The WHO resolution on Digital Health1 that was adopted by the member states during the 71st World Health Assembly in May 2018 had India as a lead sponsor. The Indian delegation led by Honorable Health Minister participated in a ministerial side meeting on leveraging digital health for Universal Health Coverage . India shared its grand vision on how it proposes to implement digital health interventions to strengthen its health systems towards achieving Health For All. India further committed to fast tracking the digital health policy framework to create an enabling environment in this regard.
In just 18 months since the WHO resolution on Digital Health, India has finalized the National Digital Health Blueprint (NDHB) . NDHB articulates the vision for building a digital health ecosystem for 1.37 billion citizens and leveraging frontier technologies to future proof health systems.
Health systems worldwide face numerous challenges with respect to performance, rising costs and the need to more rapidly integrate evidence and innovations. Healthcare establishments the world over deliver highly compartmentalized, specialty focused, episodic care and most health information technology solutions mimic the workflows of this disintegrated approach. Recent years have also witnessed an abundance proliferation of mobile applications with narrow disease focus. A citizen is compelled to use multiple such apps for different aspects of care coordination and this is more pronounced among those with multiple morbidities.
A recent systematic review of mhealth and telehealth interventions implemented in India identified that most of the reported interventions were being implemented as standalone solutions often with no health systems integration strategy.
Despite the promised potential of digital health interventions in improving care coordination and influencing clinical outcomes positively, these mobile apps and standalone digital health interventions have resulted in further fragmentation of the clinical care coordination. A key feature that most such applications offer is push notifications, however in the absence of contextual personalization, these results in alert fatigue. Alert fatigue is a primary reason as to why the end users stop using the mobile health apps.
Integrated care delivery mandates using a risk stratification based rather than a disease-specific approach, coupled with the need for periodic reassessment and treatment modifications. Current digital health systems in most settings are narrowly focused on diseases and implemented within vertically focused programmes and therefore result in duplication of data collection. More over there is little effort to consolidate data across the vertical programmatic silos that could inform comprehensive policy interventions.
The National Digital Health Blueprint recognizes the above outlined gaps, missed opportunities and the enormous waste of resources due to islandization of data. It has therefore articulated the need for an ecosystem approach. The blue print is not limited to a technical architectural vision, but provides granular guidance on its implementation. It is envisaged that clinical data would be collected in a systematic manner across the care delivery ecosystem leveraging user interfaces that enhance participatory approaches. It proposed a system of Electronic Health Records, based on international standards, which are easily accessible to the citizens and service providers based on conditional access based on citizen consent. Further, it anticipates that clinical data would be transformed into machine processable coded formats. Another critical aspect is avoidance of duplication of data resulting in the concept of single source of truth.
It envisages a federated architecture, with a multi- tier system that ensures the highest levels of data security and ensuring privacy with citizens as the owners of their data. Open APIs that would enable all authorized ecosystem players to plug and provide relevant digital / data services.
The Blueprint has also outlined the need for adherence to standards that would allow seamless interoperability, with a clearly defined vision for an interoperable digital ecosystem or health information exchange. An example being the use of SNOMED CT . It allows the clinical information to be converted into standardized clinical terminologies which then make the data ready for use by computerized systems such as machine processing and algorithm driven approaches such as machine learning.
Learning Health Systems are systems where science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience. A national digital health ecosystem to be delivering value and influencing outcomes would need to consider how agile and learning frameworks could be an integral component.
This Blueprint is akin to an architects drawing for the vision of a building, however as in a building project, it would take inordinate effort to level the ground, dig deep to lay the foundation, raise the supporting pillars and then on lay the bricks and mortar. This requires that all stakeholders come together and collectively build this ecosystem.
A recently published book “Bridgital Nation”, suggests that digital technologies could serve as a vital bridge to address access challenges in health delivery. This could be achieved through re-imaging processes, technology and workforce would be paramount. Digital technologies could be both the back bone as well as wraping envelope for the health systems.
It is important to recognize that digital health is just an enabler. The investments into infrastructural capacity to deliver the services, the availability of essential diagnostics and medicines and digitally literate and technology augmented workforce are pivotal to the success. NDHB implementation should take this into account.
A grand vision like the blueprint also runs the risk of stakeholders looking for their piece of the pie and focusing only on enlarging the size of their pie, an ecosystem approach would need a collaborative and consultative approaches. There is an urgent need to develop the tools and techniques to monitor and evaluate the efficiency, effectiveness and inclusiveness of any such interventions aimed at health systems. Unless proactively addressed digital interventions could result in perpetuating existing inequities and amplify biases and discriminatory practices. Emerging technologies in particular have serious ethical implications that would need to cautiously addressed.
It is imperative that the governance mechanisms of the NDHB through national digital health mission takes into account a broader representation of the stakeholders from across the ecosystem such as the frontline health workers, patients, providers, payers, public policy experts and academic researchers.
A grand vision such as the NDHB requires a committed budget to build infrastructural and human resource capacity for many years. This would need a clear strategic investment . Hence identifying how the National Digital Health Mission will be funded is an important aspect to outline before the enthusiasm about the launch of the vision fades.
An opportunity awaits India to showcase to the global community the power of data driven decision making at scale, given its computational talent pool and wealth of health systems expertise if all stakeholders are engaged in a synchronized and harmonized manner this can be achieved within the time frames articulated for the sustainable development goals.
This is an opportunity not to be missed, as this could be India’s global contribution towards building health systems that are future ready and for improving the health of the citizens of the world.
- Agenda item 12.4. Digital health resolution. In: Seventy-first World Health Assembly, Geneva, 26 May 2018. Geneva: World Health Organization; 2018
About the Author:
Dr Oommen John is a Senior Research Fellow at The George Institute for Global Health India and Secretary of Asia Pacific Association for Medical Informatics. He is also a founding director of the Digital Health India Association leading its strategic partnerships.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I have no relevant conflicts of interests to declare.