Tag: NHP2017

Some perceived shortfalls in the proposed Indian National Health Stack by Dr. Pramod Jacob

There is ongoing work in India for a Nationwide Information Technology platform, that will support and facilitate the deployment of the Ayushman Bharat program, which is called the “National Health Stack”, the objective of which is to help achieve Continuum of Care across Primary, Secondary and Tertiary care for each of its citizens and facilitate payment for the care.

A draft of the National Health Stack (NHS) strategy and approach was put out in July 2018 for feedback and comments till July 31, following which no final draft has been published in the public domain. Hence the shortfalls brought out in this write up are based on the July 2018 draft and so these are perceived shortfalls, because the final version may have addressed these concerns. If so, request that the final document be published in the public domain. http://niti.gov.in/writereaddata/files/document_publication/NHS-Strategy-and-Approach-Document-for-consultation.pdf  


There is  recognition for the need of holistic longitudinal individual electronic health records for citizens, rather than just collated population-based data, for which one of the key components in the NHS Stack is going to be the Federated Personal Health Record. But is this requirement of an individual’s record to ensure continuity of care or mainly to avoid fraud and bring greater trust into the claim handling process? If it is for the stated objective of fulfilling the National Health Policy 2017 that states 

“The attainment of the highest possible level of health and wellbeing for all at all ages, through a preventive and promotive health care orientation in all developmental policies, and universal access to good quality health care services without anyone having to face financial hardship as a consequence… “

Then, in this write up I focus on two issues of immediate concern.

1.  No requirement explicitly stated for compliance to Healthcare Information Technology (HIT)/EHR standards as recommended by MOHFW and published on December 2016 

2. Different applications being developed at various levels of care, both in the public and private healthcare domain, which are not proven to “talk” to each other i.e. exchange healthcare data (interoperability)

Going into greater details about each of these issues:

1. No requirement explicitly stated for compliance to Healthcare Information Technology (HIT)/EHR standards as recommended by MOHFW and published in December 2016, except for patient/beneficiary identification. 
https://www.nhp.gov.in/categories-for-adoption-of-standards_mtl

It is understandable that when the program starts – the focus is going to be on assembling the registries of beneficiaries, providers, empanelled hospitals etc and the claims or payment for healthcare services rendered by providers. For validating the claims there is going to be proof of services rendered to be provided by filling forms and uploading supporting documents, such as test results, into the claims component of the stack by the hospitals/providers. However, instead of just having a checklist format of proof of service, if the data input is coded compliant to recommended standards (such as SNOMED CT for Diagnosis or LOINC for lab results) instead of just free text or proprietary codes –– then the healthcare data being collated is of much more immense value for clinical study and analytics. More importantly, this would bring about the perception that the information being asked for and checked on, has value in providing in-sights to providing better healthcare, instead of being perceived as an overseeing billing validation into the services provided by the clinicians, and so will facilitate onboarding clinicians to digitization.  

For continuity of care and to facilitate quality clinical care, the assumption that having an open API based paradigm for fetching the records of a citizen from across different points of care, without the need for being standard compliant, maybe misplaced. Ok, so touch points will bring across data from corresponding associated fields when different healthcare systems exchange data, for example diagnosis from the exporting system into the importing system. However here lies the problem if not standard compliant, when attempting to consolidate the diagnosis section of a patient in a repository or into a consolidated longitudinal record: – say a patient has Pulmonary Tuberculosis and over time, goes to 3 different doctors in a few years. It is very possible that the first doctor may record the diagnosis as “Pulmonary Tuberculosis”, the next doctor may have logged in this diagnosis as “Tuberculosis of the Lung” and yet a third doctor may have put in the diagnosis as “Pulmonary TB”. So, when the data is being collated – the computer will not understand that all these three different terminologies represent the same concept and site of the disease, and may record them as separate problems. However, if the diagnosis was standard compliant and coded with the recommended SNOMED CT code (Concept ID 154283005), then the compilation and consolidation of this individual’s diagnosis list will be correct, since this standard code consolidates all three terminologies as the same disease and site. Similarly, lab tests results may have various terminologies, for example Fasting Blood Sugar aka Fasting Blood Glucose aka FBS, but if the recommended LOINC code (1558-6) is tagged, then during consolidation of a patient’s test results, the correct interpretation that these are results of the same test will occur and so will be trended accurately. This will come into play even at the claims phase. Healthcare is knowledge intensive, with whole lot of concepts, terminologies, semantics and nuances involved, which needs a framework of standards to convey the correct meaning and interpretation, when exchanging information between different HIT systems.

