April 2018

How can Digital Health be Implemented as envisaged in the National Health Policy 2017? by Prof. Supten Sarbadhikari @supten

/ POLICY / 15 minutes of reading

The National Health Policy 2017 (NHP-2017) of India correctly identified the need for creating many new institutions like the National Digital Health Authority (NDHA).  However, the ground realities don’t appear to have been considered well enough. Early setting up of a functional NDHA is essential for India to avoid a digital health mess in future. The first job for the proposed NDHA will be to formulate a robust National Digital Health Strategy / Policy, in consultation with all the stakeholders. Caution needs to be exercised before cross referrals and sharing disparate information among different systems of medicine. Health informatics education must be embedded as an integral part for health and hospital management. It may be prudent to include Health in the Concurrent list of the Constitution of India. That will ensure a smooth adoption of digital health in India. Seeking comments on the Draft Bill DISHA (Digital Information Security in Healthcare Act) is a good start.


 It has been now more than a year that the (third edition of the) National Health Policy 2017 (NHP-2017) of India has been notified. While the accompanying Situation Analysis didn’t mention anything about Digital Health, the Policy correctly identified the need for creating many new institutions like the National Digital Health Authority (NDHA).

 Now, let us look at where do we stand one year later, regarding the ushering in of Digital Health in India.

First let us glance at some of the key provisions of the NHP-2017 as mentioned in the various sections. Just beneath the quotes from the relevant sections of the NHP-2017, I’m commenting on certain issues for thought.

2.4.3.3 Health Management Information

a. Ensure district-level electronic database of information on health system components by 2020.
b. Strengthen the health surveillance system and establish registries for diseases of public health importance by 2020.
c. Establish federated integrated health information architecture, Health Information Exchanges and National Health Information Network by 2025.

 Comments: The NHP-2017 focuses on Digital technology, right from the beginning. Some timelines are also proposed here. However, while some states have been doing very well, some others are lagging. We would further elaborate on this aspect towards the end.

 3.3 Organization of Public Health Care Delivery: 
For effectively handling medical disasters and health security, the policy recommends that the public healthcare system retain a certain excess capacity in terms of health infrastructure, human resources, and technology which can be mobilized in times of crisis.

In order to leverage the pluralistic health care legacy, the policy recommends mainstreaming the different health systems. This would involve increasing the validation, evidence and research of the different health care systems as a part of the common pool of knowledge. It would also involve providing access and informed choice to the patients, providing an enabling environment for practice of different systems of medicine, an enabling regulatory framework and encouraging cross referrals across these systems.

Comments: Here there is a need for more caution since the other streams of medicine – viz., Ayurveda, Yoga and Naturopathy, Siddha, Unani and Homeopathy, follow entirely different principles from those followed by modern medicine. Therefore, cross referrals may add to the complexity and confusion, ultimately harming the patient.

 11.1 Medical Education: 
The policy recognizes the need to revise the under graduate and post graduate medical curriculum keeping in view the changing needs, technology and the newer emerging disease trends.

Comments: There have been a lot of issues regarding the Medical Council of India and the National Board of Examinations in the past, followed by a proposed revamping through the National Medical Commission. Despite all the proposed changes, one of the essential features that is amiss is the incorporation of health informatics essentials in all branches of health professional education. Without doing that, a smooth adoption of digital health is extremely difficult.

 11.8 Public Health Management Cadre: 
The policy proposes creation of Public Health Management Cadre in all States based on public health or related disciplines, as an entry criteria.

Comments: In continuation of the previous section, health information management must be embedded as an integral part for health and hospital management. Health Informatics weds both health information technology and health information management. Scaling up, public health informatics combines health informatics and population demographics.

 13.12: Health Information System: 
The objective of an integrated health information system necessitates private sector participation in developing and linking systems into a common network/grid which can be accessed by both public and private healthcare providers. Collaboration with private sector consistent with Meta Data and Data Standards and Electronic Health Records would lead to developing a seamless health information system. The private sector could help in creation of registries of patients and in documenting diseases and health events.

Comments: Most of the times various health information systems don’t talk to each other and therefore there is a dire need of Standards for interoperability. I would discuss this issue in greater details this issue towards the end, where I would talk about the Clinical Establishments Act.

 14.2: Regulation of Clinical Establishments: 
A few States have adopted the Clinical Establishments Act 2010. Advocacy with the other States would be made for adoption of the Act. Grading of clinical establishments and active promotion and adoption of standard treatment guidelines would be one starting point. Protection of patient rights in clinical establishments (such as rights to information, access to medical records and reports, informed consent, second opinion, confidentiality and privacy) as key process standards, would be an important step. Policy recommends the setting up of a separate, empowered medical tribunal for speedy resolution to address disputes /complaints regarding standards of care, prices of services, negligence and unfair practices. Standard Regulatory framework for laboratories and imaging centers, specialized emerging services such as assisted reproductive techniques, surrogacy, stem cell banking, organ and tissue transplantation and Nano Medicine will be created as appropriate.

Comments: Discussed below separately.

 14.5: Medical Devices Regulation: 
The policy recommends strengthening regulation of medical devices and establishing a regulatory body for medical devices to unleash innovation and the entrepreneurial spirit for manufacture of medical device in India. The policy supports harmonization of domestic regulatory standards with international standards. Building capacities in line with international practices in our regulatory personnel and institutions, would have the highest priority. Post market surveillance program for drugs, blood products and medical devices shall be strengthened to ensure high degree of reliability and to prevent adverse outcomes due to low quality and/or refurbished devices/health products.

Comments:  Medical Devices Rules, 2017 that has come into force with effect from 1st day of January, 2018, has included in the Part-I of the first schedule Parameters for classification of medical devices other than in vitro diagnostic medical devices. There, Software as Medical Device (SaMD) is defined as: (iii) Software, which drives a device or influences the use of a device, falls automatically in the same class. This is indeed a very forward looking and welcome legislation, ahead of the times in our country.

 22: Health Technology Assessment: 
Health Technology assessment is required to ensure that technology choice is participatory and is guided by considerations of scientific evidence, safety, consideration on cost effectiveness and social values. The National Health Policy commits to the development of institutional framework and capacity for Health Technology Assessment and adoption.

Comments: We can combine these aspects with the digital health technology, described in the next section.

 23: Digital Health Technology Eco – System: 
Recognising the integral role of technology(eHealth, mHealth, Cloud, Internet of things, wearables, etc) in the healthcare delivery, a National Digital Health Authority (NDHA) will be set up to regulate, develop and deploy digital health across the continuum of care. The policy advocates extensive deployment of digital tools for improving the efficiency and outcome of the healthcare system. The policy aims at an integrated health information system which serves the needs of all stake-holders and improves efficiency, transparency, and citizen experience. Delivery of better health outcomes in terms of access, quality, affordability, lowering of disease burden and efficient monitoring of health entitlements to citizens, is the goal. Establishing federated national health information architecture, to roll-out and link systems across public and private health providers at State and national levels consistent with Metadata and Data Standards (MDDS) & Electronic Health Record (EHR), will be supported by this policy. The policy suggests exploring the use of “Aadhaar” (Unique ID) for identification. Creation of registries (i.e. patients, provider, service, diseases, document and event) for enhanced public health/big data analytics, creation of health information exchange platform and national health information network, use of National Optical Fibre Network, use of smartphones/tablets for capturing real time data, are key strategies of the National Health Information Architecture.

 23.1 Application of Digital Health: 
The policy advocates scaling of various initiatives in the area of tele-consultation which will entail linking tertiary care institutions (medical colleges) to District and Sub-district hospitals which provide secondary care facilities, for the purpose of specialist consultations. The policy will promote utilization of National Knowledge Network for Tele-education, Tele-CME, Tele-consultations and access to digital library.

23.2 Leveraging Digital Tools for AYUSH: 
Digital tools would be used for generation and sharing of information about AYUSH services and AYUSH practitioners, for traditional community level healthcare providers and for household level preventive, promotive and curative practices.

 Comments: This is a very correct decision and the first job for the proposed NDHA will be to formulate a robust National Digital Health Strategy / Policy, in consultation with all the stakeholders. The first constituents of the Authority will lay down the rules of the game as to how will digital health be adopted in India. The earlier the NDHA is set up and functional, the better it will be for India to avoid a digital health mess in future. Any delay in the process might make us deal with non-interoperable legacy systems, as has been the case in many developed nations. However, cross referrals and sharing disparate information among different systems of medicine may add to the complexity and confusion, ultimately harming the patient. Currently, the MoHFW is seeking comments on the proposed DISHA (Digital Information Security in Healthcare Act) that will be the Bill setting up the NDHA / NeHA.

