Health IT

Session 10
National Health IT Implementation and
Interoperability

Abhay Nath Mishra

Professor and Kingland Systems Faculty Fellow
Iowa State University
Quiz
 Agenda
• Quiz
• Discuss Assignment 4
• Why National Health IT Implementation and
Interoperability?
• Issues with Standardization and Interoperability
• The Indian situation
• Course Evaluation
• Motivation for national level HIT in India
• Challenges and Opportunities
• Decade of Health IT in India
• Summary and Takeaways
 Assignment 4
• How does Meddo change the care process for
patients? Please provide two specific examples.
1. Integrated and comprehensive medical service access –
patients can now get access to a wide variety of services
under one roof. This eliminates the need to visit different
facilities, reduces hassles, streamlines the process, and saves
them time.

2. Digitization of records – Patients get digital reports, digital

prescriptions which they can use to buy medicine anywhere,
and medicine reminders. These digital records can be shared
among care providers, improving personalized treatment
plans and appropriate care. It reduced the travel required to
receive care
 Assignment 4
• How does Meddo change the care delivery process for doctors? Please
provide two specific examples.
1. Professional Clinic Management/Availability of trained clinic managers/
Streamlining of Processes: A trained phlebotomist manages the clinic,
relieving the doctor from doing so. The doctor can focus on the clinical and
medical aspects of care delivery. This eliminates ad hoc actions and
streamlines the processes (booking appointments, handling billing, managing
patient records).
2. Comprehensive Digital Platform for Doctors/Availability of digital
records/Enhanced Data Management: Meddo has created a digital platform
that enables doctors to access patient information at the point of care. It also
integrates prescriptions, inventory and other business data, making clinical
operations more efficient.
3. Additional Revenue Generation: Meddo has a revenue sharing model with
doctors wherein they earn additional revenue from lab tests, diagnostic
services and in-clinic purchases.
4. Extended Reach and Engagement: The use of telemedicine allows doctors
to provide patient care beyond their clinic.
 Assignment 4
• Meddo is a multisided platform – it intermediates between patients,
clinics, labs and pharmacies. Discuss two challenges Meddo faces due to
being a multisided platform.
1. Alignment of stakeholder interests: There are multiple parties --
patients, clinics, labs, and pharmacies – with conflicting interests and
Meddo needs to balance all of their interests/ incentives for the platform
to function.
2. Ensuring consistency and quality: Meddo is an intermediary without
direct control on the process of anyone – clinics, labs, pharmacies – yet
patients may want to hold it accountable if something goes wrong. So, to
ensure that all stakeholders are working on quality outcomes and the
processes followed by them are consistent is a big challenge.
3. Recruiting of stakeholders on all sides of the platform: As is true for all
multisided platforms, recruiting and onboarding different stakeholders is
a challenge. For any stakeholder, the larger the number of other
stakeholders, the large the potential benefit to them. So, in other words,
the platform has a chicken and egg problem.
 Assignment 4
• What scaling challenges confront Meddo? Mention
two challenges and discuss one potential solution for
each.
1. How to ensure quality? Solution: Continuous evaluation and
enforcement of quality standards, reward quality and penalize the
lack of quality
2. How to ensure professional clinic management/hire trained
phlebotomists? Solution: Hire local phlebotomists and establish
tie-ups with training and accrediting bodies to train and certify
them
3. How to convince different stakeholders to join? Solution: Share
use cases, engage in discussions, provide training programs on
digitization and professional clinic management, emphasize quality
and efficiency benefits and new business generation
 Assignment 4
• How can Meddo adjust its model to reach patients
and doctors/clinics at the bottom of the pyramid
(BoP)? Discuss two specific ways.
1. Telemedicine: Can enhance access for BoP patients without
them having to travel to seek care
2. M-health: Providing a mobile health app can enable patients to
seek care without having to travel
3. Partnership with public health organizations: Clinics that can
benefit from ABDM can be good partners, as can other
