India has been making steady progress in leveraging information and communication technologies in healthcare for over two decades. Efforts to build and act in the health information systems and electronic medical records in both public and private healthcare settings have been underway. For example, the Centre for Development of Advanced Computing (C-DAC), a premier research and development organization of the Ministry of Electronics and Information Technology (MeitY) developed and deployed India’s first indigenously developed total hospital information system (HIS) software in the 1990s.
Electronic medical records and hospital Information Systems have been implemented in several corporate and a few public sector hospitals. Despite these efforts, the use of clinical data for monitoring clinical outcomes, contextual clinical decision support has been limited. There has hardly been any research output from India on the implementation experiences or improvements in clinical outcomes, efficiency or effectiveness associated with use of digital health tools. With widespread availability of mobile phones, lower costs of mobile ownership and usage, mobile health applications have been widely used in health services delivery, most notably to support frontline health workers in automation of their tasks, record keeping and reporting. Despite its importance for evidence-based decisions, health information systems in most low and middle income countries are weak, fragmented and often focused exclusively on disease-specific program areas.
Current Scenario of Digital Health in India:
In India, under the National Health Mission, a variety of mobile applications and software programs have been implemented to support the vertical service delivery programmes. However, current applications do not meet process required for sharing of common data or facilitate referrals across the healthcare delivery ecosystem. Absence of integrated information and use of multiple applications leads to duplication and places a heavy burden on health professionals caused by redundant, fragmented and inconsistent methods and instruments for data collection, aggregation and reporting.
Road Map for a digitally Enabled Ecosystem:
The National Health Policy (NHP) 2017 envisioned the attainment of the highest possible level ofenvisions attainment of health and wellbeing for all. It articulates that all developmental policies emed , through a preventive and promotive health care orientation in all developmental policies, andFurther, achieving universal access to good quality health care services without anyone having to face financial hardships. as a consequence. The the pivotal role of health management information systems as per the NHP 2017 had articulated the pivotal role of health management information systems as outlined below.are as outlined below.
- Ensure Ensuring district-level electronic database of information on health system components. by 2020
- Strengthening the health surveillance system and establishing disease registries for diseases of public health importance by 2020
- Establishing a federated integrated health information architecture, Health health Information Exchanges resulting in a and National Health Information Network. by 2025.
- Further Moreover, the NHP had specifically outlined outlines the need for the changes to curriculum for undergraduate and postgraduate medical education. It highlights the need for taking into cognizance consideration evolving disease burdens and patternsof the changing needs, technological advances and threats posed by newer emerging disease diseasestrends.
It is no surprise that the COVID-19 pandemic has taken the country by surprise. There has been scant attention devoted to equipping the medical graduates, and postgraduates or registered practioners through providing mandatory continuing medical education that focuses on epidemic threats of pandemic potential. Despite wellarticulated intentions of transforming the curriculum through incorporating the fundamentals of clinical data, health informatics or the role, application of emerging technologies such machine learning, artificial intelligence and robotics in health care domain there has been little translation of these into the teaching programme.
Challenges and Opportunities in the context of COVID19
The COVID-19 pandemic has highlighted the glaring gaps in the medical curriculum and lack of preparedness of the health workforce at all levels. In particular, the lack of familiarity in rapid translation of emerging evidence into clinical practice combined with a near total absence of national level integrated health information systems to generate locally relevant clinical insights or monitoring of clinical outcomes in the context of an emerging infectious disease is reflected by the abysmal research output from India despite having one the largest caseloads across the globe. Several digital health interventions such as COVID19 contact tracing mobile application were launched with much enthusiasm, its effectiveness in the public health response to the pandemic has been limited.
Overcoming this these challenge requires that digital tools take into consideration the end user functionality requirements, for which the health care professionals need to have a basic understanding of the principles of digital health and the importance of clinical data management. A possible approach as suggested by the review was to consider that thethe State and the Union Government to ensure the mass installation of a single contact tracing app collaboratively or work towards common data models where compelling circumstances require different tools to be used. In contrast, theThe.
State-specific mobile apps for COVID-19 would still be a vitalserve as a critial medium of providing contextspecific information, clinical protocols, embed tools to fight misinformation and thereby supporting local health systems.
National Digital Health Mission and Citizen centric health:
It is therefore timely that the National Digital Health Mission (NDHM) has was been launched on 15th of August 2020. The vision of NDHM is aims to create a national digital health ecosystem that to supports India’s progress towards universal health coverage in antaking into consideration efficientefficiency, accessibleaccessibility, affordability, inclusiveness, affordable, timely and safety. It further envisages to facilitate availability of manner, that provides a relevant clinical and operational datawiderange of data, information and infrastructure services, duly through leveraging open, interoperable, standards-based digital systems, . It recognizes that and ensures ensuring the security, confidentiality and privacy of health-related personal information is a key priority.
