How To Make Ayushman Bharat A Success? By Building A Medical Record For Every Citizen

In 1946, a committee led by an Englishman presented its report to the Government of India. Sir Joseph Bhore committee’s report took a comprehensive view of India’s healthcare landscape and made several far-reaching recommendations. The newly independent country accepted the report in 1952. To this day, the Indian healthcare administration has followed the framework laid out in the report, with a pronounced emphasis on prevention and public healthcare.

India’s Constitution assigns the highest priority to health: “The State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties.” Indian leaders have, time and again, voiced their commitment to making healthcare the central pillar of their governance. Prime minister Jawaharlal Nehru’s dream of an egalitarian India included public health as a thrust area. Even the famous “Twenty Point Programme”, launched in 1975 by Indira Gandhi, included “health for all” as a key goal. Prime Minister Narendra Modi has repeatedly underscored the importance of good health to the nation.

Constitutional directives and political rhetoric notwithstanding, the investment and interest of the political class in healthcare has bordered on lackadaisical. Isolated institutions of excellence were created, and programmes were launched to tackle specific problems, several of which even achieved notable success. However, in the seven decades since the comprehensive reforms unleashed by the Bhore Committee report, no initiative took a big-picture view of India’s healthcare. Until now.

In the Union budget of 2018, the Finance Minister made several health-related announcements. These included launching the world’s largest insurance programme to provide cover to 50 crore Indians and the creation of 1.5 lakh wellness centres. They were greeted with much scepticism by many, and with joy by many others, mostly along partisan lines. None of the pundits, however, recognised them for what they really were: arguably, the largest healthcare reform since those that followed the Bhore Committee report. The government’s willingness to take a holistic look at healthcare is itself a major shift in thinking and deserves to be welcomed.

Equally surprising was the absence from the commentary of any mention of the information technology-enabled solutions which would be critical for the success of these new ambitious schemes. The economists, wonks, and policy mavens animatedly discussed all possible solutions for the astronomical challenges that Indian healthcare faces – except information technology (IT). This was odd because the incumbent government believes in the catalytic power of IT; sector after sector has been revamped to maximally exploit information and communications technology (ICT). However, in the case of healthcare, a similar vision is missing. Can Digital India truly be “digital” without a digital infrastructure for health?

A realisation long overdue is that ICT is an enabler, and we must steer healthcare towards a paradigm that is value-based and outcome-driven while being accessible and affordable for all. Not only can ICT improve care interventions and processes, it is obligatory in measuring costs, utilisation, quality, and effectiveness of care.

Therefore, it is to the government’s credit that it soon followed up the Ayushman Bharat announcement with the release of the document on National Health Stack (NHS), an information infrastructure backbone for Ayushman Bharat. The NHS was presented in a “consultation document” on the 6 July with a request for comments. The NHS itself is proposed to be built on the infrastructure already in place – the India Stack, which is in use for Aadhaar-related systems, particularly for cashless payments.

Still, the NHS alone will not be enough. To fully exploit ICT, India also must develop a digital record system – the National Electronic Medical Record System (NEMRS).

National Electronic Medical Record System (NEMRS)

The government must launch a programme to create the NEMRS in an open-source project. This system would provide the means to record the health data of every citizen and make it accessible to every authorised healthcare professional. The system should include all necessary modern tools for healthcare professionals to manage their patients in the most optimal way, all free of cost to them.

The NEMRS will be the locomotive and train to the rail tracks of the NHS. Indeed, the needs of the NEMRS should guide how the NHS is developed, and it should be the layer on which all the other pieces of IT infrastructure should be built. The NEMRS should be the main component of NHS, the lynchpin, and not just one of the many other components.

Since the clinical process is core to the entire healthcare industry, an IT representation of it must be created as early as possible, guided by the NEMRS needs. The representations for all other processes must be created based on the common model for patient data in the core process. Such an approach will ensure that even the systems for non-medical functions will rely upon data from clinical activities – the true north of healthcare.

Challenges NEMRS Can Help Tackle

The major changes currently underway have the potential to make Indian healthcare much better. Yet, without an effective electronic medical record system, there is a risk that they will fail, or yield only meagre benefits. Here, we discuss how NEMRS can help ameliorate some of the toughest problems of India’s massive healthcare delivery system.