organizations such as NGOs, government primary health centers
4. Partnership with clinics: Meddo can customize its pricing and
services for clinics in underserved and BoP areas – it can offer
them lower cost solutions or offer higher incentives.
National Health IT Implementation and
Interoperability
• EHR vs. EMR
– Health Information Exchange
• Enable efficient clinical and business processes
• Enable interoperability
• Foster electronic transmission of information
across organizations
• Enable collaboration between different entities
• Enable availability, affordability, accessibility,
inclusiveness and safety of care
• Strengthen public health
 Standardization and Interoperability
• Data standards are an agreed-upon and
consistent way to record and exchange
information. Critical for INTEROPERABILITY
• Data standards are detailed guides to facilitate
the creation, storage, retrieval and sharing of
text, image, audio and video data.
• Two important aspects of data standards:
– Syntax: structure of communication (HL-7)
– Semantics: meaning of communication
(SNOMED)
 Standardization and Interoperability
• Many different standards in use in
healthcare – terminology standards, data
exchange standards, transaction
standards, data content standards, and
others
• Two prominent standards
– ICD - 10
– HL-7
 ICD - 10
• Diagnostic classification system
– 3-5 digits for ICD – 9 (V02.61: Hepatitis B carrier)
– 3-7 digits for ICD-10 (A69.21: Meningitis due to Lyme disease)
• Procedure classification system
– 3-4 digits ICD – 9 (44.42: Suture of duodenal ulcer site)
– 7 digits for ICD – 10 (0DQ10ZZ: Repair upper esophagus, open
approach)
• ICD – 9 has been around for 30 years; ICD – 10 for around 24
(ICD – 9 was used for a long time in the U.S., now ICD-10)
• ICD 10 used widely in other developed nations (e.g., Germany,
Australia, Canada, France, UK, India)
 HL-7
• Not-for-profit ANSI accredited standards development
organization.
• Provides a comprehensive framework and related standards
for the exchange, integration, sharing and retrieval of health
information.
• Has over 1,600 members and presence in 50 countries!
• HL-7 standards are used to pass messages between health
systems; integrating applications; specifying decision rules,
structuring documents; defining the meaning of content;
structure vocabulary; etc.
 Clinical and Administrative Data
Transfer and Interoperability Using HL-7
• This standard helps communication between:
– Patient administrative systems (PAS)
– Electronic practice management systems
– Lab information systems (interfaces)
– Pharmacy (clinical decision support)
– Billing
– Electronic health records (EHRs)
 Health Information Exchange
• Health information exchanges allow electronic information
sharing between health care organizations and information
systems while maintaining the meaning of the information
being exchanged.
• These exchanges also provide the infrastructure for secondary
use of clinical data for purposes such as public health, clinical,
biomedical, and consumer health informatics research as well
as institution and provider quality assessment and
improvement.
Health Information Exchange: Types of
Data Shared
• Clinical results: Lab, pathology, medication , allergies,
immunizations and microbiology data
• Images: Actual images and radiology reports
• Documents: Office notes, discharge notes and emergency
room notes
• Clinical summaries: Continuity of Care Documents (CCDs);
XML-based documents that standardize and summarize care
• Medication data: Electronic prescriptions, formulary status,
and prescription history
• Public health data: Infectious diseases outbreak data,
immunization records
• Referral management: Management of referrals to specialists
 Benefits of Health Information
Exchanges
• Provide interoperability among EHRs maintained by individual
physicians and organizations
• Provide a vehicle for improving quality and safety of patient
care
• Help public health officials meet their commitment to the
community
• Provide the backbone of technical infrastructure for leverage
by national and state-level initiatives
• The connecting point for an organized, standardized process of
data exchange across statewide, regional, and local initiatives
 • Use of homegrown tools
• Lack of standards adoption
• Data fragmented into silos
• Legacy systems frequently in use
The current • Lack of Minimum Data Sets
state of • Lack of significant funding to support
adoption
health IT in
• Lack of tools for preventing duplicative
India? care