 25. Health Research: 
The National Health Policy recognizes the key role that health research plays in the development of a nation’s health. In knowledge based sector like health, where advances happen daily, it is important to increase investment in health research.

 25.1 Strengthening Knowledge for Health: 
The policy envisages strengthening the publicly funded health research institutes under the Department of Health Research, the apex public health institutions under the Department of Health & Family Welfare, as well as those in the Government and private medical colleges. The policy supports strengthening health research in India in the following fronts- health systems and services research, medical product innovation (including point of care diagnostics and related technologies and internet of things) and fundamental research in all areas relevant to health- such as Physiology, Biochemistry, Pharmacology, Microbiology, Pathology, Molecular Sciences and Cell Sciences. Policy aims to promote innovation, discovery and translational research on drugs in AUSH and allocate adequate funds towards it. Research on social determinants of health along with neglected health issues such as disability and transgender health will be promoted. For drug and devices discovery and innovation, both from Allopathy and traditional medicines systems would be supported. Creation of a Common Sector Innovation Council for the Health Ministry that brings together various regulatory bodies for drug research, the Department of Pharmaceuticals, the Department of Biotechnology, the Department of Industrial Policy and Promotion, the Department of Science and Technology, etc. would be desirable. Innovative strategies of public financing and careful leveraging of public procurement can help generate the sort of innovations that are required for Indian public health priorities. Drug research on critical diseases such as TB, HIV/AIDS, and Malaria may be incentivized, to address them on priority. For making full use of all research capacity in the nation, grant- in- aid mechanisms which provide extramural funding to research efforts is envisaged to be scaled up.

 25.2 Drug Innovation & Discovery: 
Government policy would be to both stimulate innovation and new drug discovery as required, to meet health needs as well as ensure that new drugs discovered and brought into the market are affordable to those who need them most. Similar policies are required for discovering more affordable, more frugal and appropriate point of care diagnostics as also robust medical equipment for use in our rural and remote areas. Public procurement policies and public investment in priority research areas with greater coordination and convergence between drug research institutions, drug manufacturers and premier medical institutions must also be aligned to drug discovery.

 25.3 Development of Information Databases: 
There is also a need to develop information data-bases on a wide variety of areas that researchers can share. This includes ensuring that all unit data of major publicly funded surveys related to health, are available in public domain in a research friendly format.

 25.4 Research Collaboration: 
The policy on international health and health diplomacy should leverage India’s strength in cost effective innovations in the areas of pharmaceuticals, medical devices, health care delivery and information technology. Additionally leveraging international cooperation, especially involving nations of the Global South, to build domestic institutional capacity in green-field innovation and for knowledge and skill generation could be explored.

Comments: For health research and innovation the government’s role of encouraging Standards for interoperability and allowing open data for analysis will go a long way.
Apart from the NHP-2017, there are certain existing legislations that affects the adoption of digital health in India. The first and foremost is the 2012 Amendments of the Clinical Establishments Act 2010. The other guidance comes from the Constitution of India. Both of these are discussed below.

 Clinical Establishments (Registration and Regulation) Act (CEA): 
In 2012, the MoHFW amended the CEA (2010) and added Clause “9 (iv): the clinical establishments shall maintain and provide Electronic Medical Records (EMR) or Electronic Health Records (EHR) of every patient as may be determined and issued by the Central Government or the State Government as the case may be, from time to time”.

Comments: The Act has taken effect in the four states namely, Arunachal Pradesh, Himachal Pradesh, Mizoram, Sikkim, and all Union Territories since 1st March, 2012 vide Gazette notification dated 28th February, 2012. The states of Uttar Pradesh, Uttarakhand, Rajasthan, Jharkhand, Bihar and Assam have adopted the Act under clause (1) of article 252 of the Constitution. 

The Ministry has notified the National Council for Clinical Establishments and the Clinical Establishments (Central Government) Rules, 2012 under this Act vide Gazette notifications dated 19th March, 2012 and 23rd May, 2012 respectively.

 The Act is applicable to all kinds of clinical establishments from the public and private sectors, of all recognized systems of medicine including single doctor clinics. The only exception will be establishments run by the Armed forces.

 The good point is the enactment of the necessity for EMR / EHR. The Ministry of Health and Family Welfare has been notifying Standards for EHR since August 2013 and the second edition of the Guidelines were notified in December 2016. That is the right way to move forward. However, Health being a State subject, not all the states are equally keen to adopt it.

 Concurrent List: The seventh schedule of the Constitution of India lists “Health” (Public health and sanitation; hospitals and dispensaries) under the Item 6 of List-II (State list). As expected, like the Union ministry, health ministers of various states have also agreed to equipping PHCs and CHCs with latest technology.

Comments: However, as seen in the previous section, the CEA has not yet been adopted by most of the states of India. Therefore, although the CEA mandates EMR / EHR, most of the states are not yet bound to follow it. Since Health is neither in the Union list, nor in the Concurrent list, it may be prudent to include it in the Concurrent list. In that case adoption of digital health would be much smoother.

 Conclusions:
While the NHP-2017 is bold in its thoughts and foresight, for facilitating digital health, the ground realities don’t appear to have been considered well enough. Early setting up of a functional NDHA is essential for India to avoid a digital health mess in future. Inordinate delays might make us deal with non-interoperable legacy systems. The first job for the proposed NDHA will be to formulate a robust National Digital Health Strategy / Policy, in consultation with all the stakeholders. 

Caution needs to be exercised before cross referrals and sharing disparate information among different systems of medicine. Health informatics education must be embedded as an integral part for health and hospital management. Since Health is neither in the Union list, nor in the Concurrent list of the Constitution of India, it may be prudent to include it in the Concurrent list. In that case adoption of digital health would be much smoother. 

Seeking comments on the Draft Bill DISHA (Digital Information Security in Healthcare Act) is a good start.

 References:
[1]: Ministry of Health and Family Welfare, Government of India, National Health Policy 2017: https://www.nhp.gov.in//NHPfiles/national_health_policy_2017.pdf (Accessed 19th February 2018)

[2]: Ministry of Health and Family Welfare, Government of India. Situation Analyses: Backdrop to the National Health Policy – 2017, New Delhi. Available from : https://mohfw.gov.in/sites/default/files/71275472221489753307.pdf

[3]: Sundararaman T, National Health Policy 2017: A Cautions Welcome, Indian J Med Ethics. 2017 Apr-Jun;2(2):69-71

[4]: Sarbadhikari SN. A farce called the National Board of Examinations. Indian J Med Ethics. 2010 Jan-Mar;7(1):20-2

[5]: Thomas G, Medical education in India – the way forward, Indian J Med Ethics. 2016 Oct-Dec;1(4):200

[6]: Government of India, The Gazette of India, dated 31/01/2017: http://www.cdsco.nic.in/writereaddata/Medical%20Device%20Rule%20gsr78E(1).pdf (Accessed 19th February 2018)

[7]: Government of India, The Gazette of India, dated 19/8/2010, Clinical Establishments (Registration and Regulation) Act 2010:
 http://clinicalestablishments.nic.in/WriteReadData/969.pdf  (Accessed 19th February 2018)

[8]: Government of India, The Gazette of India, dated 23/5/2012, Clinical Establishments (Registration and Regulation) Act, (Amendments) 2012:
http://clinicalestablishments.nic.in/WriteReadData/386.pdf (Accessed 19th February 2018)

[9]: Ministry of Health and Family Welfare, Government of India.  http://clinicalestablishmentstraining.nic.in/cms/Home.aspx (Accessed 19th February 2018)

[10]: National Health Portal, Ministry of Health and Family Welfare, Government of India, EHR Standards: https://www.nhp.gov.in/electronic-health-record-standards-for-india-helpdesk_mty (Accessed 19th February 2018)

[11]: Government of India, The Constitution of India  http://lawmin.nic.in/olwing/coi/coi-english/coi-4March2016.pdf  (Accessed 19th February 2018)

[12]: Press Information Bureau, Government of India, Shri J P Nadda chairs 12th Conference of the Central Council of Health and Family Welfare to discuss Draft National Health Policy, dated 27/02/2016: http://pib.nic.in/newsite/PrintRelease.aspx?relid=136961 (Accessed 19th February 2018)

[13]: Ministry of Health and Family Welfare, Government of India. https://mohfw.gov.in/newshighlights/comments-draft-digital-information-security-health-care-actdisha (Accessed 28th March 2018)

[14]: National Health Portal, Ministry of Health and Family Welfare, Government of India, EHR Standards: https://www.nhp.gov.in/ehr-standards-helpdesk_ms (Accessed 28th March 2018)

The article was first published on Dr. Supten’s Blog here, its been re-published here with the author’s permission.

