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Dr Anurag Agrawal currently focuses on the use of information technology and big data analytics for the effective application of community health efforts and the development of pattern-based diagnostics. (Photo Dr Anurag Agrawal)

Can Technology Still Save India’s Collapsing Healthcare System?

Low government spending on healthcare (1,28% of the country’s GDP), poor infrastructure, inequalities in access to medical services, high out-of-pocket expenditures, shortages of health professionals, unmanageable patient-load – healthcare in India is struggling. Meantime, there are 760 mln smartphone users and over 620 mln active internet users. Will technology rescue the system that nearly crashed during the COVID-19 pandemic? An interview with Dr Anurag Agrawal, co-chair of The Lancet & Financial Times Commission Growing up in a digital world: Governing health futures 2030.

In your opinion, the healthcare system is broken in terms of accessibility, efficacy, and universality. Digital health can help to bridge that gap. What do you mean by that?

The healthcare system as it exists is highly heterogeneous in terms of resource concentration and quality. Much of it is fee-for-service based and driven by symptomatic treatment of illnesses, with underutilized preventive services other than vaccination. Digital health is well placed to bridge this gap by enabling telehealth services, promoting wellness and preventive care, and enabling more efficient utilization of limited resources

Can you outline the architecture of the digital health ecosystem in India?

The digital health ecosystem in India is still in a nascent stage. EMR are limited to corporate hospitals and a few tertiary centres. However, there is a strong digital presence, IT, and backbone digital services for non-health sectors, most importantly – electronic identity and financial transactions. A national digital health mission and authority have been created to build health as a digital service on this national core

What must be done to improve the maturity of digitalization?

There are three critical steps to improving digital health system architecture:

  • Investment into digital infrastructure suitable for truly digital workflows. This has to include health devices and information systems. Core components of this must be public goods with standardized and interoperable APIs;
  • The transition from the digitization of analogue processes to truly digital workflows with verifiable data;
  • Continuous use of digital health data, with solid but lean governance to ensure beneficial use, improve healthcare quality and delivery, and generate insights for precision health and precision public health.

While many digitalization challenges are common to many countries – for example, reimbursement for digital health services or legislative shortcomings – there are also many national barriers to adopting digital health technologies. Which of these in India are the biggest obstacles today?

The most significant barrier is that most healthcare is via low-cost, high-volume individual practices on fee-for-service mode, without insurance. Thus, the financial incentives are misaligned for small practices. However, much of the core system will be created as a public good under the national mission. It is expected that this would spur innovative low-cost models in health as it has done in other sectors

Your research group has developed integrated solutions for healthcare delivery and digital data collection in resource-limited settings. Could you please elaborate on this?

We had worked with Hewlett Packard on cloud-connected e-health centres created in shipping containers for transparent health service delivery and data collection.

The eHealth Center (eHC) was created in cargo containers, with verifiable cloud-based electronic workflow and records, telemedicine capability, and automated online reporting of summarized health data and operational status.

The eHC, capable of providing primary health care (PHC) services, was pre-fabricated within two half-size (20 ft×8 ft) shipping. The design includes a registration area for the initial patient encounter and recording of vital signs, two air-conditioned telemedicine studios with provision for minor surgery or wound care, a lab area, and a pharmacy. In addition, electrical generator sets were incorporated for self-sufficiency.

Equipment available in the eHC has a digital output, wherever possible; for example, for infant/adult scales, thermometers, automated blood pressure devices, pulse oximeters, electrocardiograms, spirometers, and glucometers. These components are connected to a mixed wired and wireless local network, forming a self-sufficient local health network (HN). Critical analogue equipment use, such as refrigerators, has been added to the HN by monitoring their electrical consumption. Access to eHC is via biometric login, intended to mitigate provider absenteeism.

A modified version of the OpenEMR electronic medical record (EMR) system, running on a local server, receives clinical data and enables the clinical workflow. The eHC data stream and EMR are connected to a remote health cloud via the nearest mobile phone tower. Telemedicine may be enabled between the eHC and any tertiary care hospitals via the health cloud. Other than audio and video connectivity between sites, cloud-based access to the EMR allows direct entry of orders and notes and desktop sharing.

A web-based dashboard provides an overview of the operational status of the eHC, provision of health care, and critical alerts. EMR data, available in MySQL format, can be continually analysed for data trends, such as the number of new cases, diagnoses, demographic breakup, etc. In addition, critical alerts can be set as per requirement, such as notification of very late arrival of the health care providers at the eHC. The dashboard integrates the health-data analysis, usage of various types of equipment, alerts, and a real-time view of the premises. This novel aspect of the eHC design can bring transparency to health care delivery and is a potential game-changer.

Where do you see the greatest opportunities of using big data analytics in Indian healthcare? And how to turn this potential into tangible projects and benefits?

If the system of eHealth centres is scaled and data used for enhanced healthcare delivery and targeted wellness care, it would be the low-hanging fruit. The forthcoming Ayushman Wellness Center program may be structured along this line.  

The core IndiaStack – a set of APIs that allows governments, businesses, startups, and developers to utilize digital infrastructure – is in place. What’s more, a national digital health mission has been announced, with wellness promotion at the core of the Ayushman Bharat program. It is now a matter of execution balancing the privacy requirements with efficient, ethical data sharing for public and private applications. This is, of course, much more complex than it seems, and the forthcoming Lancet-FT commission report has the necessary core principles and a call to action.


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