• YET, SIGNIFICANT PROGRESS and

LAUNCHING PAD READY FOR BLAST
OFF
 Transformation in Progress
Yesterday’s India The India Being Built
• Inconsistency in how • Unique patient identifiers
patients are identified in that are common across
records healthcare facilities
• Patients make upfront cash • Bills are settled cashlessly,
payments before care is and patients do not need to
delivered have cash to receive care
• Data is stored on paper, free • Data is machine-readable,
text, or scanned documents enabling analytics
• Data privacy is not well • The privacy of patient data
regulated is protected by law
 Key Health Related Events in India
• Aadhaar – biometric unique identifiers
• Cashless India – accelerated by November 2016 cash crisis
• National Electronic Health Record Standards (2013/16) – storing
health information in a common, machine-readable way
• Ayushman Bharat – health insurance for low income people, with
cashless payments, replacing RSBY
• State-based claims databases for public insurance schemes
• Proposed Digital Information Security in Health Care Act (DISHA) –
privacy standards for digital data
• Ayushman Bharat (formerly National) Digital Health Mission –
creation of a uniform HealthID, the Digi Doctor provider database,
and Health Facility Registry facility database
• National health stack (2018)
 Numerous Digital India health initiatives

Government-
Online registration
Online lab results backed personal
system
health record

Government- Government-
developed developed hospital
mHealth apps rating tool
 Ayushman Bharat Digital Mission
(ABDM)
• Launched in 2021
• Building Blocks
– Ayushman Bharat Health Account (ABHA)
– ABHA Application (PHR)
• Health Professional Registry (HPR)
• Health Facility Registry (HFR)
• Drug Registry
• The Unified Health Interface (UHI) provides an open protocol for digital health
services between patients and health service providers, including
– Appointment booking
– Teleconsultation
– Service discovery
• Multiple applications have integrated with ABDM, including PayTM, CoWIN, and
DigiLocker in order to promote
– Standardization
– Digitization of health records
– Seamless data exchange
– Digital sharing of records
• Health Claims Exchange
 National Health Claims Exchange Purposes

• Standardization & Interoperability of Health Claims

• Seamless exchange of data, documents and images
between payer (insurance company/TPA/Govt
scheme administrator) & Provider (hospital/lab/poly
clinic)
• Data exchange with FHIR compliant e-claims format
through a single gateway using standard protocols
(APIs)
• Enable transparent and efficient claims processing
• Reduce operational cost related to claims processing
 National Health Claims Exchange
(NHCX)
• Building Blocks
• ABHA Number, HFR, HPR
• Stakeholders of NHCX
• Payers, providers, insured person
• Process
• Common claim standard format (FHIR objects) to be used across
Govt / Pvt Health claims defined by NHA
• Open APIs
• Validate the meta data (sender & receiver info) and route to
designated Insurer / TPA (at NHCX)
• Digitally verify documents, auto adjust claims, manually
adjudicate some claims
 The Ayushman Bharat Digital Mission Piloted in
Six Union Territories
• Andaman & Nicobar Islands
• Chandigarh
• Dadra & Nagar Haveli and Daman & Diu
• Ladakh
• Lakshadweep
• Puducherry
Hospital Satisfaction Rating
Online Laboratory Results
MyHealthRecord
EMR Standards
 Key Components of the Indian Standards
• Data is maintained by healthcare providers
• Patients must be able to inspect and view their data
without time limitation, and must have ultimate authority
on who can access their data
• Records must be preserved for the entire lifetime of
patients, and may only be destroyed 3 years after death
• Changes to previously saved data are not permitted
• Healthcare providers must supply data to courts upon
request
• Healthcare providers may deny information to patients if it
would endanger their life or safety, or that of others
• Data is to be stored with 256-bit encryption
 Integrated Health Information
Program (IHIP)
• The Government of India intends to introduce a uniform system for
maintenance of Electronic Medical Records / Electronic Health
Records (EMR / EHR) by the hospitals and healthcare providers in
the country.
• An Expert committee was set up to develop EMR / EHR Standards
for adoption / implementation in the country.
• To provide interoperability of various EHR systems already
implemented, an Integrated Health Information Platform (IHIP) is
being setup by the Ministry of Health and Family Welfare (MoHFW).
• The goal of the initiative is to enable the creation of standards
compliant Electronic Health Records (EHRs) of the citizens on a pan-
India basis along with the integration and interoperability of the
EHRs through a comprehensive Health Information Exchange (HIE)
as part of this centralized accessible platform.
Patient-level Claims Data from Arogyasree are
Available to the Public, Facilitating Analytics
Meta Data and Data Standards (MDDS)
Covering the Health Domain
 Assorted State-Based Initiatives
Andhra Pradesh:
• eVaidya – Telemedicine Project Pilot In Urban Health Centers (PPP): The State has given two Urban
Health centers in Vijayawada and Visakhapatnam on pilot to eVaidya, a tele, ePHC concept. The
EMR of the patients are hosted on cloud enabled infrastructure and the access to various MIS
reports is made available.
• Rashtriya Bal Swasthya Karyakram (RBSK): Rashtriya Bal Swasthya Karyakram (RBSK) is a new
initiative aimed at screening over 27 Crore children from 0 to 18 years for the 4 Ds - Defects at
birth, Diseases, Deficiencies and Development Delays including Disabilities. The RBSK program has
been enabled through a cloud based, Tablet PC system, providing dashboard based reports for
various levels of administrators/doctors at all levels.
Gujarat:
• Gujarat Hospital Management Information System (GHMIS): GHMIS is state-of the-art healthcare
solution to provide better care to patients by addressing all the major functional areas of the
hospital & the entire gamut of hospital activities. The main aim is to maintain electronic health
records of patients.
• Ability Gujarat: A web based application named “Ability Gujarat” is developed. ‘Ability Gujarat’, is
innovative as it is intended to harness the benefits of ICT to improve effective and efficient delivery
of services to PwDs. The project has been designed to cover the entire state of Gujarat. The key
component of the project is to identify Persons with Disability (PwDs) and undertake issuance of
“disability certificates” to the individuals within a specified time period.
Tamilnadu:
• First state to implement a digital health program; a comprehensive HMIS
Kerala:
• Digitize healthcare sector by launcing e-Health Kerala
 A LOT can happen in a Decade:
The American Story
Stage Cumulative Capabilities Q4 2007 Q4 2017