Clinical Leadership for Digital Health Implementation:
It is envisaged that the implementation of NDHM will significantly improve the efficiency, effectiveness, and transparency of health service delivery. However, to improve efficiency and effectiveness of health services through digital tools, the healthcare professionals have to be equipped and trained to maximize the benefits offered by the digital health technologies. Experiences from other countries that introduced electronic health records without taking into consideration the acceptance, usability, level of user preparedness and adequate process reengineering suggests that clinicians experience stress and burnout directly linked to additional burden posed by Electronic Health Records . The introduction of EHRs often results in shifting many clerical tasks to clinicians.
Since national digital health mission is being operationalized it through the Ayushman Bharat PM JAY, the initial implementation is likely to focus on generation of electronic health records in the context of health insurance 46 reimbursement of PM JAY beneficiaries availing health services.
It is paramount that clinicians and all health professionals contribute through designing and implementing digital health systems in their own contexts with a focus on improving clinical service delivery, monitoring outcomes longitudinally. Past experience around automation in health services delivery in India suggests that key decision makers who allocate budget for automation often settle for health information systems that primarily focus on generating billing codes for facilitated insurance reimbursements.
For clinicians to meaningfully contribute to building clinically oriented digital health systems would entail that they familiarize themselves with tools and techniques that digital health offers to improve quality of care, efficiency and effectiveness. The WHO guideline recommendations on digital health interventions provides an overview the evidence that is available as well as implementation considerations within health systems.
Digital Health for Improving Clinical Decisions:
There is a body of evidence that suggests that embedding of clinical decision support systems (CDSS) tools within the clinical workflows in a healthcare delivery setting improves outcomes. Incorporating evidence-based treatment guidelines and best-practice pathways into CDSS and EHR platforms is a widely recommended and extensively adopted Antibiotic Stewardship Programme (ASP) strategy . CDSSs aid clinicians in selecting appropriate antimicrobial therapy for various infections as well as in avoiding preventable errors, and have been shown to improve the overall quality of care .
Future Ready Health Professionals to enable citizen centred digital health:
The long-term goal is to overcome the information asymmetries and thereby enablingempower citizens have access to authentic, validated, most updated and individuals with accurate information to enable informed decision making and increase transparency and accountability of healthcare providers. Future ready health professionals would be ones who will embrace digital health tools and leverage data driven approaches to deliver evidence informed care. They will leverage digital tools to automate repetitive, monotonous tasks that are not cognitively intensive and could be easily executed by validated algorithms.
The time thus redeemed would for used by these professionals to engage in human centred engagement and thereby establish pathways to bridge the trust deficit that plagues the healthcare delivery system in the current context. Patients, their relatives and citizens in general will gain more confidence in the healthcare establishments as they are provided access to real-time information, their own health records and insights on their health and thereby enabling shared and informed decisions.
Extending this to the health domain, there have been an exponential surge in the availability of wearable devices and Internet of medical things (IoMT). Such tools in the context of the current pandemic is becoming an integral part of an average person’s life. These devices are continually collecting data of those who are on selfquarantine, home isolation or those recovering after acute COVID19. An interactive exchange between humans and new technologies is expected to grow as the pandemic grows beyond the capacity of the health systems to deliver care, moreover human activities would be complemented by digital activities of these technological entities. Artificial Intelligence will enable clinicians to improve results and more efficiently monitor activities. Avatars based on artificial intelligence can be used to manage personal health data through an integrated digital representation of a human. In this way, clinicians can deliver individually tailored medical interventions to a particular patient[OJ10]
The Future of healthcare professionals are equipped to operate in an environment of massive volumes of citizen generated data yet have the skills to glean the most appropriate clinically important signals from the noise that these data deluge will present and deliver highly person centred care with empathy and the human touch which every person particularly when they are going is through a health crisis. The digital tools in our hands should therefore enable us and free us of the cumbersome manual and repetitive tasks so that we can use our hands to extend the human touch and show that we care.Future ready health professionals are the ones who will embrace the digital health tools and participate actively in the digital health ecosystem that is being built under the ambitious National Digital Health Mission.
The digital tools in our hands should therefore enable us and free us of the cumbersome manual and repetitive tasks so that we can use our hands to extend the human touch and show that we care.
This article was first published here, and has been republished here with the author’s permission
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