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Prof. Supten Sarbadhikari

Digital Health Influencer & Project Director at Centre for Health Informatics of the National Health Portal; President IAMI (2016)
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Clinical Decision Support Systems: Resolving the “Build or Buy” Dilemma – Part 2 by Dr. Ujjwal Rao, @drujjwalrao

/ EMR/EHR/HIMS / 6 minutes of reading

The 2 part paper (review part 1 here): Discusses the key role of evidence-adaptive clinical decision support systems (CDSS) in the healthcare system of the future. Weighs the pros and cons that hospitals should consider when deciding to buy or build such decision support tools


Healthcare providers today face the challenge of delivering up-to-date, evidence-based care given the ever burgeoning pool of medical evidence, which is not only prone to inconsistencies but also take an average of 17 years to make their way into routine clinical practice. 

Coupled with the hassle of meeting advance electronic health record (EHR) platform integration requirements, Dr. Rao proposes that buying knowledge-based CDSS is increasingly more favorable and the way forward. 

A number of major initial and ongoing hurdles with home-grown solutions – including the significant time and effort needed to constantly update evidence – could overwhelm and overburden healthcare organizations, taking time away from delivering standardized and evidence-based care. 

Dr. Rao offers five ways on how these challenges can be avoided with the purchase of third-party CDSS platforms.


 Care that is important is often not delivered. Care that is delivered is often not important1.

IMPLICATIONS OF BUILDING CDSS

While the idea of building a CDSS that perfectly fits your organisation’s unique workflows appears an obvious choice, it eventually becomes clear that maintaining such a one-of-a-kind system can be unsustainable.

Medical knowledge-base construction and maintenance is a significant challenge. After the first few years of creating the knowledge base, adding new evidence to the system is no longer research – it is system development. As such, it becomes increasingly difficult to recruit a cadre of medically knowledgeable individuals who can devote substantial effort to knowledge-base maintenance over time. Creating a Clinical Practice Guideline (CPG) usually takes three to six months (or even a year), depending on the subject matter9. 

The maintenance of a CPG is likely to take more than a quarter of the time it took to originally develop the Guideline10. To develop CPGs, a standard set of guidelines covering all specialties, represents 12,000 hours of work at a cost of more than 1 million USD for just the content alone10. The total cost of authoring, reviewing, and EHR integration can surpass 3 million USD for just 200 Order Sets11. With the growth of Fifth and Sixth Generation EHRs, the concept of building in-house CDSS will increasingly become less favorable.

BENEFITS OF BUYING CDSS

As we move from logical (rules-based) CDSS to a foreseeable future of statistical (machine learning-based) systems, the decision to purchase rather than build and maintain knowledge-based CDSS becomes a sensible, convenient and cost-effective choice (Table 2).



First and foremost, choosing to “buy” third-party CDS Solutions can help to outsource the huge burden of managing and updating the clinical knowledge base to a vendor that provides the dual advantage of access to peer-reviewed content created by experts, and amalgamating organisational workflows with
evidence-based practices via collaborative platforms. Building consensus amongst “experts” becomes easier when the source of evidence is credible.

Advanced CDSS are usually built on accepted and defined standards that have been peer-reviewed and fine-tuned to provide higher sensitivity and specificity for each condition.


Customisation can also be taken a step further by selecting solutions that have a content management system for ease of customising the content to fit specific guidelines of the organisation. These external CDSS may also have a proven track record of effectiveness with other organisations, which in turn results in costs savings for less ‘trial-and-error’ as compared to “building” CDSS. The return on investment is primarily in the form of reduced spending on unnecessary tests and procedures as well as avoidance of costly adverse events (and in many systems, malpractice litigation claims), and secondly in the form of saved care replacement costs that result from pulling clinicians away from care processes (to build CDSS). These savings can add up to significant amount annually – almost 2.6 million USD as per one estimation11. 

Furthermore, such standard CDSS implementations enable interoperability in Health Information Exchanges. As far as project implementation is concerned, an external influence provides the opportunity to reengineer improvements into your original processes. Advancements in interoperability standards also facilitate more seamless integration with EHR. Professional practice services for EHR integration and implementation support that are provided by progressive knowledge partners, can cut down the implementation costs significantly and improve the efficiency and effectiveness of a large-scale CDSS roll-out. 

Lastly, with pharmacogenomics becoming an emerging field in patient care, demand for this new form of CDSS is increasing. In this case, building this knowledge base seems even less of an option when considering the expertise and time needed to manage and update it.

CONSIDERATIONS IN SELECTING CDSS


As with all third-party platforms, the convenience that comes with buying often includes challenges that need consideration. These include the integration effort for disparate platforms, investment in system upgrades and the additional effort from IT staff for monitoring the performance of these external platforms. Legacy stand-alone CDSS systems need to be integrated or discontinued. Yet, certain safeguards or mitigation plans can be considered to maximize the advantage of buying CDSS. 

These are best summarized in the following five C’s: 

1. Clinical team: Selection and implementation of the CDSS should involve the clinical teams to ensure that it meets the needs of the end-user for successful adoption and continued usage 
2. Credibility: Consider vendors with a proven case of working with other providers to smoothly manage the change experience 
3. Capability: Evaluate vendor’s ability to effectively synthesize evidence into evidence-adaptive technology platforms, thereby successfully bringing about true practice transformation 
4. Configuration: Ensure EHR platforms have been configured to integrate with CDSS and updated to comply with latest interoperability standards 
5. Computation: Define metrics that measure performance of each CDS element and outline a clear process for monitoring to tweak elements that are underperforming 

Following the appointment of a vendor, healthcare organizations should further establish governance structures and develop a clinical knowledge management framework that can consistently track and improve effectiveness of their chosen CDSS platform. In all, keeping in mind the above considerations will enable providers to better chart out their journey towards a successful CDSS adoption.

CONCLUSION

With the deluge of evidence that is often fallible and slow to diffuse into clinical practice, along with advanced EHR platform integration requirements, hospitals must reconsider their likely initial inclination towards building their own CDSS. A number of major initial and ongoing challenges with home-grown solutions, including care replacement costs, time and effort to constantly update evidence; usability; implementation and maintenance costs; and accepted functional practice integration can be overcome with the purchase of proprietary CDSS. Overall, the selection of CDSS should also involve the clinical team from the start, as well as careful selection of vendors who show a high level of willingness to partner in the transformation journey.


Author

Dr. Ujjwal Rao

Dr. Ujjwal Rao is Senior Clinical Specialist in Integrated Decision Support Solutions, and is based in New Delhi, India. He provides strategic counsel to health providers on designing world-class clinical decision support systems with Elsevier’s comprehensive suite of current and evidence-based information solutions that can improve the quality and efficient delivery of healthcare.

An experienced emergency physician, executive, clinical informaticist and technology evangelist, Dr. Rao has a decade of experience serving in trust and corporate hospitals in various roles ranging from clinical administration, hospital operations to quality & accreditation. In his former positions, Dr. Rao led EHR implementations for large hospital groups and designed bespoke healthcare analytic solutions to raise profitability.

His passion to see transformation through technology led him to volunteer as a quality consultant with the United Nations. He also currently serves as an Assessor on the Panel of the Quality Council of India for the National Healthcare Accreditation Standards body, NABH.

Dr. Rao obtained his degree in Medicine and then specialized in Hospital and Health Systems Management, Medical Law and Ethics before completing his PhD in Quality and Medical Informatics.

Clinical Decision Support Systems: Resolving the “Build or Buy” Dilemma – Part 1 by Dr. Ujjwal Rao, @drujjwalrao

/ #DIGITALHEALTH / 6 minutes of reading
Healthcare providers today face the challenge of delivering up-to-date, evidence-based care given the ever burgeoning pool of medical evidence, which is not only prone to inconsistencies but also take an average of 17 years to make their way into routine clinical practice. 


