Current State of EMR standards in India and its implications on patients

In April 2013, the EMR Standards Committee, constituted by the Ministry of Health & Family Welfare, and coordinated by the Federation of Indian Chambers of Commerce and Industry (FICCI), developed India’s first set of standards recommendations for the Government of India to adopt. http://clinicalestablishments.nic.in/WriteReadData/107.pdf

 

In this blog post, we will decipher the specific recommendations made, and the implications those recommendations will have for patients.

 

In order to develop these standards, the Committee worked with payers and providers, and studied EHR standards implemented successfully in 9 different countries (Australia, Austria, Canada, Denmark, England, Hong Kong, Netherlands, Singapore and Sweden). After thoroughly reviewing its recommendations, we found various path breaking recommendations in this report:

1. The report defined all the fields that should be captured through the implementation of a minimum data set (MDS) that should be recorded for every individual patient. The recommendations were thorough – not only were the fields defined, but also the type of data (alphanumeric, numeric, text, etc.), the length of data, the format / values that should be captured, whether capturing the piece of data should be required or optional, and additional observations that ought to be recorded.
2. The report recommended the use of the Unique ID, a nationwide unique identified program currently being implemented, as its basis of identifying individuals. In the absence of the availability of the number, the report provided vendors the option to capture any other unique identifiable information. This is a terrible strategy. The report should have defined a list of acceptable forms of unique identification, given the rampant prevalence of fake identification papers across India. As of March 2014, over 600 million people have been issued the Aadhar Unique ID. Having this healthcare system based on that as the Unique ID would have forced a greater adoption of the ID across those factions that haven’t yet enrolled in the program.
3. The report-defined standards on capturing drugs administered, and based it on various internationally accepted drug-naming standards.
4. The report stated that network and data security should be planned and implemented, yet was silent on best practices that need to be adopted to protect the data security. Given that the information being captured is sensitive personal information, inadequate stringency around data security may have undesirable consequences in the long run. Additionally, the language around data security and privacy was not as forceful, suggesting that this issue may not be taken this issue as seriously.
5. The report did a great job of defining who owned the data (the patient) – this limits the ability of companies interested in building medical records systems for selling data to pharmaceutical companies without getting waivers first from patients or their next of kin (which may not be as difficult, given how little individuals read before signing off electronic waivers). The report clearly states that personal identifiable information (PII) will have to be excluded from such reports, and goes on to define the full list of fields that constitute PII.
6. The report is silent on additional functionality that might be desirable for patients, including being able to access lab reports, make appointments, and buy prescription drugs. Given the lack of definition around acceptable norms, it may be hard for entrepreneurs to develop suitable technologies without running the risk of being thrown out of the market for not having complied at a later date.
7. The report is also silent on next steps for the Government, and in particular how these recommendations need to be implemented.

The Government of India launched its first Electronic Health portal with advise for patients and end users in September 2013, and announced its set of Healthcare standards. Essentially, the standards announced were the same as those recommended by the FICCI report (to the extend that language / tables were copied verbatim).

What does this mean for the vendor community?

Having implemented a set of standards is a great first step for the Government to have taken. However, this isn’t sufficient. The next thing for the Government to do is to enforce the implementation and adoption at healthcare providers and payers by incentivizing adoption, similar to what we say with the successful implementation in Denmark. The Government could also potentially start implementation at Government hospitals, where the quality of care and service is often criticized in the press for being poor.

Entrepreneurs interested in this space have a choice – is this the right time to invest? Or do we need additional legislation and incentives for investment in this space? First-mover advantage and developing relationships with key medical establishments will enable successful implementation of EMR in India. The other choice entrepreneurs have is – whom will they target? Will high-end customers and medical institutions are a suitable customer? Are we interested in providing a service to everyone, and don’t really care about making profits?

Watch this space for exciting developments; India is at the cusp of a healthcare revolution that will likely transform the lives of a billion people for the better.

