consent request to the patient before accessing his medical history. The patient chooses what data to share with the hospital and for how long the hospital can access the data. Finally, when the patient leaves the hospital, he gets a notification that the medical reports are ready,” he describes.
Adds Dr K Hari Prasad, President for Hospitals Division at Apollo Hospitals Enterprises Ltd: “NDHM is a revolutionary reform in the complicated and large Indian healthcare sector. The mission aims to simplify healthcare access by creating a digital and robust technology-backed ecosystem of services. Providing a health ID will lead to significant benefits to the patient as the longitudinal medical history will be correctly recorded, leading to early detection and intervention in managing the person’s health. It will help to bring focus on prevention and wellness, thereby helping manage NCDs. NDHM will significantly improve the efficiency, effectiveness, and transparency of health service delivery.”
JP Dwivedi, CIO, RGCIRC says that the government embarked upon the journey of making use of technology is a decisive step to improve healthcare infrastructure in the country. “NDHM was formed to become a national aggregator and nodal agency to facilitate and manage digital health infrastructure in India. It has come to be a formal body providing a bedrock to the healthcare ecosystem. Having all healthcare professionals, facilities, electronic health records, patients with a unique ID, it will make the healthcare accessible to the patients with speed and quality of care delivery as well as minimise wastage of precious resources.”
Every Indian will get a unique Health ID that will store the individual’s demographics, medical records, including doctor visits, diagnosis and diseases, the line of treatment, and drugs taken, says Abdullah Saleem, Group CIO, Omni Hospitals. “The ID will be integrated with the facilities which could be using telemedicine, E-pharmacy applications, creating a national health registry. From a doctor’s appointment to hospitalisation for any treatment, this unique ID will be very essential.” He adds, “The key feature of NDHM is the technology part; it will support open digital systems to provide high-quality healthcare for each citizen. The digital health mission will integrate with various digital health services to create an ecosystem that can accustom the existing health information systems.”
Sameer Mehta, Executive Vice Chairman at Dr Mehta’s Hospital and Vice President at CAHO says that NDHM has set clear standards and a framework to bring the key decision-makers to the table. “India has a complicated health system – one like no other. We can borrow components, but also need to design a uniquely low cost and easy-to-change or plug n play system, which will bring many participants together. Our tapestry of health delivery while inferior to many global systems in purely statistical terms has some truly world-class advantages such as our talent, our values and our adjacent industries’ capacity in pharma, tech, vaccines, and precision manufacturing. We need relevant standards – an open system which enables many potential innovators to provide sub infra while we give performance maintenance contracts to the big tech and health firms to implement, realise the value and keep systems and people safe.”
The outbreak and a continuous surge of the Covid-19 have driven many developments in the healthcare space. One such push is NDHM, says Anurag Khosla, CEO, Aetna India. “NDHM propounds a transformational approach that will overhaul the healthcare ecosystem in India. In a country like India where healthcare infrastructure per capita is still below average, the policy framework provides strong support to every stakeholder towards capacity building.”
Advent of the Internet of Medical Things
With international collaboration to fight the pandemic, healthcare innovations that would have traditionally taken years took just weeks or days, says Medicover Hospitals’ Neeraj Lal. “We made much advancement in the use of artificial intelligence (AI) and Machine Learning (ML), which has improved the healthcare systems and delivery. We are also seeing the Internet of Medical Things (IoMT), a connected infrastructure of medical devices, software applications, and health systems and services that allow real-time monitoring and notification, play a significant role in personalised healthcare.”
Lal says that ML in medicine is helping using clinical data and molecular research, predictive modelling for understanding potential candidate molecules that have a high probability of successfully developing into drugs. “Using predictive modelling helps eliminate the overall cost and time required for trial and monitor processes are usually seen in drug discovery. Monitoring live data from patients and feeding it directly into the system helps the model to adapt to the ever-changing patient’s medical history. Besides, precision medicine aids in the development of personalised treatment plans for each patient based on their unique genetic, environmental, and behavioural conditions.”