The 2 part paper: Discusses the key role of evidence-adaptive clinical decision support systems (CDSS) in the healthcare system of the future. Weighs the pros and cons that hospitals should considered when deciding to buy or build such decision support tools

Coupled with the hassle of meeting advance electronic health record (EHR) platform integration requirements, Dr. Rao proposes that buying knowledge-based CDSS is increasingly more favorable and the way forward. 

A number of major initial and ongoing hurdles with home-grown solutions – including the significant time and effort needed to constantly update evidence – could overwhelm and overburden healthcare organizations, taking time away from delivering standardized and evidence-based care. 

Dr. Rao offers five ways on how these challenges can be avoided with the purchase of third-party CDSS platforms.

Care that is important is often not delivered. Care that is delivered is often not important1.

The importance of clinical care grounded in a reliable evidence base cannot be over-emphasised. Evidence-based care processes, supported by automated clinical information and decision support systems, offer the greatest promise of achieving the best outcomes2. Proprietary Clinical Decision Support Systems (CDSS) built on evidence-adaptive platforms incorporating clinical knowledge that continually reflects current EBM gleaned from both the research literature and sources of practice expertise will soon outgrow self-synthesised (home-grown) solutions. This paper explores this process.

 Clinical practice is full of contradictions, not only where individual professional experiences conflict, but even where “evidence” partially or completely disagrees. The primary reason for these inconsistencies is that evidence is dynamic and emergent, never constant.

The Fallibility of Evidence

Evidence can often be incomplete, with varying levels of quality and strength of recommendations3. Keeping up with latest evidence and eliminating its inconsistencies is quite an arduous task and carries the inherent risk of practicing outdated medicine (with occasional catastrophic consequences). 

 Consider the following scenario:

 A 2 month-old infant comes to your office suffering from heart failure. She has a prescription for two drugs that reduce excess fluids from the body (diuretics), prescribed by a cardiologist based on evidence demonstrating the effectiveness of the two medications when administered together. One of the drugs reduces the body’s level of potassium (an important electrolyte) while the other conserves potassium. You are doubtful that two drugs are required for the treatment of such a young patient. Given the amount of time it will take to find evidence to address your skepticism, you call the cardiologist. Unfortunately, the prescribing cardiologist is unavailable, so you then call another renowned cardiologist. He tells you to stop the second drug based on professional experience that it causes growth problems in infants as well as his belief that potassium loss is of little concern in infants. You are now left wondering what is best for your tiny patient, having moved from a stage of having no information to a stage of conflicting “information noise.”

 Given such realities of evidence-based medicine, one must consider: is the business of extrapolating evidence something providers and healthcare organisations are willing to do on their own?

THE EVIDENCE DELUGE

It has been estimated that greater than two million articles are published in the biomedical literature each year4. If a physician were to attempt to keep up with this literary explosion by reading two articles each day, at the end of one year, that physician would be more than sixty centuries behind! If physicians were to read everything of possible clinical relevance, they would need to read around 6,000 articles a day! 

 Compounding this problem is the conundrum of diffusion. “Diffusion” is the spread of best (research) evidence on managing diseases and symptoms to the patient bedside5. According to conventional wisdom, it takes an average of 17 years for validated clinical research findings to make their way into routine clinical practice6. In an age where global public health emergencies (like the recent Zika virus outbreak) require “knowledge hyper-loops” for rapid diffusion of knowledge into general practice, the 17-year latency needs to be radically shortened to 17 hours or even less.

A SOLUTION TO ACCELERATE LEARNING HEALTH SYSTEMS

Clinical Decision Support Systems (CDSS) have been described as the Computerised Patient Record (CPR) System’s Crown Jewel7. According to Gartner’s CPR generations (Fig 1), CPRs or Electronic Health Records (EHRs) have had an increasingly positive impact over the last few decades in reducing medical errors. With the inclusion of CDSS, the EHR evolves from being a provider “colleague” to a “mentor,” with the power to cover the entire care continuum in guiding clinicians at all points of care.



We are now seeing the evolution of the Sixth Generation EHR – “The Seer,” that has computable, standardised clinical data able to invoke clinical decision support from evidence-adaptive CDSS platforms. Although at present evidence-adaptive platforms require human intervention, we are now beginning to see the inclusion of artificial neural networks (deep learning), Bayesian networks, reinforcement learning, and other artificial intelligence techniques for synthesising evidence relevant to patient data in real-time, with potentially unprecedented insights for clinicians. Intelligence Augmentation (IA), where technology amplifies the decision-making capabilities of humans, has linked healthcare providers to vast amounts of patient data with relevant clinical knowledge, in real-time, at the point-of-care. We are likely to soon witness wide-scale proliferation of IA in Sixth Generation EHRs that incorporate evidence-adaptive CDSS. 

This kind of evidence-adaptive CDSS is at the heart of a Learning Health System (LHS)1, wherein evidence influences practice and the practice, in turn, generates evidence, creating self-propagating, virtuous cycles that bring about better, safer clinical care at optimal costs.



 There are six critical success factors (Table 1) for a CDSS, based on the ACUDIR model (Latin for “Come to the Rescue”), that can form the foundation of such a rapid LHS.


 CDSS solutions like Order Sets, Care Plans, and Clinical Pathways are a combination of evidence-based content and advanced technology platforms. The dilemma which healthcare organisations face today is whether they can “build” such advanced CDSS on their own or if they should “buy” proprietary CDSS products.

Read the Part 2 of this blog post by Dr. Ujjwal Rao, here

 Author

Dr. Ujjwal Rao

Dr. Ujjwal Rao is Senior Clinical Specialist in Integrated Decision Support Solutions, and is based in New Delhi, India. He provides strategic counsel to health providers on designing world-class clinical decision support systems with Elsevier’s comprehensive suite of current and evidence-based information solutions that can improve the quality and efficient delivery of healthcare.

An experienced emergency physician, executive, clinical informaticist and technology evangelist, Dr. Rao has a decade of experience serving in trust and corporate hospitals in various roles ranging from clinical administration, hospital operations to quality & accreditation. In his former positions, Dr. Rao led EHR implementations for large hospital groups and designed bespoke healthcare analytic solutions to raise profitability.

His passion to see transformation through technology led him to volunteer as a quality consultant with the United Nations. He also currently serves as an Assessor on the Panel of the Quality Council of India for the National Healthcare Accreditation Standards body, NABH.

Dr. Rao obtained his degree in Medicine and then specialized in Hospital and Health Systems Management, Medical Law and Ethics before completing his PhD in Quality and Medical Informatics.

How do we value your #startup?  Part 2 by Arpit Agarwal, @arpiit

/ Startup Showcase / 3 minutes of reading

In the previous post we talked about how VCs perceive valuation and how to broadly deal with it. It was aimed to dispel some misconceptions most first-time entrepreneurs may have about this very important aspect of our business. This posts builds on that and another and gives you actual numbers to play with. Before you go on, it maybe a good idea to take a look at the way I define stages of a startup.

Round sizes and dilution benchmarks in India

Now that you know the only two thing that matters to a VC is the stake she’s getting and the amount she’s investing, it is best that you play accordingly. If you’re seen as obsessed too much about valuation, you’re likely to be considered a hard-nosed founder. So be smart and play for ‘lower dilution’ instead. In case you argue that these are one and the same thing, think again 🙂
The table below presents a broad structure of startup funding in India today. This is what is considered ‘average’ in our industry. Please note that all these numbers are only representative in nature and deals frequently happen on both sides of these extremes. Also, like any well-functioning market, these prices represent only a momentary equilibrium and this changes over time:
© Blume Ventures, 2018 — Please don’t republish without permission. Write to aa+help@blume.vc
What are the Terms and Conditions?
  1. At any stage of investment, the investor is making a forward judgement on the exit outcome. Hence, it is common for investors to bake the exit scenario in the way you are being valued. For example, if a Series A investor, who’d typically expect a startup to exit at $500M, may value a startup which may exit at only $250M (in their minds) much more harshly than a startup which could easily build a $1B or more as an outcome.
  2. All the rules of the market —namely, demand and supply — still apply. It is not uncommon for serial/exited entrepreneurs to raise money at 5–10x valuation than first-time entrepreneurs.
  3. Valuation remains the last step. Hence, if you don’t pass any of the filters a VC has in their model, your willingness to price yourself very attractively doesn’t count.