 

Analyzing a success story and learning how to adapt it to India

In this blog post, we will develop an understanding of critical success factors and best practices that enabled the successful implementation of Electronic Health Records in Denmark. We will then evaluate how those critical success factors can be applied to the Indian context. Gartner wrote a well-received case study on Denmark’s Healthcare IT system, published in 2006. http://www-03.ibm.com/industries/ca/en/healthcare/denmark_portal_sw.html

 

Denmark is a successful case-in-point for having developed a centralized electronic health record portal called sundhed.dk. The portal cost 15 million euros to build, and costs 4.5 million euros to administer. It’s a one-stop portal for the entire Danish population of over 5.6 million people and health care providers to access for their health records. Patients can view their health file, their medical journal, personal records from primary care physicians, medicines prescribed, an overview of all your doctor’s appointments and visits, providing a similar level of transparency to practitioners and patients alike. It also enables e-commerce and telemedicine, including purchasing medicines and electronic consultations.

 

Why did Denmark succeed, and what are the lessons we can draw from Denmark’s success when applying to a country like India?

 

First, Denmark is a country with 5 million people. The scale of the problem thus was manageable. India, on the other hand, is a country of a billion. Thus, potentially solving the problem at a state level and city level may make solving the problem more manageable. Lets say that we would like to solve this problem for the residents of Kolkata, a city with 15 million residents. The challenge with this approach is that different cities may develop different electronic data interchange standards, resulting in the problem that the US finds itself in today. The mitigation to this challenge is partnering with the Government of India to develop a set of standards that various states and cities can use to apply in developing health records.

 

Second, Denmark recognized in the 90s that a significant portion of administrative costs went in handling paper, and making records electronic might result in time and cost savings. In response, Denmark established Medcom, a coordinating organization for healthcare IT in 1994, to develop standards for electronic data interchange, with funding from multiple key stakeholders. 50% of its funding came from the Danish Ministry of Health, 35% from the Association of County Councils, and the other 15% from the Danish Pharmacy Association, municipal bodies and other organizations. Buy-in from the stakeholders was a critical success factor. In Kolkata,, healthcare is not all Government managed. Partnering with stakeholders like the Department of Health and Family Welfare in the Government of West Bengal, medical colleges and hospitals, the Kolkata Municipal Organization that runs various health clinics, immunization programs and the emergency response systems, will be critical. Additionally, partnering with the Association of Healthcare Providers of India (AHPI), the Consortium of Accredited Hospitals (CAHO), the Association of Hospitals (AOH), and the Indian Pharmacists Association will enable adoption and implementation.

Third, Denmark instituted schemes to incentivize greater adoption of the records system from practitioners. In particular, Denmark reimbursed physicians using the system quicker, and gave a cash incentive of 1500 Euros / year to spend on EMR systems. This enabled a greater adoption among the practitioners. Similar incentives would have to be provided to practitioners in India. According to the state’s annual health report in 2011-2012, Kolkata had 48 Government hospitals, and 366 private medical hospitals; the state has 51000 medical practitioners; each doctor and nurse serves on aggregate 1780 ad 1543 people in the state’s population. Reaching and incentivizing that large a number of practitioners to implement electronic health records will be challenging and expensive.

Fourth, Denmark established precise standards to communicate exact content in working with clinics. This exactness and clear communication of standards allowed little room for interpretation in the vendor community about what each piece of software supporting the healthcare standards had to communicate. This resulted in the creation of information that could easily flow through the country’s IT systems, and connect disparate vendors’ information through a single, usable portal. Defining those standards from scratch in the context of India may be challenging given the scale. Perhaps the quickest way to achieve exactness would be to partner with Denmark, learn the standards recommended by Medcom, present those standards as a starting point to the medical community in Kolkata through associations and forums, and have the associations recommend changes worth implementing.

Finally, and perhaps most importantly, Medcom had a project based approach to the problem. Medcom wasn’t in the business of creating an organization; it used half of its funds towards its organization of 15 individuals, and the other half of its funds towards building tools, healthcare standards and software. This project-based mentality enabled Medcom to succeed. Adopting this will likely be the hardest in the context of India, given the manpower driven economy and labor market. But to the extent we can successfully do so in India, we will find it well worth the reward.