‘Pathology and Radiology are Converging’
The “real” problem has always been analyzing unstructured data. With AI, ML and Advanced Analytics, that problem has been solved to a great extent, says RGCIRC’s JP Dwivedi. “Clinical notes stored in form of documents and analysed in a context-sensitive manner. For example, you have a tool that searches for diabetes, you train the system to search for diabetes or diabetic. But, if the doctor writes non-diabetic, it will still count that patient as diabetic. Now, you further train it to check if the word diabetic is preceded by non or not, discard it. It again will not check if the doctor writes ‘does not appear to be diabetic’. This simple example shows the complexity of the algorithms that need to be built to analyze such data and it cannot happen using structured databases being accessed by traditional programming languages. We need systems that are capable of learning on the fly and adapting to more and more real-life scenarios.”
He adds that the use of AI and ML diagnostics has opened a new frontier altogether. “The pathology and radiology are converging to provide accurate diagnosis not just on the absolute basis of an image or a tissue, but also on the basis of repository of such images and tissues being compared with this one. An intelligent correlation of clinical diagnosis, radiological diagnosis and pathological diagnosis is able to pinpoint the nature, extent and spread of the disease much more succinctly.”
Dwivedi also observes that robotic process automation is helping in diagnosis, treatment and supportive procedures. For example, Trans Arterial Chemo Embolization (TACE) and Trans Arterial Radiation Embolization (TARE) is helping in the accurate delivery of chemotherapy or radiation right at the location of the tumour rather than delivering it using the distribution system of the human body. Robotic surgery, which was introduced in 2009-10, has now become so advanced that it can reduce blood loss and the duration of hospitalisation significantly. Clinical Decision Support Systems powered by AI and ML are capable of helping doctors to choose the most suitable and effective treatment protocol.
“At the end of the day, nothing can challenge the supremacy of the human mind. All these technology solutions are going to strengthen human abilities and change the roles of our care providers empowering them to make the correct diagnosis, choose correct treatment and deliver it most effectively and efficiently,” he quips.
‘Massive Rise of AI’
Apollo Hospitals’ Dr K Hari Prasad notes that there has been a “massive” rise in the use of AI in diagnosing various symptoms of the Covid-19. “According to the EYImperial College London survey, phone and video consultations have seen the greatest uptake across all technology solutions, with phone consultations being offered by 81% of HHS organisations (up from 39% before the pandemic) and video consultations available from 71% of organisations (up from 22% before the pandemic). Compared to this, the uptake has been higher in India at 86% for a phone consultation (up from 48% before pandemic) and at 83% for video consultations (up from 33% before pandemic). The public sector organisations in India preferred digital tools for self-help (92% organisations) and online self-assessment tools (89% organisations) over the phone consultation and video consultation.”
The AI, ML, Deep Learning has come of age, remarks Access Health Digital’s Pankaj Gupta. “7% of Google searches ie about 70,000 searches per minute are healthcare-related. Google AI, ML and DeepMind produce the most relevant results in split seconds. Deep Mind has recently announced that it can predict protein folding with amazing accuracy, which is a game-changer in drug discovery. I was a Jury member in one of the MedTech grand challenges held recently. Out of 50-odd startups, at least 30 had AI, ML, Mobile, Cloud, IoT offerings are built into it for automation of the analysis, inferences and actions. Apple, Fitbit and GOQii wearables do real-time monitoring of vitals. AI is built into our phones; it is silently sitting and sleeping with us and knows more about our behaviour patterns than any of our own family members.”
Need for Wide EMR, EHR Adoption
While IoT technology is just in the evolving stage and would add “great” value to the clinicians and healthcare providers at the point of care, Omni Hospitals’ Abdullah Saleem points out that the bigger challenge is that most of the HCPs have not implemented and adopted the basic EMR or EHR at the organisation level, so the biggest question is where is data to run developed the IoT-based algorithm to test it out under the R&D unit and then put it in the main product stack.”
Pandemic Boosted Digital Payments in E-health
The pandemic has provided a boost to digital payments worldwide, says Neeraj Lal. “According to Quantum Metric, the online transaction has increased by 52% and the number of online customers by 8.8% since the pandemic began. The WHO’s recommendation to people for avoiding cash payments and switching to contact less payments to limit the spread of the virus is turning out to be a catalyst for the Fintech industry.
He adds that digital payment volumes are also receiving a boost through the government, which has pledged monetary assistance to the poor via direct transfers to bank accounts. “Analysts say the psychological factor of people thinking of cash as unclean could prompt more adoption of things like Google Pay and Apple Pay. E-wallets and contactless cards are the top payment methods benefitting from this change, as consumers use less cash. This has helped in evolving the digital health ecosystem as we can see the evolving role of E-payments in teleconsultation, home quarantine and online appointment.”