How can you use this information?

First, it is always a great idea to know what’s the playbook on the other side. At the same time, smart people would know that such discrete classifications can’t be taken for granted. Second, whenever you have term-sheet on offer, you should know that valuation is largely formulaic for a VC, hence pay immense attention to the terms that come along with it. That’s the detail most first-time entrepreneurs struggle with!
Finally, as most experienced entrepreneurs will tell you,

forget valuation and focus on creating things of value.

If there’s value, valuation cannot be far behind. And creating anything of value is incredibly hard in any economy, doubly so in India. Once you are past your curiosity about valuation, you’d notice that life after raising VC money becomes much harder. In fact, the more you raise (by corollary, the higher your valuation) the more complicated it will get!

What’s more?

Hope these two posts satisfy a lot of your curiosities. As you can imagine, the art of valuing a startup is much deeper than what we covered here. Do post your responses and ask me if I skipped a step in my explanation.

The article was first published in the Arpit’s Medium Blog here,  and has been republished here with the Author’s permission.

Author
Arpit Agarwal

Arpit has been involved with promotion of startups and ecosystem since 2006 when he co-founded Headstart Network, today India’s largest early stage entrepreneurs’ network with over 20 city chapters.

Arpit has been with Blume for last four years as a Principal, responsible for scouting science-led and hardware businesses, apart from managing a portfolio of about 15 companies, which include companies in a variety of sectors ranging from used goods market to IOT to Healthcare to Enterprise services.

He’s based in Delhi, in an MBA from IIT Bombay and holds a BTech from NIT Trichy

How do we value your #startup?  Part 1 by Arpit Agarwal, @arpiit

/ Startup Showcase / 5 minutes of reading

This is the favorite topic of every single startup entrepreneur in early stages of their evolution. It also incites an academic curiosity in a large number of people who, like the 3 adorable dads in this video, have a highly misplaced notion about it. A big reason why this happens is because we don’t write about it so often in India and, perhaps, everyone understands this quite well in US or China.


Before I begin talking about it, I must put the usual disclaimers — this applies mostly to a tech startup in India, comes from our colored experience of valuing companies and often reflects the mood of the industry at this point of time. Each of these are important as we will see below. Also, please read my prequel post on stages of evolution of a startup to get the context and definitions right.

Valuation is in the eyes of the beholder

It won’t be a hyperbole if I say that startup valuation is more of an art than a science. There are only a handful of thumb-rules and rest everything is a highly subjective item. Another thing to understand about valuation is that while a general thumb rule is widely accepted, there are several well-known exceptions that prove the rule that this is a very subjective exercise.
In most cases, it will appear as if you have been valued less by your investors and the startup run by your friend was valued much higher. Please note that getting a round itself is relatively rare event. You can do your best to optimize on the available options, but once you are past it, look ahead and move on. Basically,

A high or low valuation is not simply a function of you, your business or the traction. Raising money is a highly subjective topic and by no means should a founder value her ‘true worth’ by it, because it is not.

Valuation is the final step

In my sales job, I learned a very key lesson that applies to many things in life: pricing is always the final step. Why? Because pricing is something that brings the deal to a Yes or a No situation. It is also a true test of how well the value has been explained to the buyer. Most institutional investors won’t even talk about valuation and deal structures unless they have gone through several rounds of discussions, both with you and internal. Our process mirrors a series of filters. There are easily tens, if not hundreds, of filters that we apply before we decide to roll out the term-sheet. And you should know that this is a Series of filters and it is rare that someone is able to bypass any of them. But that topic deserves a post of its own.

Demand-Supply rule

Let’s assume that you fortunately passed through these filters easily and there’s strong expressed intent of the investor to invest in your company. One dirty secret that you need to remember is — there’s no real science behind valuing a startup, in any economy, leave alone India where the availability of market data is quite shallow in itself. Coupled with the fact that technology is going to, sooner or later, disrupt existing markets (think book retailing) or create completely new markets (think local taxis), it is nearly impossible to accurately value early stage startups. Hence,

Valuation of a startup is a function of the demand it is generating in the investor market

As simple as that! Now, if you argue that at some point this valuation should catch up with the public market multiples, you are right. But that will happen at least 5–7 years after the first round of funding. A lot of technology, regulation and other macro factors can change in this period. Hence, experienced investors have come up with thumb-rules that they use to propose a deal.

A word on the VC business

Each institutional investor has a clearly thought-out strategy to deal with investments. This determines what kind of companies they like (think of filters, as above), the kind of exit value they seek and what is the minimum they want to make as a return per investment.
For example, Blume Ventures loves all things tech — both B2B and B2C. Conversely, we have tried and failed in building consumer brands. Hence, we don’t like to invest into your apparel brand or restaurant chain or even a niche e-commerce business. If we choose to invest into a company, we expect it to deliver at least a $100M exit value and we want to give back our LPs at least $10M at your exit. This means we need to be holding at least 10% at exit. Given 3–4 rounds of dilution after our first check in, it is possible to hold 10% at exit only if we start closer to 18–20%. Further, as a constraint on our fund size ($60M) and the number of companies we want to invest in (40), our ticket size per first check is about $500k-1M (₹3.5–7Cr) or thereabout. Our ideal scenario is that we start with approximately 20% stake in the first round. Some of our recent term-sheet reflect this strategy exactly as I described.
But, did you notice that we didn’t even think of a valuation so far? That’s because

Valuation is a derived amount in VC business

We don’t obsess about valuation so long as our stake target is met and the check size doesn’t exceed our comfort level.

Stay Tuned

This post must have given you some food for thought on how to deal with investors and funding rounds. In Part 2, we will talk about the benchmark numbers, round sizes and, most importantly, how can you use all this knowledge to your best advantage.

The article was first published in the Arpit’s Medium Blog here,  and has been republished here with the Author’s permission.

Author
Arpit Agarwal

Arpit has been involved with promotion of startups and ecosystem since 2006 when he co-founded Headstart Network, today India’s largest early stage entrepreneurs’ network with over 20 city chapters.

Arpit has been with Blume for last four years as a Principal, responsible for scouting science-led and hardware businesses, apart from managing a portfolio of about 15 companies, which include companies in a variety of sectors ranging from used goods market to IOT to Healthcare to Enterprise services.

He’s based in Delhi, in an MBA from IIT Bombay and holds a BTech from NIT Trichy

5 product management hacks to build great products by Subhadeep Mondal, @smondal1008

/ PRODUCT MANAGEMENT / 5 minutes of reading

In the past 5 years, I had the opportunity to build and ship great consumer products which touches the lives of millions of people around the world. Recently, Branchmetrics invited me to share some of my learnings at Innov8 CoWorking Space along with speakers from UrbanLadder, HeadSpin, Branch.io and Glispa Global.

Here are some tips to keep in mind while building products.

1. Think Big, Start Small

A complex product that works is always an evolution of a simple product that worked.

If you have built a complex product from the scratch, it’s not gonna work. You have to start and figure out that simple product which works. This is relevant for any startup which is about to launch its product or an existing company who is about to launch a new product feature. You may have big ideas, but going to market as soon as possible should be your priority. So find out that simple, small functional part of your overall product that you potential users need the most and launch it. As Reid Hoffman says:

If you are not embarrassed by the first version of your product, you’ve launched too late.

2. Be obsessed about product definition

Over the last 5 years, I’ve realized startups often spend most of their efforts at the wrong steps of the product development process.
Suppose if you had 100 minutes to finish the end-to-end of a product. Most of the time I’ve seen startups spending time like the following.
85/100 minutes are spent on designing, building and beta testing, so what’s wrong with this process? Well, building a product is a combined effort of various cross-functional inter-dependent teams. To make sure, all the teams work in sync product definition is the most important step. The role of a product manager or a founder is to freeze on his thoughts and communicate the same very clearly across all the cross-functional teams. Why is it so important? It’s simple, it takes time and money to build a product. Each change you make, after the product definition step, will exponentially increase the go-to-market time which in turn increases the total cost of building the product.
So, spend as much time as you can prioritising and defining a product rather than getting lost in the vicious cycle of agile development between designers and developers. It will save lot of product development time and money for your startup.

