Thursday, 28 April 2016

Workflow and Interoperability approach to National eHealth Authority (NeHA) in India


Author: Manish Sharma
24 April 2016, Bangalore, India

The Ministry of Health and Family Affairs in India recently published a Concept note on the National eHealth Authority and called for comments and feedback on the formation of NEHA, India. All comments and suggestions can be emailed to [email protected] on or before 20th April 2016.

NEHA is envisioned to be, to quote from the concept note, "a promotional, regulatory and standards setting organisation to guide and support India's journey in eHealth and consequent realisation of benefits of ICT intervention in Health Sector in an orderly way"

Workflow Optimisation

While considering the implementation of DigitalHealth Solutions in India, its is very important to understand the "Workflow" of the patients and understand the Information requirements within the Identified workflows.



Since Healthcare has always been considered to be the "last bastion" to be Digitised for many years, the approach to Digitize Healthcare Workflows has always taken the "Traditional" approach, i.e., Go to the hospital, Study their workflows, gather all the current paper being generated and Digitize IT. And hence we came up with the "Paperless Hospital" approach.

But the flaw in the paperless approach, in my opinion is the approach that caused the creation of Information silos. We Digitised the Paper, and not the workflow.

Take for instance the workflow of a Doctor in a hospital. She is inundated with information which her training is able to Streamline as a workflow, but give the doctor a system, she is faced with a daunting task of having to "feed" the system with the information, because the system is not designed to help her streamline her workflow in her specialty.

The problem in the usecase of the doctor is that we have Digitised the feeding the information part, but not the workflow of the doctor-patient relationship and by that extention the care provider-doctor-patient relationships.

There have been many recorded and unrecorded cases of HIT implementations wherein the Clinical workflows are the last to be IT-enabled and at times not even enabled, due to this very reason.

World over the learnings of other National eHealth Implementations are definitely pointing towards the absence of patient and healthcare professional workflows being digitised, leading to dissatisfaction with the current Digital Health solutions.

Suggestion 1: 

NEHA should consider "Workflow Digitisation" in a Healthcare Facility as the driving force instead of Data Generation or Data Capture. It is important to identify and define the workflows across the healthcare organisation considering each care providers role and responsibilities. And to endeavour incorporating these workflows into the HIMS of the future.

Major and Minor workflows need to be identified and incorporated within the ambit of the pragmatic workflow optimisation, to ensure the relationship model between the care providers and the patients are well documented.

The Interoperability Red-herring

Most often than not, the main premise of setting up a National Level eHealth Authority in most countries has been to provide for "Interoperability" of information between the "Silos of Information" within and outside of the hospital.

As the report points out, Lack of Interoperability leads to "Ineffective Results". 

In the discussion about Interoperability, I would like to for the need of discussion define "Exchange of Information" to be subcategorised as two specific areas

-  INTRA-operability:  between Digital Health systems within the Hospital. Most vendors are contracted with the hospital and hence there is more control for the hospital management in this particular aspect, from a solutioning point of view.

- INTER-operability: between Digital Health systems within the Hospital and "External" Digital Health systems that could be government bodies, patients, Digital Health Apps, etc. 

The above sub-categorisation can help in identifying areas of information flow and help the NEHA define the standards for each of the presenting usecases.

Consider the various Digital Health solutions within a Healthcare Organisation and you will realise the presence of "Standards" that each are specific to the type of Digital Health solution

For instance, 
  • a Laboratory equipment exchanges information via the RS232 port or RJ45 port in a ASTM format. 
  • A Radiology imaging platform deals with DICOM standards. 
  • The Patient Monitoring system in the hospital is a fortress of information, "Designed" to "Lock-in" the information that is "Proprietary" to the vendor that has supplied the system.

Just take the above three scenarios, and try and get a quote from a vendor to build you a system that "Integrates" all these three data streams (or information silos) into a patient's EHR. It will be considerable. I would guesstimate 10-20% of the cost of ownership of a enterprise Digital Health solution.

Now, lets say you have been able to take up the implementation of such an "integrated" system, it took you a good year to stabilise your system with "INTERoperable" solution. And after the year of stability, you need to start sharing all this Information with the new app that has become famous with the patients.

Lets assume, that the new app is built on a standard that is different version (or perhaps proprietary) from the one that you have implemented during the past year. The entire process begins again to now "INTERoperate" with the new app.

Suggestion 2: 

I would suggest that the NeHA identify Digital Health information sources and fix the VERSION of messaging formats for each of these Digital Health Information sources for a period of 7 years so that all the sources of Digital Health Information are talking the same language without the need to constantly keep changing the standards of information exchange.

There should be a clear roadmap for version upgrades within the NEHA framework to allow for newer usecases but avoid changing the messaging format altogether year on year.

Streamline and standardise the INTERoperability and INTRAoperability standards for Digital Health Information sources.

As an additional step, it is important to mandate the implementation of common Digital Health Standards in all the Medical Devices that is OPEN and can be easily extracted from existing and new Medical Device implementations. 

Ideally, solutions, EHR products, medical devices and any other patient information generation device or software solution should adhere to a fixed set of standards, that allow for easy exchange of information.

Finally, NEHA can provide an Infrastructure to provide "Open and Secure Digital Health Exchange Services/ APIs". This will definitely remove the cost barrier to interoperability of Digital Health information.
I would suggest the use of "a Pragmatic approach to Interoperability" that helps NeHA identify and enable Interoperability of Digital Health information that provides the context in patient care. Physicians, Specialists and Chronic and palliative care experts should be consulted to define the usecases for patients need of Digital Health information. 

Questions to consider for Patient Information Inter / Intra Operability : 

  • Does the Doctor really need the "Womb to Tomb" record of a patient
  • What percent of patients need a "Womb to Tomb" record? 
  • Is it really possible to have such a record available, if one version of the HIMS is different than the other?
  • What percent of Patient's benefit from Digital Health Interoperability?


To remove the boundaries between information silos in a Hospital workflow are the key aspects that should be identified and addressed in a pragmatic interoperability approach for an optimised workflow approach rather than a paperless or less paper approach
Author

Manish Sharma


Founder HCITExpert.com, Digital Health Entrepreneur.



Additional Articles by the Author:

  1. Health ID as Patient IDs unifier in India  by Manish Sharma  
  2. 5 Steps towards an Integrated Digital Health Experience in Indian Healthcare in 2016 
  3. Top Healthcare & Digital Health Predictions for 2016
  4. Zen Clinicals: An Activity & Workflow based solution (1 of 3)
  5. RFID in Healthcare: Usecases from Hospitals
  6. 10 Solutions for the Healthcare IT Fringes

Suggested Reading:


  1. CHIME Calls for More Transparent, Uniform Interoperability Standards for Medical Devices
  2. The future of depends upon the secure exchange of electronic data - Deloitte Healthcare
  3. Pragmatic interoperability: Interoperability's missing workflow layer | Health Standards - Dr. Charles Webster ( @wareflo on Twitter)

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