India’s digital health mission

(ORF: Expert Speak)

Dec 16: India’s digital health mission – https://www.orfonline.org/expert-speak/indias-digital-health-mission/ 

TOPIC:

• GS-2 – Government policies and interventions for development in various sectors and issues arising out of their design and implementation.

India’s digital health mission

Context: The 2017 National Health Policy’s mandate was to bring India closer to achieving universal health coverage. 

• This policy envisioned healthcare access of the highest level to all age groups, and the use of a preventive approach for treating diseases. In its implementation, the Ministry of Health and Family Welfare (MoHFW) acknowledged that to achieve these aims, India needs to digitise healthcare. 
• Commonly referred to as the Ayushman Bharat Digital Health Mission (ABDM), its establishment was recommended by India’s National Digital Health Blueprint under a committee set up by the MoHFW.

The growing need to introduce electronic health records 

• In the current form, ABDM lays little emphasis on the use of this health data by the public health research community. 
• Electronic health records are most useful to public health research. In the absence of electronic health records, data for public health research studies is usually collected by public health agencies or research institutes as part of an ongoing or new study. 
• This requires time to plan the study, recruit participants, and train field staff before the actual data collection. 
• To facilitate longitudinal analysis, such data collection also needs to be carried out at pre-decided future intervals that could be months or years apart. 
• The limitations to this include high cost and lengthy durations of time. Having access to pre-collected data will address both these limitations. Most importantly, data from the health ID is likely to be more complete as compared to most hospital records in India, which comprise of paper prescriptions or manual register entries.
• The COVID-19 pandemic has made it clear that to obtain evidence-based findings real-world data needs to be available. While there is no doubt that with prior health records, a doctor or physician can flag the severity of COVID-19 for someone who has a history of diabetes or blood pressure, the reverse of this is also true. 
• Using medical history and disease end-point data, unknown risk factors of the disease can also be identified. This would require that electronic health records be made available and supplemented with additional information of the patient such as lifestyle. 
• For western countries, electronic health records are maintained at the hospital level, and they commonly store responses to basic lifestyle questions as part of the patient’s health record.

Unique Health ID

One of ABDM’s objectives is to develop a repository of verified hospitals, clinics, doctors, physicians, nurses, and pharmacies. As claimed by the ABDM, this will help filter out all the unscrupulous medical entities to avoid fraud. The ABDM relies on the premise of creating a unique health ID (identifier) for Indians. 

The idea is to allow an individual to integrate all their health records onto one platform. Subject to the consent of the participating individual/patient, their health data will be made available for use by the treating doctor or physician, and more parties such as health insurance companies. 

This health ID is different from the Aadhaar ID; multiple health IDs can be generated for the same individual. 

• ABDM claims that this will allow individuals to keep certain medical records private such as those relating to sexual history. 
• Armed with a retrospective medical history of the patient, a physician can make better diagnoses. This will improve quality of treatment and overall healthcare, and bring down financial costs for the patient.
• Subject to the consent of the participating individual/patient, their health data will be made available for use by the treating doctor or physician, and more parties such as health insurance companies.

Technological Infrastructure

The involved digital infrastructure for storage and accessing this data will be built on the National Health Stack. 

• The stack is a collection of pre-written code (or commonly referred to as APIs) specific to interface with the ABDM system. 
• This will be one platform where those interested (and approved) file for insurance claims, can perform analytics in addition to storing individual health data and hosting the repository of various medical agencies. 
• This health stack will also integrate with payment gateways. 

Currently, around 14 crore users have enrolled for a health ID with the ABDM and the programme has been piloted for a year in six union territories in India.

What are the challenges?

Although ABDM is visionary and can be the much-needed digital intervention to improve healthcare access in India, its implementation and overall objectives need more thought. There are some issues that can be foreseen. These include patient-physician trust, technological challenges, and data protection. 

• Public Trust: In instances where remote or specialised consultation is being sought, a new physician or a doctor will need to gain the patient’s trust for obtaining consent of the patient to share their electronic health records.
• Internet Connectivity Problems: The public sector IT systems lack faster internet speed, robust websites, and lags in providing a seamless user experience. For a country where rates of computer illiteracy are high, interfaces need to be kept simple and should be more user friendly. 
• Training Personnel in Rural Areas: There is the issue of citizens living in rural areas accessing such a facility digitally. These citizens would need to rely on their treating doctor or physician, who is local to them, to register them for the health ID. 
  • This treating doctor or physician would also need to be trained in dealing with patients’ personal details and, most importantly, the fact that enrollment into the ABDM Health ID is voluntary, and not mandatory. 
  • Explanation on how the system works and the involved intricacies would also need to be communicated to allow citizens, especially in rural areas, to make an informed decision.
• Data protection: In the absence of data protection laws, both storage of one’s health data and its use will need to be governed by well laid down rules, even if there is consent by the individual/patient. 
  • Currently, there is a Data Empowerment and Protection Architecture (DEPA) drafted by the NITI Aayog in 2020 to govern access of such data by public and private agencies. 
  • For ABDM, the DEPA entails that if the individual/patient provides consent then their data can be shared to the agency requesting access. 
  • Granting of ‘consent’ to a doctor or any other involved agency such as insurance companies should not mean that the data can be used for any other purpose than what the consent was granted for or be stored by them locally. 
• Informed Consent: ABDM claims that the individual is at liberty to deny consent in sharing their data; however, this may lead to some penalisation of the individuals who do not provide consent. For example, an insurance company may incentivise those who consent to share their electronic health data and make processes more rigid for those who do not. 
  • Additionally, in some cases, consent may be sought from the organisation and not the individual. This would bypass individual consent for each request and needs another set of data governing rules, which are well-advertised and explained to the individual providing consent.

Can you answer the following question?

1. Digitalisation of healthcare in India is a game changer but it must be done with caution and awareness of the challenges associated with it. Discuss.