Electronic Medical Record – An illusion?

We live in the world of Big Data. Everything we do, is recorded. Even when we think we are not connected to the internet. Companies spend millions trying to gauge whether you are more likely to buy a Birkin or a Coach. The age of big data is here, albeit about 15 years later than promised. And Facebook, Twitter and Instagram know more about your likes and dislikes than your husband does.

 

In such a world where technology has defeated personal privacy, one would wonder, or perhaps somewhere secretly hope, that there is a black box somewhere collecting everything there is to know about your health. A Utopian world where should you fall sick, and need assistance, there is enough that everyone knows about you so that no matter where you are, who you are with,  you can get treated. So that if you were, God forbid, ever in a serious accident, lost your consciousness, the paramedics would just need to put in your name in a secure cloud, discover your history of sickle celled anemia, and prescribe treatment accounting for that information. No time lost. Smooth, synchronous, accurate, organized, actionable information.

 

Yet, no such master repository of information exists anywhere in the world.

 

One is forced to wonder – why is that the case? What are the specifics of the global healthcare industry that have not allowed us to capture everyone’s blood groups and chronic illnesses, yet have allowed us to capture through the likes of Facebook the television shows we like watching? I have heard several arguments in my career, none of which I find convincing.

 

One argument is – it would be expensive to build a system that captures information about everyone. That couldn’t be more far removed from the truth. The US Government just enacted a trillion-dollar legislation mandating universal health care coverage, and spends 18% of its GDP on healthcare. Most technologists estimate that startups like Facebook would cost a million dollars to build (http://thenextweb.com/dd/2013/12/02/much-cost-build-worlds-hottest-startups/). A trillion-dollar budget could build a million Facebooks. A million Facebooks. We can reject this argument outright.

 

The second argument is – who would maintain it? Again, it would cost too much. Well, every time you’d visit your doctor’s office, they’d simply add whatever diagnosis and prescription they provided to your record. They already spend a couple of minutes doing that for you manually. Surely, doing it electronically doesn’t take away from their ability to treat other patients by requiring more of their time (unless you build a really poor version of Facebook. Sort of like healthcare.gov).

 

The third argument is – its not the building, or the maintaining that’s troubling. Its too much information about us being on the web. I get that there are privacy concerns around an individual’s health history. But there are also privacy concerns around having Google know that I last bought a dress on Rue La La, and that they ought to advertise other dresses, bags or shoes to me the next time I open my Gmail account.  Heck, they’d probably already know if I were pregnant, had a smoking addiction, or suffered from amnesia based on the topics I was searching for using a uniquely identifiable IP address associated with my computer. Google knows about my health history, because I use Google to search for things concerning my health. Even if one were to assume there were legitimate privacy concerns, I think complying with HIPAA should address those sufficiently.

 

The fourth argument is – no one is thinking about it. You should start it. I might. But in the meanwhile, the organizations building dedicated electronic medical records for providers and payers could just as easily build a system for profit that becomes a platform that the world adopts. The purpose of this system is to consolidate the fragmented health care world.

 

So what is really going on?

 

Through this blog, I will explore the specific challenges that exist in the electronic medical records industry, the opportunities and risks, specifically in the context of the Indian market.

Why India? Well, other than the fact that I’m from there, from the perspective of any enthusiast of medical records’, India should be the epicenter of all this innovation. Millions of Indians don’t have access to basic food and water, yet have access to mobile devices connecting to the internet. It represents both the developed world and the developing world – it has obesity and undernourishment and micronutrients deficiencies all in the same country. It has diabetes and water-borne malaria.

India provides a platform for huge impact to be created, affecting billions of lives. That is the opportunity that India presents to an enthusiast of electronic medical records.

 

Lets explore this space through the medium of this blog. And lets find a way to solve the greatest challenges of the world.