3. Look at AARRR metrics daily

Make sure you track everything, observe and analyze the pirate metrics on a regular basis. This is very important because the first step of “product prioritization” is dependent on your pirate metrics. Make a habit of looking at data everyday morning while going to the office or starting your day at the office. You may or may not have to take immediate actions but the habit helps you keep numbers at your fingertips whenever you need to make instant decisions about the product. There are several tools to help you track AARRR metrics, here are few of them.

4. One new feature isn’t a solution

Most of the time you’ll think adding a new feature will improve one of my pirate metrics, but in reality, it’s the opposite. Often good products which have a really good core feature has seen a decrease in the engagement of the core features after 2 new features were introduced. So, give a lot of thought on “why” do your users need what you think they need and validate that hypothesis without even writing a single line of code. A new feature is not always the solution for your current problems.
How can you solve your metrics problems then? Well, small incremental efforts towards optimising your AARRR funnels will help you improve your pirate metrics not always a new feature.

4. Celebrate Usage and Not Shipping

This is very common among various product companies — they celebrate shipping of new products/features rather than celebrating usage numbers. Shipping actually means nothing! You have just shipped your products to your users and you have no idea how its adoption is going to be or how it is going to impact your overall AARRR metrics in days to come. Don’t waste your beer and money celebrating shipping of products, instead, keep usage numbers as the targets for your teams and celebrate those moments with your team.

5. Spent 30 mins with your users every day

All of us work from the comfort of our home or office analyzing and taking all sort of hypothesis on what a user wants. After making mistakes repeatedly, I’ve learned that speaking with 2–3 users every day gives you the knowledge and insights about your products which you have never thought about. It helps you know the stories of your users and how your product has been helpful to them in their day to day lives and also gives you relevant ideas on how you can make your product better. Don’t be shy, ask your users for 10 mins and they will be happy to give it you — but the first step is you asking them.
That’s it, I hope these insights will help you build your own startup, improve your current product development process, understand your customers better and improve your startup metrics. Happy to hear your current product development process and would be glad to share my thoughts.

Subhadeep Mondal

CoFounder of PregBuddy — a women healthcare platform, currently focused on expecting mothers. Prior to PregBuddy, I’ve led Product & Growth at SignEasy, Stayzilla, Gaana.com and cofounded Flixstreet.in back at my IIT days. Feel free to reach to me on Twitter @smondal1008 or at subhadeep@pregbuddy.com.

The article has been republished here with the Authors’ permission. The article first appeared in the author’s LinkedIn pulse page.

Author
Subhadeep Mondal

Co-founder & CEO of PregBuddy | Looking for Android FullStack Engineer | Speaker | Ex-Product at SignEasy, Gaana.com

Vision 2025: What Health Care Could Look Like a Decade from Now by Dr. Vicky Parikh, @ParikhVicky

/ #DIGITALHEALTH / 8 minutes of reading

Value-based care, coordinated care, information technology integration . . . healthcare is undergoing transformation.

Sweeping changes are putting pressure on the entire system, particularly from an administrative standpoint. With all the paperwork and logistics to worry about, it’s easy to grow frustrated and lose sight of what we are working to achieve: economically viable solutions for providing the highest level of care to all our patients.
Sometimes it helps to take a step back, to forget the red tape and day-to-day grunt work of overhauling a 2.8 trillion dollar industry. For a moment, let’s allow ourselves to focus only on the possibilities. Looking ahead, we’ll explore one patient’s journey through health care in the not-so-distant future. This is a story about health care in the year 2025.
Introducing Mr. Average Patient
Our patient – we’ll name him Philip – is a 35-year-old man in average health. Like many Americans, Phil tries to eat right and exercise, but enjoys rich foods, fails to sleep adequately, and relies on calorie-laden designer coffees, energy drinks to keep him energized. For months, he’s been ignoring symptoms of frequent urination, fatigue, and dry mouth. But when Phil’s smartwatch repeatedly alerts him of high blood pressure readings, he decides to speak with a doctor.
This is 2025, so Phil won’t be taking any time off work for an office visit. Instead, he logs into his personal health management system – a cloud-based program accessible via web browser or specialized app – for a video chat with a member of his care team (let’s call her Dr. McCoy).
While Phil describes his symptoms, the user interface provides Dr. McCoy an overview of his medical history. Phil’s vitals have been uploaded from his smartwatch and 20 pounds of weight gain have been registered by his smartscale over the past year. Dr. McCoy notes a family history with genetic predisposition of heart disease and diabetes, and that Phil’s most recent blood work, drawn over a year ago, showed an elevated blood glucose level.
Suspecting diabetes as the source of Phil’s woes, Dr. McCoy uploads an order for a CBC and A1C while sending Phil instructions for scheduling his outpatient appointment.
Exploring the untapped potential of mobile health
In this scenario, two trends diverge with promising results. First, we are taking advantage of the increased popularity and decreased cost of the Internet as a way to passively monitor patient health. Familiar devices already track heart rate, sleep quality, activity levels, weight and BMI for non-clinical purposes. Before long, these technologies will advance, allowing us to discreetly record temperature, blood pressure, pulse oximetry, and maybe even blood chemistry. Like crash avoidance systems on a car, these devices can act as early warning systems, alerting patients of brewing health problems and encouraging them to contact a health professional.
Secondly, we are combining this with the growing availability of “doctor on demand” services. Telemedicine companies such as Teladoc have seen exponential growth in recent years, largely fueled by changing reimbursement schedules. Currently, this low-cost alternative to traditional office and urgent care visits is limited to addressing the most common of health concerns (runny noses, etc). But, we envision telemedicine as an integral part of coordinated patient care. An on-call doctor with access to telemetry from wearables and a complete medical record could remotely diagnose and manage a wide variety of medical issues. In this futuristic system, patients benefit from convenience, doctors from increased efficiency and reduced overhead, and payers from lower costs.
Mr. Average Patient skips the waiting room
After Dr. McCoy signs off, Phil follows the link she sent him to make his outpatient appointment. Scrolling through the list of available providers, he sorts by location, price, patient ratings, and earliest availability. He chooses a location near his home and schedules a same-day appointment. Before logging off, he pays his copay and downloads directions to his phone’s GPS.
At the outpatient clinic, Phil checks in by tapping his smartphone to the reception kiosk. It provides him on-screen directions to the lab. There, he is greeted by his nurse who performs a quick physical examination before drawing Phil’s blood. All told, the appointment takes no more than 30 minutes out of our patient’s day.
How patient self-service benefits everyone
Consumers today are accustomed to booking airline flights, hotels, rental cars, even haircuts online. There is no reason health care providers shouldn’t benefit from this same technology. Early adopters have discovered that online appointment scheduling simultaneously reduces administrative burdens (and associated costs) while increasing patient satisfaction. The Oregon-based Zoom+ health system, for example, has established a positive reputation for itself by providing on-demand health care services with transparent pricing and online appointment scheduling. As more patients and providers join in, we foresee sites like ZocDoc evolving into Expedia-like clearinghouses complete with payment and review functions.
Further automation will take place on-site at medical centers. Already, some hospitals have discovered that both patients and staff enjoy the shorter lines and reduced wait times that check in kiosks accommodate. In our scenario, these kiosks have evolved to incorporate technology borrowed from modern mobile payment systems. With a tap, encrypted information is exchanged between the patient’s smartphone and the provider’s practice management system: uploading doctor’s orders, insurance authorizations, patient records, and payment information. The result is a near instantaneous check-in, freeing up staff, virtually eliminating paperwork, and dramatically speeding up appointment turnover. Once again, patients benefit from convenience while providers increase the number of patients they can see in a day, which lowers per-patient costs for payers.
Mr. Average Patient learns about self-care
The day after his appointment, Phil receives an email notification that his test results have come back. The email contains a link for another video chat with Dr. McCoy. She informs Phil that his labs indicate diabetes; she’d like to have a nurse practitioner come visit with him, or, if he’d prefer, she can schedule an appointment with his PCP. Phil opts for the nurse practitioner.
When Beverly, our local nurse practitioner, receives Dr. McCoy’s order, she calls Phil to schedule their face-to-face meeting. She brings with her his new medications and supplies (including a bluetooth-enabled glucose meter which will automatically record readings in Phil’s health management system). Together, she and Phil develop a care plan that includes follow up labs and visits with his GP. They set up reminder texts that help Phil remember to take and refill his medications on time. Phil also agrees to use his smartwatch to better manage his activity level and a nutrition diary to help him (and his care team) watch his caloric intake. Before leaving, Beverly leaves behind her contact information and informs Phil she’ll be checking in with him by phone once a week for the next several weeks.
Furthermore, Phil’s diagnosis automatically adds him to an email list for patients with diabetes. Unless he opts out, Phil will receive daily educational emails with informational articles, videos, healthy recipes, as well as lifestyle tips and challenges. He’s invited to attend local diabetes classes and to join an online forum for diabetics and their families.
Personal attention keeps patients out of hospitals
Patient non-compliance is currently costing the American health care system an estimated $290 billion every year. That number will only grow unless we improve patient engagement in self-care. Many factors have been identified as contributing to patient non-compliance. In this scenario, we tackle several of these issues.
Poor communication between patient and provider has been identified as one component in patient non-compliance. This is why we have given our patient a choice between visiting his GP or meeting a nurse practitioner in an environment where he feels more comfortable. The nurse practitioner serves the dual role of educating the patient and providing one-to-one support for someone who has just received a life-changing diagnosis. By staying in touch over time, she fosters a positive patient/provider relationship that can lead to greater trust and hence greater compliance.
Next, we are making sure to involve our patient in his own care planning. He is provided tools such as electronic reminders and an app-based nutrition diary to help him stay on track. By monitoring medication usage, diet, and exercise via the health management system, Phil’s care team is able to intervene if he is not following his care plan.
Finally, we are taking full advantage of modern multi-media resources for educational purposes. Being well-educated about one’s condition, medications, and long-term prognosis can help patients stick to their care plan. Since not all patients absorb information in the same way, our scenario uses a mix of articles, videos, game-like challenges, live classes, and online interactions with peers to keep him motivated.
The future of health care
Health care is looking to technology to boost efficiency and thereby lower administrative costs. Some in our industry worry this will detract from doctor/patient relationships, forcing doctors to spend more time staring at computer screens and less time interacting with patients. However, our scenario demonstrates how technology can actually increase personalization, contributing to higher patient satisfaction and better clinical outcomes. Nothing presented in our story is far-fetched; in fact, most of these technologies are already in use or under development in pockets across the nation. Our challenge is to identify and proliferate those innovations that most benefit the health care system as a whole: patients, providers, and payers alike.