1) Unavailability Of Reliable Data

Healthcare data is difficult to come by and is often not reliable. The problem is aggravated by the data structure and format being different for each location. As a result, public health policy formulation in India does not always accurately reflect the situation on the ground or the needs of the people. Insufficient data is also a major impediment for the type of research which relies upon quality data in large volumes for good results. Even the insurance sector, which relies heavily on large data sets for designing products, and on data from individual patients to verify claims, is stymied by the lack of availability and poor quality of data.

Also, currently there is no way for a doctor to access data collected by a different hospital. This leads to records being fragmented and incomplete, especially if the patient has passed through multiple doctors and hospitals, as is the case with many patients with chronic ailments.

An information infrastructure supporting the entire nation’s healthcare sector will unify data with a common structure and standards. It will create a seamless data repository which will not just improve patient care, but also allow better policies to be framed and will be a boon to biomedical research.

2) Limited Participation By Private Health Sector

Although the government is keen that private hospitals and practitioners play an active role in public health initiatives, the private sector has existed mostly in a parallel universe, with only nominal coordination with the public-sector healthcare machinery.

With a shared information infrastructure, a much higher level of cooperation can be achieved between public and private health organisations. The insurance component of Ayushman Bharat will be the gateway to health IT for most private and public health personnel of the country, but it will have to be the NEMRS that will make sure they are continually engaged with the system, providing precious data to drive progress.

3) Health Insurance Travails

Apart from the industry’s reluctance to provide affordable and inclusive insurance coverage, the insurance sector’s services leave a lot to be desired. Doctors and hospitals frequently complain that insurance reimbursements do not reflect the market price for procedures and treatments, and that the claims settlement process is cumbersome and error-prone. Government insurance schemes have also been plagued by inefficiencies and fraudulent claims.

All these problems can be traced to unavailability of software systems that can interoperate with patient records – yet another problem that the NEMRS will help overcome.

4) Shortage Of Qualified Doctors In Rural And Remote Areas

Even the shortage of qualified doctors in far-flung, underserved areas is a problem that ICT can help address. A de-facto redistribution of qualified medical manpower can be achieved by making the NEMRS a hub for doctors in urban or centralised locations to remotely guide and direct peripheral health workers in patient care. Some of this guidance will be mediated through real-time telehealth tools and automated clinical practice guidelines. Indeed, for many cases, automated medical guidelines can further reduce the reliance on an experienced doctor at the backend, as they execute depending upon the data of individual patients and give precise patient-specific advice at each step. The more the patients are attended to at their own locations, the less they will need the services at hospitals, reducing the burden on doctors and facilities at secondary and tertiary care centres.

5) Accountability In Healthcare Personnel – Absenteeism And Pilferage

Rampant absenteeism among peripheral healthcare workers has been identified as a problem by several analysts. This is partly due to the nature of grassroots work that takes them into community enclaves, away from the normal supervision available in offices. An ICT platform can make them more accountable by linking the tasks of the workers with their real-time location and patients’ residences.

Lax supervision of workers is also related to the problem of unavailability of drugs and other supplies at government hospitals; the shortages are partly due to pilferage, adding to the cost of healthcare. An ICT platform that crosschecks medical treatment with the utilisation of drugs and equipment, and tracks their inventory, would make such thefts difficult.

An Economic Imperative

It is difficult to come up with a concrete figure, but an EMR system deployed nationally could easily save the country thousands of crores of rupees. Most insurance programmes – even in the West, where record-keeping is of much higher quality – are plagued by frauds; 10-15 per cent of the claims are believed to be fraudulent. Though data is not available for India, one can surmise that government-sponsored insurance schemes are similarly losing a large chunk of money to fraud. With Ayushman Bharat expanding the scope of health insurance manifold, the risk of real monetary loss to the nation has also jumped significantly. Just as the dramatic expansion of the pool of insured people has opened up the possibility of many innovative business models in the healthcare space, it could also sharply increase the opportunities to defraud the government. Without a national health information infrastructure, Ayushman Bharat runs the risk of being a drain.

The NEMRS will make it nearly impossible to fabricate a sequence of events in support of a fraudulent claim. On the other hand, time-stamped data of each real event in a sequence of events in a care episode will itself be an irrefutable claim for every genuine case; all claims would be settled with just the click of a button. With the events being recorded in a blockchain-linked database, a legitimate claim will never be denied, and a fraudulent one will never be approved.

