How can Digital Health be Implemented as envisaged in the National Health Policy 2017? by Prof. Supten Sarbadhikari @supten



The National Health Policy 2017 (NHP-2017) of India correctly identified the need for creating many new institutions like the National Digital Health Authority (NDHA).  However, the ground realities don’t appear to have been considered well enough. Early setting up of a functional NDHA is essential for India to avoid a digital health mess in future. The first job for the proposed NDHA will be to formulate a robust National Digital Health Strategy / Policy, in consultation with all the stakeholders. Caution needs to be exercised before cross referrals and sharing disparate information among different systems of medicine. Health informatics education must be embedded as an integral part for health and hospital management. It may be prudent to include Health in the Concurrent list of the Constitution of India. That will ensure a smooth adoption of digital health in India. Seeking comments on the Draft Bill DISHA (Digital Information Security in Healthcare Act) is a good start.

It has been now more than a year that the (third edition of the) National Health Policy 2017 (NHP-2017) of India has been notified. While the accompanying Situation Analysis didn’t mention anything about Digital Health, the Policy correctly identified the need for creating many new institutions like the National Digital Health Authority (NDHA).

Now, let us look at where do we stand one year later, regarding the ushering in of Digital Health in India.


First let us glance at some of the key provisions of the NHP-2017 as mentioned in the various sections. Just beneath the quotes from the relevant sections of the NHP-2017, I’m commenting on certain issues for thought.

2.4.3.3 Health Management Information

a. Ensure district-level electronic database of information on health system components by 2020.
b. Strengthen the health surveillance system and establish registries for diseases of public health importance by 2020.
c. Establish federated integrated health information architecture, Health Information Exchanges and National Health Information Network by 2025.

Comments: The NHP-2017 focuses on Digital technology, right from the beginning. Some timelines are also proposed here. However, while some states have been doing very well, some others are lagging. We would further elaborate on this aspect towards the end.

3.3 Organization of Public Health Care Delivery: 
For effectively handling medical disasters and health security, the policy recommends that the public healthcare system retain a certain excess capacity in terms of health infrastructure, human resources, and technology which can be mobilized in times of crisis.

In order to leverage the pluralistic health care legacy, the policy recommends mainstreaming the different health systems. This would involve increasing the validation, evidence and research of the different health care systems as a part of the common pool of knowledge. It would also involve providing access and informed choice to the patients, providing an enabling environment for practice of different systems of medicine, an enabling regulatory framework and encouraging cross referrals across these systems.

Comments: Here there is a need for more caution since the other streams of medicine – viz., Ayurveda, Yoga and Naturopathy, Siddha, Unani and Homeopathy, follow entirely different principles from those followed by modern medicine. Therefore, cross referrals may add to the complexity and confusion, ultimately harming the patient.

11.1 Medical Education: 
The policy recognizes the need to revise the under graduate and post graduate medical curriculum keeping in view the changing needs, technology and the newer emerging disease trends.

Comments: There have been a lot of issues regarding the Medical Council of India and the National Board of Examinations in the past, followed by a proposed revamping through the National Medical Commission. Despite all the proposed changes, one of the essential features that is amiss is the incorporation of health informatics essentials in all branches of health professional education. Without doing that, a smooth adoption of digital health is extremely difficult.

11.8 Public Health Management Cadre: 
The policy proposes creation of Public Health Management Cadre in all States based on public health or related disciplines, as an entry criteria.

Comments: In continuation of the previous section, health information management must be embedded as an integral part for health and hospital management. Health Informatics weds both health information technology and health information management. Scaling up, public health informatics combines health informatics and population demographics.

13.12: Health Information System: 
The objective of an integrated health information system necessitates private sector participation in developing and linking systems into a common network/grid which can be accessed by both public and private healthcare providers. Collaboration with private sector consistent with Meta Data and Data Standards and Electronic Health Records would lead to developing a seamless health information system. The private sector could help in creation of registries of patients and in documenting diseases and health events.

Comments: Most of the times various health information systems don’t talk to each other and therefore there is a dire need of Standards for interoperability. I would discuss this issue in greater details this issue towards the end, where I would talk about the Clinical Establishments Act.

14.2: Regulation of Clinical Establishments: 
A few States have adopted the Clinical Establishments Act 2010. Advocacy with the other States would be made for adoption of the Act. Grading of clinical establishments and active promotion and adoption of standard treatment guidelines would be one starting point. Protection of patient rights in clinical establishments (such as rights to information, access to medical records and reports, informed consent, second opinion, confidentiality and privacy) as key process standards, would be an important step. Policy recommends the setting up of a separate, empowered medical tribunal for speedy resolution to address disputes /complaints regarding standards of care, prices of services, negligence and unfair practices. Standard Regulatory framework for laboratories and imaging centers, specialized emerging services such as assisted reproductive techniques, surrogacy, stem cell banking, organ and tissue transplantation and Nano Medicine will be created as appropriate.