The article is republished here with the authors’ permission. The article was first published here. 

Author
Dr. Vicky Parikh

Healthcare Executive who combines clinical, public heath, and data management knowledge and success, transforming healthcare systems and improving delivery and quality. Leads continuous improvement processes, creating fundamental change in healthcare industry with new value-based care delivery systems, innovative collaborations, and partnerships for a sustainable healthcare model. Strives to improve quality of healthcare while lowering costs. Specializes in advancing efforts in population health and care delivery models, addressing increased healthcare costs and improving quality of patient care.

#HIMSS18: Where the brightest mind in healthcare meet !! by @ tejasvdeshmukh

/ Uncategorized / 5 minutes of reading

Pinksocks HIMSS

















With more than 100+ meetings, exploring innovation, healthcare use cases and technologies defines a whole new equation of healthcare. It’s been over 3 weeks post HIMSS18 in Las Vegas; I am almost done with all my follow-ups and before getting caught up with ATA18 preparation, allow me to share my experience!


Known as the Mecca of Healthcare, HIMSS is a platform to explore innovation, meet thought leaders, network and partner. That said it is easy to get lost, loose orientation and miss out on meetings, when you are dealing with 40k+ attendees and 1000+ exhibitors. It is overwhelming the moment you enter Sand Expo and see HIMSS banners all over the place.
The Pinksocks meet-up that took place on the March 5th at Money Play Restro was filled with the most exuberant people. Nick Adkins has taken an initiative to consolidate all Healthcare professionals, who are determined to disrupt the industry with innovation. The HIMSS Social Media Ambassadors are part of this group and real meaningful exchange of information happened at the meet-up.
Disrupting technologies + Digital transformation = Better Patient Care
Let’s take a look at the trending topics at HIMSS18 that promise Better Patient Care:
  • Disrupting technologies  
    • Artificial Intelligence, Machine Learning, Big Data
    • Blockchain
  • Digital transformation
    • Mobility and Cloud
    • Wearable and IoT
    • Consumerism
  • Telehealth (From Synchronous to Asynchronous model)
Healthcare companies have finally realized the potential of Artificial Intelligence, Machine Learning in addition to Big Data. The ability to perform complex predictions in a blink of a second will result in advanced decision support, chat bots resulting in real time efficient care delivery system. From Ayasdi to Google Deep Minds, everyone is set to disrupt the traditional healthcare with super-efficient ecosystem.        

HIMSS18

  • Blockchain
It is another technology having tremendous potential to transform health care, shifting the patient at the core of ecosystem, coupled by enhanced data security, privacy, and interoperability.Blockchain will provide a new benchmark for interoperability by enhancing secure and efficient health data exchange. While it is not going to address all the healthcare challenges, it does provide a sense of confidence to explore, invest and test its actual potentials in Healthcare. PokitDok, Health Wizz and Hyperledger are amongst few to watch.
  • Mobility and Cloud
It is estimated that by end of 2018, 65% of healthcare interaction between patient and providers will occur using smart phone devices. 80% of doctors are already using one or other medical app to engage with patients.
Cloud is further transforming the way providers deliver quality and cost effective healthcare services. Adoption on cloud strategy significantly reduces infrastructure and administrative cost, thus providing relief from the ever growing pressure of cost reduction.
On one hand patient are demanding instant quality healthcare services and on the other hand government is pushing on use of common standards further monitoring the quality stringently. This complicates the matter further with existing infrastructure and legacy systems. Providers are gearing up to address the increased demand and support 24/7, access to top-quality healthcare, and adopting cloud strategy. Cloud and mobile access is technological reason for the actual consumerism.
Few of the innovators to watch in this space are CloudMine and AlphaSoftware
  • Wearable and IoT
Wearable and IoT has taken the healthcare out of hospitals, and into our homes. Healthcare at home is a win-win for all patients, providers and insurance. Remote monitoring coupled with video collaboration platforms have innovated the space with low cost high quality patient care. Innovative startups like Care Innovation backed by large giants like Intel, Google are making lot of noise in this space.
  • Consumerism in healthcare
Transformation of digital landscape, has led to serious disruption, patients of 21st century are experiencing empowerment. As we unlock the barriers of EHR for better access and quality, consumer satisfaction increases.
Patients can now have similar experiences to retail and shop for best value products based upon their needs. For example, someone with chronic illness, injuries, wrong procedure, and misguided surgeries can get expert advice from companies like Best Doctors, Second Opinion Experts, Amino for as low as $300. Ability for patients to make best choices in terms of treatment, procedures with right information, is going to be a blessing. And imagine how much cost health insurance companies are going to save!

  • Diving into telehealth

While Telehealth has been around for decades, yet the real potential has been unlocked just few years back. Federal backup, technological advancement and infrastructure maturity has helped it gain the momentum. Today’s telehealth products are a combination of video and specific use case catering to diverse areas, from Behavioral health to Physiotherapy and so on.
While big players like AmericanWell, Teladoc and other continue to dominate the space. Small players like Cloudbreak, Zipnosis, and Avera with specific requirements are making lot of noise.

 Telehealth has demonstrated over and over the improved outcomes with minimal cost. The new age products are equipped with advanced analytics, addressed reimbursement and legislative concerns. The use of advanced technologies like AI and ML on top of telehealth component will be soon gaining momentum to further enhance patient experience and optimize healthcare cost.

 It was my 3rd consecutive time to attend HIMSS and every time one has so much to learn. You can digest as per your appetite; I am a Healthcare Professional turned into technologist, and was really amazed to see innovation all around me. All this experience gathered is shared with the clients for whom we build products, it gives them an insight on where the industry is heading.

 Faichi Solutions is technology service provider, under the umbrella of Saksoft Inc, New Jersey. We are 1000+ employees, across 3 continents, with Healthcare service as a focused vertical.

 We are trusted partners in Innovation for Healthcare ISV’s and Technology companies. Focused on:
-Digital Transformation                     
-Product Development                       
-Mobility and Cloud
-Analytics and BI                    
-Data Warehouse                   
-Managed Services

The article has been re-published here with the Authors permission. The article first appeared here

Author
Tejas Deshmukh

Highly skilled and motivated professional with rich experience of 13+ years in software product development for Healthcare and Life Sciences vertical, proven track record of building innovative solutions, providing strategic consulting, pre-sales and operational management.