Another trend is that in those states that already have such universal health coverage programs deployed, there is a tendency to come up with proprietary codes for procedures in each of these different schemes, to suit the billing/claims end users. For example, Andhra Pradesh’s NTRVS program has got procedure codes like S5 for orthopaedics procedures, drilling down to S5.1 for fracture correction in orthopaedics procedures, further drilling down to S5.1.4 for reduction of compound fracture and external fixation. The same procedures have a different proprietary coding system in the program run by Tamil Nadu. So, what happens when you try to compare outcomes from the same procedures between these two states?  If the recommended SNOMED coding system for procedures was applied in both the states – then carrying out such comparative studies become much more feasible and meaningful. Instead of reinventing the wheel with proprietary or local codes, if the recommended international standards that have been developed over the years by domain experts are put into place, then not only can we carry out such studies between our states but also between India and other countries, leading to adoption of the most efficient, cost effective, least invasive interventions with best outcomes. 

It is of utmost importance that these recommended standards, including clinical standards, be introduced at the foundational phase of the framework for the National Health Stack. With about 20% more effort upfront, it is possible to plug in the look up databases for these standards into their respective fields- such as Diagnosis, Labs, Procedures, Medications etc. Even better, that these standards be deployed and utilized (where relevant) even for claims (as explained above), while place holders be put into place for those  standards (mainly clinical) that may come into play only when the Federated PHR phase is activated. Importantly, to enable exchange of data between HIT systems, it is highly advisable to be compliant to HIT messaging standards such as HL7/FHIR. That will be the only way that the National Health Stack will have the robustness and flexibility to handle billing, claims and clinical healthcare functionalities optimally. If this is not done at the foundational phase and if the NHS framework is mainly set up for billing and claims, this will straitjacket the framework to effectively introduce these standards later and lead to fitting a square peg into a round hole situation. Also, an even bigger problem that proprietary codes could lead to, is if down the line wisdom prevails, and a decision is made to mandate recommended HIT standards, then the big headache issue of retrospective mapping of these proprietary codes to standard codes comes up for existing patients with past visits/admissions. It should not be billing and claims requirements that be the primary driving force for the National Health Stack, but ideally should be patient care and provider requirements in conjunction with billing/claims requirements that should be the driving force. 

 2. Different applications being developed at various levels of care, both in the public and private healthcare domain, which are not proven to “talk” to each other i.e. exchange healthcare data (interoperability)
   
The NHS document states that the National Health Stack a. Is designed to bring a holistic view across multiple health verticals and enable rapid creation of diverse solutions in health b. To enable patients to effectively become a Healthcare Information Exchange (HIE) of one: as meaningful data accumulates in a patient controlled repository, a complete picture of the patient emerges, resulting in improved quality of care across a range of providers.

For the above stated objectives to be attained, it requires at least these two conditions to be fulfilled: –

a. The diverse HIT systems that are involved in healthcare of the beneficiaries should ” talk to each other ” with ability to exchange data appropriately and without loss of meaning and interpretation in the exchange i.e. Interoperability. That is how accurate meaningful data of a patient should be accumulated.  Considering that 70% of healthcare in India is provided by the private sector, this accumulation of a patient’s data will require visits/admissions to private hospitals to be brought in. For this, there is the most important requirement and need to publish the open APIs specifically being used in the NHS, so that these private healthcare organizations’ systems can integrate and exchange healthcare data with the NHS. 

For example, if I am an authorized doctor for a patient – what is the API to be used to fetch this patient’s healthcare longitudinal record  from the National Health Stack?  Again, if the recommended standard like HL7’s FHIR (which is API based) was adhered to for data exchange, it would have made this deployment, hooking up and integration with NHS much easier and effectively feasible.

b. For the data to be meaningful, classified and categorised correctly with terms implying the same concept put into the same category and not into different ones, need the variations in terminology (especially clinical terminologies) to map back to the correct concept as that intended by the provider – which requires the recommended HIT standards to be mandated. Only then can the healthcare data be meaningfully analysed, trends and patterns including outcomes be detected (by deploying statistical methodologies including machine learning and AI) and standard protocols with best outcomes for the various respective Indian ethnicities be formulated, thus achieving the stated goals and objectives of the NHS

If the National Health Stack does provide the latest and greatest in this  platform- with the recommended standards, then with our large numbers, English speaking brilliant human resources, internationally renowned prowess in Information Technology and Healthcare ; this assimilation  of a treasure trove of Healthcare Information, along with the  well-known Indian ingenuity, presents a huge opportunity for the country to leap frog healthcare to the next level and bring about betterment for humanity. 

Author

Dr Pramod D. Jacob (MBBS, MS- Medical Informatics)

After completing his medical degree from CMC Vellore and doing his Master of Science in Medical Informatics from Oregon Health Sciences University (OHSU) in the US, Dr Pramod worked in the EMR division of Epic Systems, USA and was the Clinical Systems Project Manager in Multnomah
County, Portland, Oregon. He went to do Healthcare IT consultancy work for states and counties in the US and India.

At present he is a Director and Chief Medical Officer of dWise Healthcare IT solutions. He was also a consultant for WHO India in the IDSP project and for PHFI for a Non Communicable Diseases Decision Support Application.

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


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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