NITI Aayog’s National Health Stack - a Healthy Stack?! by Divya Raj @divyaraj1




Extraordinary problems need extraordinary solutions. And creating a country level IT infrastructure addressing challenges in India's Healthcare management for its 1.3 billion population definitely falls very well into that category. 

NITI Aayog's “National Health Stack - Strategy and Approach” document published in July ’18 is a good starting point in the direction of digitizing India's healthcare management for meeting the challenge of healthcare of India's masses. It’s a clear reflection of the realization that India’s Healthcare needs a digital infrastructure. The National Health Stack (NHS) is outlined as a "visionary digital framework" with four key components -- electronic health registries of health service providers and beneficiaries, a coverage and claims platform, a federated personal health records framework and a national health analytics platform. 



However at the same time there are some gaps and untouched aspects which must be taken care sooner than later to ensure initiatives across the nation start on robust and comprehensive foundations. Ironically, while the document as well clearly recognizes that Ayushman Bharat has a 2 pronged strategy -- setting up of 1.5 lakh Wellness Centers in Primary Healthcare and increasing the financial protection for secondary and tertiary care – the Wellness Centers are not at all touched upon in the proposed Digital framework. There can be no two thoughts about the high criticality of the Primary Healthcare system in India’s healthcare. NHS implementations designed with primary focus on insurance claims and coverage will be a lopsided strategy for the scale of efforts involved. In fact, extending this further beyond the Wellness Centers, the NHS must plan to give adequate provisioning for Anganwadi and other grassroots level Health-workers who are working most closely with the masses and form the lowest layer of healthcare services hierarchy which is extremely critical for preventive and primary healthcare. Any digitization initiative leaving these grassroots workers out of purview would be stunted and ineffective. Options must also be explored to address all existing gaps in this is extremely critical layer. 


Coming to the technical aspects of the NHS stack it is important to understand that in our highly democratic and federal setup it may be justified for NITI Aayog to restrict their guidelines only till technical stack level. However leaving the next line of details totally to various public and private stakeholders will likely lead to anarchic and incompatible solution outcomes across the country. It is imperative that NITI Ayog comes up with next level of guidelines and pushes the states and all stakeholders to align to those guidelines. Without going into the modalities of the way it will be done, the rest of this article will focus on some of the key design considerations which must be included by various implementers for ensuring there is basic hygiene and consistency in this National registry of this scale. 


Envisioning National Health Electronic Registry as a national one, as "a single source of truth for and manage master health data of the nation" sounds very ambitious. Rather than letting this happen at the “democratic” pace, this needs to be executed with greater authority, careful planning and a best-in-breed technology platform. At the same time we must also look at the returns on investment for this grand registry or repository – do we really see a significant proportion of patients moving across states for health treatments? 


Instead of trying to build a mammoth data repository a more practical and effective approach may be to maintain the repositories at state-level for now, provisioning the central registry to have only meta-data for querying and pulling information from the state health repositories. 


For unique identification of patients across various systems and networks a standard and uniform mechanism will have to be ensured while giving due regard to all the various Government approved Identity mechanisms and not just Aadhar. This is to ensure that the treatment are not delayed or denied for lack of Aadhar or any other identity mechanism. This needs to be balanced carefully with the need to provide robust mechanism for avoiding any Data duplication or Data redundancy. 


Another extremely important aspect to be looked into is data privacy and data security. Vision of having a centralized registry of health data for 130 billion people entails a huge challenge in terms of ensuring the data is secure, only authorised and appropriate data is accessible to stakeholders and the data cannot be misused by technical or non-technical individuals, agencies, organizations or negative forces. This requires very strong and explicit guidelines to be provided to all the implementers at different levels because any gaps and nuisances with respect to data security and data privacy can have cascading effect and has tremendous detrimental potentials on this mega initiative. 


The envisioned health registry will be the central registry for all Health establishments, professionals, patients, health workers, medical personnel and other stakeholders. And it will be closely integrated with the Health data repository which should have all the data or meta-data for all patients, their visits to all different health-establishments, diagnosis, scans, test-reports and treatments. Considering the scales, volumes and complexities it is obvious that a digital platform connecting all these cannot afford to be based on any manual data updates without any data-duplication. All the different applications will have to be integrated in a seamless manner and in real-time basis using open APIs. Hence all participating applications need to be mandated to expose APIs in a standard way. API formats and protocols need to be laid out clearly rather than leaving it to participating organizations and stakeholders. 


NITI Aayog deserves a pat on the back for envisioning the National Health Stack which will push the digitization initiative in India’s Healthcare in a big way, paving the way for numerous healthcare benefits to the masses including the financial protection and also other benefits including policy making, governance, research and so on. In doing this NITI Aayog have set the bar high for themselves. However it will be extremely important to translate this framework into large scale adoption and follow it up with detailed IT architecture guidelines for National or State Health IT Platforms, or possibly even the solution architecture itself, incorporating the inputs highlighted here among all other considerations. They must also apply the crucial lessons learnt from the India stack adoption. Only then we can be assured that this Digitization initiative goes beyond a cliche and fetches results in the range of expectations!  

The article was first published on the Author's LinkedIn pulse blog, its been republished here with the author's permission. 
Author
Team HCITExperts
The author, Mr. Divya Raj, is Head of Programs at E-Health Research Center (EHRC) of International Institute of Information Technology - Bangalore where he is also an adjunct faculty. EHRC has mental health, malnutrition and disabilities as the strong focus areas. Mr. Divya Raj comes with around 2 decades of IT industry experience with a specialization in Artificial Intelligence and Enterprise Integration technologies and is passionate about IT based public and social initiatives.

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