Complete EMR; CCD transactions to share data; Data 0.0% 6.4%

Stage 7
warehousing; Data continuity with ED, ambulatory, OP
Physician documentation (structured templates), full 0.8% 33.8%
Stage 6
CDSS (variance & compliance), full R-PACS
1.4% 32.9%
Stage 5 Closed loop medication administration

2.2% 10.2%
Stage 4 CPOE, Clinical Decision Support (clinical protocols)

Nursing/clinical documentation (flow sheets), CDSS 25.1% 12.0%

Stage 3
(error checking), PACS available outside Radiology
CDR, Controlled Medical Vocabulary, CDS, may have 37.2% 1.8%
Stage 2
Document Imaging; HIE capable
14.0% 1.5%
Stage 1 Ancillaries - Lab, Rad, Pharmacy - All Installed

19.3% 1.4%
Stage 0 All Three Ancillaries Not Installed
 Electronic Capabilities in India between 2024 and 2034?

• More feasible (?)

– Patient, physician, nurse, OR, ICU scheduling
– Billing
– Hospital resource planning (HRP)
– Procurement and supply chain management
– Telemedicine
– Electronic medical records (single institution)
– Computerized decision support
– Computerized physician order entry
• Less feasible (?)
– Health information exchange
• Requires standardization
• Happening within some organizations; pan-India more complex
– Electronic medication administration records
• Requires CPOE and EHR implementation
• Requires unit dose dispensing of pharmaceuticals
– Single-point, integrated contact with care coordination
 Biggest Potential Sources of Failure for an Indian
Decade of Health IT?
• Changes in political will
• Lack of funding
• Lack of support from healthcare providers
• No incentives or benefits from participation
• High barriers to adoption
• Potential problems resulting from increasing the ease
with which patients can switch healthcare providers
• Poor computer literacy
• Concerns over digitization adding time but not revenue
• Privacy rights and data richness struggles
• Poor implementation and enforcement of regulations
 Potential Steps to Mitigate Failure
• Focus digitization at first on activities which generate revenue
– Patient scheduling
– Physician scheduling
– Billing
– Hospital resource planning
• Structure insurance programs or subsidies to encourage the use of
electronic health records, inpatient CPOE, and inpatient eMAR
– Tie use to government insurance scheme reimbursement
requirements
• Do not overemphasize health information exchange
– Causes concern about its impact on the physician/patient relationship
– Requires more standardization in reporting
– It is great that the government is exploring this through IHIP, so that
the necessary standards will be in place
 Potential Steps to Mitigate Failure
• Citizen-level education
– National effort to encourage digitization; customized
regionally
• Stage-based HIT implementation
– Learn from U.S. experience
• Stronger regulatory enforcement
• Standard-based systems, vendor agnostic
– Different vendors may be best suited to different
regions
– Specifying capabilities rather than vendors enables
more competition
 Takeaways
• Health system fragmentation (U.S., India) leads to a more
challenging environment for national HIT implementation
• India’s Decade of HIT
– Exciting changes and developments
– Multiple initiatives and real energy
– Regulatory changes, incentives, financing and large-scale national
push are key
 Course Takeaways
• Health system fragmentation (U.S., India) leads to a more challenging
environment for national HIT implementation
• India’s Decade of HIT
– Exciting changes and developments
– Multiple initiatives and real energy
– Regulatory changes, incentives, financing and large-scale national push are key
• Widespread use of EHRs worldwide
• Push the point of care delivery to the home
• Standard-based data exchange worldwide
• Widespread adoption and use of clinical information systems (e.g.,
CDSS) to bring about evidence-based medicine
– The outcome economy!!
• Much higher use of mobile platforms in both clinical staff and
patients
– Wearable devices
• Higher integration between public and clinical health
• SKY IS THE LIMIT FOR HEALTH AND IT IN INDIA IN THE COMING
YEARS
Thank You!!
Ivy College of Business