Adds, Dr Param Hans Mishra, COO, IQ City Medical College & Hospital: “Digital payment has strengthened the reliability in providing services. It has established a better rapport between the service provider and the service seeker. It is a must to evolve digital health.”
Digital payment systems make it “very easy” for patients and care providers to pay and receive the payment, says Dwivedi. “There are anyway certain regulatory provisions mandating that cash payment cannot exceed a certain limit per OPD visit or per admission. Writing a cheque or depositing demand draft is very much outdated. Even a vegetable shop or a street vendor accepts payment through a mobile wallet.” The other benefit of the digital payment system, he adds, is that it is instant. There is no bank reconciliation related to delay and it is very easy to pay and receive. “This space is still evolving. There are problems in payment gateways of leading banks and they need to pay attention towards it, as it is going to be the future. If they do not sharpen their gateways, other specialist players will come and occupy this space.”
Saleem says that digital payment is adding value to maintain the precautions related to the Covid-19 pandemic as it helps to avoid physical currency-based transactions. However, the digital payment system cannot replace “100%” physical currency dealing. But, its adoption could be 70-80 % of the total transactions very soon. “As per the current speed of adoption, it should be achieved in the next 3-4 years.
Digital payments have enabled the country’s healthcare sector to go “truly” contactless, says Dr K Hari Prasad. With the increased mobile and the Internet penetration, patients can easily avail E-consultation and pay fees seamlessly using their preferred digital options such as UPI, E-wallets, and payment cards.
Gupta adds, “Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is set to cover 40% of India’s population. Health Insurance consolidation is likely to cross the coverage for 53% of the population. The number of claims is set to go up by at least 10x. Health insurance has no choice left but to automate its entire claims process. When the health insurance asks for the E-claims in standard machinereadable formats, the provider falls in line and complies. We call this the financial lever of change.”
Keeping Patient Data Safe
As the healthcare industry evolves with new technology and legislation, the nature of security threat to most personal data is also changing, observes Neeraj Lal. “End-of-life (EOL) software and infrastructure provide a healthcare data security risk as vendors discontinue support for your IT systems, including vital security patches. About 80% of healthcare data is predicted to pass through the cloud at some point in its lifetime, leaving patient data prone to the vulnerabilities of the cloud. Besides, if you store data in unencrypted folders in the cloud or if you send our results via E-mail, you pave the simple pathway for a hacker to access your most personal data.”
It was not easy to take away a 500- page file of health records, but it is easy to take a scanned file in a pen drive. This is a rudimentary example, says JP Dwivedi. “As more and more data becomes available, it becomes an easy target. There are so many interested parties. A few examples are drug manufacturers and suppliers, insurance companies, research organisations, rival business houses, political leaders from opposite parties and many more. Once an insurance company comes to know you have a tendency to develop a particular disease, it will try to protect itself by either denying health insurance or by charging higher premiums. I am not suggesting any of them are practising it, but this is a real possibility.”
Also, he cites, “So many epidemiological studies are being conducted for various purposes. As long as an anonymized data is being collected and used for statistical purposes, it may still be unfairly benefitting the agencies but does cross the boundary of ethics and regulatory compliances.” However, Dwivedi adds, as soon as personally identifiable data is collected and used for the purpose not already disclosed to the data owner or patient, it is an offence. The Personal Data Protection Act (PDPA) is about to come anytime soon and it will address these issues in detail. “For now, it is important to mention that the patient discloses personal health information in strict confidence. The agency that keeps this data is called data fiduciary. Hospitals, as they contain health data, will be classified as significant data fiduciary. Compliance requirements are stricter on such fiduciaries.”
No doubt, the compliance burden is going to increase, he points out. “However, this is not new. The Health Insurance Portability and Accountability Act (HIPAA) in the US and General Data Protection and Regulation (GDPR) in the EU have been present for a long time now. India already had the IT Act 2000 that was amended from time to time. The PDPA will be much more comprehensive and capable of protecting the data privacy requirements of patients. Standards will emerge mandating all the players in the field, including hospitals, software companies serving the hospitals, IT infrastructure service providers, Cloud service providers, data processing agencies, etc and products and services may need to implement a concept called privacy by design.”
The digital health journey of the Indian health sector has gained steam over the last 18 months. The novel concept is here to stay and boom as stakeholders understand the virtues of virtual care.