Just by making preventive measures more proactive and data-based, many more diseases could be detected at the first warning signs or even earlier, avoiding the loss of countless man-hours of productivity, besides saving on expensive drugs and procedures that are needed for treating more advanced diseases. Early detection of epidemics by the system tracking patterns of disease incidence can save the nation and its citizens a huge amount.

Another cost factor that an ICT solution can address is the indiscriminate testing and duplication of procedures due to non-availability of previous results and records of previous care episodes. The alert mechanisms of the NEMRS can remind doctors when they are about to order a test, that it has already been performed recently and its results are available within the system.

India’s public healthcare system can save even more if it centralises the procurement of drugs and other supplies, exploiting economies of scale and a bigger bargaining leverage.

Why India Alone Can Do It

The vision and value of the NEMRS to the nation is one thing; India’s ability to realise it is quite another. Can India even pull off such an ambitious project?

We believe that the NEMRS project is not only feasible, but that India is in a unique position and juncture in its history to pull it off.

India’s strength and depth in software engineering are formidable, with an impressive track record of accomplishing large-scale software projects. A project like the NEMRS will not only be welcomed by the software developer community at large, it will be embraced by Indian software giants, too. Additionally, India has a nation-wide biometric identification system that gives it a tremendous advantage that most countries lack. Aadhaar, India’s biometric ID system, will help solve one major challenge that even the US has not been able to address reliably – an ability to reconcile records of individuals stored under some variant of their names and other identification details in disparate systems and regions. Aadhaar can ensure that every citizen has a single record, unique and unified, no matter where their data is stored.

Why Now?

Not only does India have the capacity and the wherewithal to accomplish this project, this is the right time for India to launch it. The country is witnessing its biggest healthcare reform in ages, which is unlikely to be a success without a comprehensive health information infrastructure that links the insurance settlement system with the medical records of patients covered by the insurance. Since the government is already in reform mode and has shown the readiness to spend a large amount of money on it, not investing a little extra in creating the software system to support it will be short-sighted. Even the wellness programme of Ayushman Bharat is an ideal setting for a record system that is continuous across health and disease.

The time is also opportune because India has not yet been overrun by EMR software companies, each promoting its own “standard” for data and software interoperability, creating numerous unconnected silos – a problem that the US is still struggling to address. In the US, the handful of companies that created an oligopolistic control of the EMR market have shown a stubborn reluctance to using shared, non-proprietary standards in their products, stifling innovation.

Technology also has evolved to allow the conceiving of systems that cover entire nations in a secure, reliable way; EMRs built before now have all depended on the thinking, tools, and technologies of the yesteryears. For example, none of the extant EMRs exploit blockchain technology to create seamless, robust, tamperproof, longitudinal medical records. We have also learned a lot from the successes and failures of past projects.

The proposal to create a nationwide electronic medical record system is not a new idea. Several international organisations, including World Bank, UNICEF, and World Health Organization have recommended making ICT an integral component of healthcare strategies for developing nations. Globally, countries, ranging from those in the Far East to nations in Central Asia, Africa, and South America, are working on creating national health information infrastructures. India can do one better; it can create a system that will be more than an electronic medical record system – it can also be a platform to administer and manage health policies nationwide.

Why It Would Be Great For India

A Healthier India

Besides helping save the country a great deal of money, the NEMRS will help make Indians healthier by making their lifelong medical records available to their doctors. As people become increasingly mobile, with the economy gaining more dynamism, such universally accessible continuous records will play an important role in their health care. But the biggest impact will be made in preventive and public health by leading to more proactive interventions and data-driven policies, by automated patient outreach programmes, and by providing evidence-based guidance to health workers.

Jumpstarting A New Technology Revolution

A project of this scale and nature will stimulate technology innovation, especially if it is done as an open-source project, with extensibility features allowing even private companies to contribute and make profits. A standards framework will also allow many individuals and companies to contribute to the project while ensuring that the entire healthcare sector data will have a uniform format, allowing it to be used for nation-level research, interventions, and policy-making.

Supercharging Biomedical Research

Many new kinds of studies will be possible once data is available from across the nation. This is especially pertinent as we head into the era of genomic medicine and precision medicine, which depend on large volumes of reliable data.

Valuable inferences are being mined in other countries, by applying big data techniques to EMR data; the insights garnered are already changing disease models and the practice of medicine itself.