How to Bridge the Healthcare Digital Divide by @Ishaq_Quadri

/ #DIGITALHEALTH / 5 minutes of reading

With the proliferation of smart phones, usage of internet coupled with the challenges of a busy modern day lifestyle, the way we transact has completely changed to an extent that availing services online is becoming first choice for a growing number of consumers. But still, adoption of IT in Hospitals is lagging by about 15 years when compared to its counterparts in Retail and BFSI.

What are the inherent challenges in adoption and why in the first place it is so difficult to target a totally digital Hospital? This article attempts to unravel mysteries of the digital divide and suggest solutions with a special focus on Electronic Medical Records (EMR) and Hospital Information Systems (HIS).

The Digital Divide

End User Concerns

The main concerns quoted by Doctors on being averse to complete adoption of Computerized Physician Order Entry (CPOE) is the paucity of time, patient safety, solutions are not user friendly, are grossly inadequate and do not suit the workflow of medical practice. The following are the reasons why we are in this mess on functionality front:
a) Lack of Standardization: There are no Industry specific standards or expectations defined on what should constitute a bare minimum functionality.
b) Solution Fitment: Vendors of all size and shape with only technology background have plunged into software development and have contributed to the divide between technologist and clinicians.
c) Usability and End User Comfort: User experience and ease of usage may sound very basic but is significant from one) poor familiarity of usage and second) Poorly designed and Complex interfaces which are cumbersome and consume more time

Technology Issues and Limitations

Technology barriers play their own damaging role in dampening and impairing implementations, the following are some commonly noticed ones:
a) Architecture: The architecture of the system plays a crucial role especially when you want to customize and expand. Check if the solution is Cloud enabled, Mobile Ready, Web Based, and follows Open architecture.
b) Interoperability: On the close lines of the Architecture mentioned above is the interoperability which is a function of integration capabilities and standards compliance without compromising security.
c) Performance: Systems tend to start weighing in as more functionality is added or data gets loaded. From an end user perspective this is a major dampener as Doctors want speed and agility in navigating the patient record
d) Security and Privacy Concerns: Information security need to be looked at in a holistic manner in the entire eco system with a clear strategy, constant vigil and proper corrective measures.

Cost and Implementation Challenges

A large cross section of medium and small Hospitals are getting interested to implement systems but are challenged on the budgets as some of the Tier1 solutions are just beyond their reach.
The inordinate delays in software delivery by vendors is a common challenge across industry. A poorly designed or incomplete system needs heavy maintenance and at the same time the Hospital which employs nonstandard practices or workflows will ask for too many changes.

Bridging the Divide

Having looked at the problems that contribute to the digital divide let us now ponder on what are the plausible solutions.

Management Interventions

In terms of Management Interventions the following needs to be done:
• Management Commitment: All Digitization initiatives need a sound and solid management blessings and backing. To put it simple, it has to be driven by the CEO or CMD office period.
• Organizational Drive/ Change Management: Ensure effective communication and onboarding of all relevant and impacted parties right from the beginning and have their say for example by way of End User Task Force.
• Enablement of the IT Function: IT is usually not given due respect and recognition and in many places reports to Finance or Admin and even HR. This practice has to stop and one need to have an empowered resource at a CxO executive level to lead the team.
• Relationship with the Solution Provider: Given the fact that there are no real ‘off the shelf’ products on the HIS/EMR space the need for changes and enhancements is quite high and so is the need to maintain a close, cordial and mutually beneficial relationship with the solution provider.
• Project Management Approach: All endeavors need to have stated goals, clear start/ end time and should create a unique product/ outcome.
• Emphasis on Training: End user Education and Training cannot be emphasized more as it decides in many cases the success of the initiative. It is a big challenge to get the Doctors and Clinical staff time but one has to be persistent in ensuring they do attend.

Technology Interventions

Following are the technology related remedies to bridge the digital divide in Hospitals
• Suitability of the Software: A careful study need to be carried out while selecting the HIS/EMR software suitable to the Hospital. There is no ‘one size fits all’ solution out there.
• Focus on Usability: To understand end user perspective, one needs to step into the shoes of the primary users i.e. Doctors and do Role Plays and User Stories, reduce the number of clicks and clutter on screen.
• Performance and Speedy Data Entry: The systems need to be optimized to enable quick review and instant storage. Also features such as templates, patient order sets need to be created and actively promoted as they drastically improve the speed to data entry and turnaround time
• Integrations: With consistent adoption of HL7 standard more and more machines used in Lab and Radiology today are integrate-able.
Look forward to your feedback and knowledge sharing.

 The Article has been republished here with the authors permission.
Author
Ishaq Quadri

Senior IT Executive with 20+ years of experience on Software Development and Implementation.

@HIMSSIndia 2018 Conference and Exhibition, Bengaluru #HIMSSIndia

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HIMSS India 2018: Annual Conference and Exhibition  will bring together key stakeholders from Government, Statutory Bodies, Healthcare Providers, Payers, Life Sciences, Medical Device, Healthcare IT and solution providers for path-breaking collaborative discussions on healthcare IT issues, best practices and the latest in tools & technologies that will drive and enhance the new age healthcare delivery and outcomes.

Why Attend

Exceptional education, world class speakers, cutting-edge healthcare IT products and powerful networking are hallmarks of this industry leading show. Attending HIMSS India Annual Conference provides an unparalleled opportunity for you to learn and experience the latest developments and trends emerging in Healthcare IT. The event will showcase how IT is transforming the full spectrum of the continuum of care. This conference will deliver insights for healthcare stakeholders to better understand the future market drivers, emerging business trends and technology opportunities impacting the healthcare IT market in India. 

  • Understand the emerging healthcare IT landscape and how it would impact medical practice and healthcare delivery 
  • High-value education and network opportunities with Government and private stakeholders 
  • Identify the latest technologies and their impact on healthcare IT 
  • Meet and interact with the leaders driving the change 
  • Insight in Emerging Technologies like AI, Population Health, Precision Medicine, Big data and Analytics in India 
  • Current Offerings in the market

Theme and Key Topics

The theme of the conference will include topics such as:

  • Healthcare IT – Current scenario and outlook for 2018-20 
  • AI, Precision Medicine and Machine Learning – The future of service delivery 
  • Advanced and Predictive analytics – Transformational insights and Clinical Decision Making
  • Standards and interoperability – for Care Continuum
  • mHealth and Tele Medicine – Unlock the value of mobile and remote patient care 
  • Innovation and Startups – Smart Solutions to Perennial Problems
  • Home healthcare & IT – Making the right connection for better health


HIMSS is a global, cause-based, not-for- profit organization focused on better health through information technology (IT). HIMSS lead efforts to optimize health engagements and healthcare outcomes using IT. HIMSS is producing health IT thought leadership, education, events, market research and media services around the world. Founded in 1961, HIMSS encompasses more than 70,000 individuals, of which more than two-thirds work in healthcare provider, governmental and not-forprofit organizations across the globe, plus over 630 corporations and 450 not-forprofit partner organizations. 

 HIMSS, headquartered in Chicago, serves the global healthcare IT community with additional offices in USA, Europe and Asia. HIMSS India Chapter was formed in 2010 and has the distinction of being the first country-specific chapter of HIMSS outside USA. The Chapter has been at the forefront in forming Industry opinion and thought leadership on Healthcare IT challenges. With the revamped Board and Committees the Chapter has broadened its base forging alliances with representation from IT Industry, Hospital CIOs and SMEs

 Important Links: 
[1]: Conference Brochure: 
http://www.india.himsschapter.org/sites/himsschapter/files/HIMSS%20India%202018%20%20-%20Brochure%20-%20Ver1.2.pdf

 [2]: HIMSS India Conference 2018 Website: 
http://himssindiaconference.org/

 [3]: HIMSS India Chapter Website: 
http://www.india.himsschapter.org/

 [4]: Registration Form: 
https://docs.google.com/forms/d/e/1FAIpQLSf_NFlpj0rWggTKFIxoL_qbKYzCZ6_NrFFwqyTsv1J90rU2MQ/viewform?c=0&w=1

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Team HIMSS India

HIMSS India Conference and Exhibition 2018
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