NHS-like Advantages

Pundits often bemoan India’s inability to create a health system that resembles the United Kingdom’s NHS, which has many advantages, including creating economies of scale and reducing costs. India cannot create an NHS, for Constitutional reasons, but it can certainly reap some of its benefits by creating a single information system for the entire nation’s healthcare. This can help in several ways. For example, it will allow projecting needs across the nation (if linked with the inventories of all government health facilities), bargaining for better prices from drug manufacturers, and needs-based personnel distribution.

Job Creation

Although IT is often blamed for job losses, in the context of Indian healthcare, it can serve to increase employment. We have difficulty in finding doctors to work in the many places where they are most needed. It is estimated that India currently has a deficiency of 600,000 doctors, mostly in rural and remote areas. The IT platform, being a highly precise means of managing remote workers, can orchestrate an army of non-physician health workers who can serve even in the remotest areas under supervision by doctors situated centrally. Each doctor could support five or more trained health workers; therefore, there is potential for creating 30 lakh new health sector jobs while significantly improving the quality of health services.

Soft Power For India

If the system is created in an open-source project, it will spur other countries, both developing and developed, to consider using it. This will be a feather in India’s cap, a further recognition of its innovative capacities in software – all in all, a boost to India’s soft clout.

“But This Has Already Been Done”

One may wonder, has this not been done before? Indeed, there are many EMRs already available, commercial as well as open-source ones. Most of those were built with outdated technologies, not leveraging the recent developments in blockchain, cloud computing, distributed databases, and real-time data updates and collaboration. Many are designed with the features most needed by healthcare professionals being given a short shrift in favour of the administrative ones. More critically, each of those systems, even the ones created in India, do not allow their data to be used seamlessly with data from another EMR – each has a format different from the next, even if following similar standards.

The Indian context demands certain features not considered essential for many other countries, including the ability to work in a low-bandwidth setting, adaptability for numerous languages, and user interfaces that work for small phone-like devices. Additionally, the new system will need to exploit the Aadhaar advantages for identification and for settlement of premiums and other payments.

Extant EMRs created by different government departments have limited functionality, are often confined to a single region or a specific health programme, and without the clinical decision guidelines, linguistic flexibility, and interoperability features that can be integrated into the NEMRS from the outset.

Ambitious But Cheap

How can India afford a system with these many hi-tech capabilities, and an ambition to record all the medical data of its 1.3 billion people? Further, having experienced the many missteps and inconveniences of similarly large-scale projects (such as Aadhaar, demonetisation, and goods and services tax initiatives), many of us are understandably wary.

This project can be different. It can start small as an open-source project, with the first phase only specifying the standards and creating a framework for subsequent development to proceed. Developers should then be encouraged to create multiple small sub-projects, each creating a different component for the NEMRS, compliant with the standards and deployable within the framework. Commercial vendors can pitch in with their contributions for the open-source components or create their specialised, standards-compatible versions. The government should fund only the core team of experts and engineers to get the project rolling and to sustain it. The aim would be to generate enough momentum for third-party developers and companies to jump in to create all its pieces.

Once the early version of the system is delivered, a pilot project must be commissioned to beta-test it and to study its impact, and to guide its deployment across the nation.

To sum up, the NEMRS will unify India’s disjointed health services into one harmonious and coherent system, giving a boost to our economic growth and development. It will improve the well-being of the people and increase the efficacy and efficiency of healthcare professionals. Additionally, it will be catalytic in triggering a new wave of innovation, allowing India to claim technological leadership globally.

India has all the elements needed to make an ambitious project like this one a success. It has the technical know-how, a workforce to implement it, and its Aadhaar (Universal Identification) programme will play a major role in unifying health records nationally.

Just as Aadhaar opened avenues for driving efficiencies and cost reduction in many areas, the NEMRS will create opportunities for improving operations in all areas that touch healthcare.

The National EMR project will be a boon for India – in terms of the economy, the well-being of the nation, addressing the needs of the people, and goodwill around the world.

Few projects have such transformative potential for so little an investment.

In writing this story, Dr Hemant Shah received inputs from Dr Amita Mukhopadhyay (associate professor of community medicine), Krishna Kant Sharma (technology professional), Vipul Kashyap, (director of Clinical Information Systems at Northwell Health), and Sanjeev Srivastava (technocrat and entrepreneur).