Comments: Discussed below separately.

14.5: Medical Devices Regulation: 
The policy recommends strengthening regulation of medical devices and establishing a regulatory body for medical devices to unleash innovation and the entrepreneurial spirit for manufacture of medical device in India. The policy supports harmonization of domestic regulatory standards with international standards. Building capacities in line with international practices in our regulatory personnel and institutions, would have the highest priority. Post market surveillance program for drugs, blood products and medical devices shall be strengthened to ensure high degree of reliability and to prevent adverse outcomes due to low quality and/or refurbished devices/health products.

Comments:  Medical Devices Rules, 2017 that has come into force with effect from 1st day of January, 2018, has included in the Part-I of the first schedule Parameters for classification of medical devices other than in vitro diagnostic medical devices. There, Software as Medical Device (SaMD) is defined as: (iii) Software, which drives a device or influences the use of a device, falls automatically in the same class. This is indeed a very forward looking and welcome legislation, ahead of the times in our country.

22: Health Technology Assessment: 
Health Technology assessment is required to ensure that technology choice is participatory and is guided by considerations of scientific evidence, safety, consideration on cost effectiveness and social values. The National Health Policy commits to the development of institutional framework and capacity for Health Technology Assessment and adoption.

Comments: We can combine these aspects with the digital health technology, described in the next section.

23: Digital Health Technology Eco - System: 
Recognising the integral role of technology(eHealth, mHealth, Cloud, Internet of things, wearables, etc) in the healthcare delivery, a National Digital Health Authority (NDHA) will be set up to regulate, develop and deploy digital health across the continuum of care. The policy advocates extensive deployment of digital tools for improving the efficiency and outcome of the healthcare system. The policy aims at an integrated health information system which serves the needs of all stake-holders and improves efficiency, transparency, and citizen experience. Delivery of better health outcomes in terms of access, quality, affordability, lowering of disease burden and efficient monitoring of health entitlements to citizens, is the goal. Establishing federated national health information architecture, to roll-out and link systems across public and private health providers at State and national levels consistent with Metadata and Data Standards (MDDS) & Electronic Health Record (EHR), will be supported by this policy. The policy suggests exploring the use of “Aadhaar” (Unique ID) for identification. Creation of registries (i.e. patients, provider, service, diseases, document and event) for enhanced public health/big data analytics, creation of health information exchange platform and national health information network, use of National Optical Fibre Network, use of smartphones/tablets for capturing real time data, are key strategies of the National Health Information Architecture.

23.1 Application of Digital Health: 
The policy advocates scaling of various initiatives in the area of tele-consultation which will entail linking tertiary care institutions (medical colleges) to District and Sub-district hospitals which provide secondary care facilities, for the purpose of specialist consultations. The policy will promote utilization of National Knowledge Network for Tele-education, Tele-CME, Tele-consultations and access to digital library.

23.2 Leveraging Digital Tools for AYUSH: 
Digital tools would be used for generation and sharing of information about AYUSH services and AYUSH practitioners, for traditional community level healthcare providers and for household level preventive, promotive and curative practices.

Comments: This is a very correct decision and the first job for the proposed NDHA will be to formulate a robust National Digital Health Strategy / Policy, in consultation with all the stakeholders. The first constituents of the Authority will lay down the rules of the game as to how will digital health be adopted in India. The earlier the NDHA is set up and functional, the better it will be for India to avoid a digital health mess in future. Any delay in the process might make us deal with non-interoperable legacy systems, as has been the case in many developed nations. However, cross referrals and sharing disparate information among different systems of medicine may add to the complexity and confusion, ultimately harming the patient. Currently, the MoHFW is seeking comments on the proposed DISHA (Digital Information Security in Healthcare Act) that will be the Bill setting up the NDHA / NeHA.

25. Health Research: 
The National Health Policy recognizes the key role that health research plays in the development of a nation’s health. In knowledge based sector like health, where advances happen daily, it is important to increase investment in health research.

25.1 Strengthening Knowledge for Health: 
The policy envisages strengthening the publicly funded health research institutes under the Department of Health Research, the apex public health institutions under the Department of Health & Family Welfare, as well as those in the Government and private medical colleges. The policy supports strengthening health research in India in the following fronts- health systems and services research, medical product innovation (including point of care diagnostics and related technologies and internet of things) and fundamental research in all areas relevant to health- such as Physiology, Biochemistry, Pharmacology, Microbiology, Pathology, Molecular Sciences and Cell Sciences. Policy aims to promote innovation, discovery and translational research on drugs in AUSH and allocate adequate funds towards it. Research on social determinants of health along with neglected health issues such as disability and transgender health will be promoted. For drug and devices discovery and innovation, both from Allopathy and traditional medicines systems would be supported. Creation of a Common Sector Innovation Council for the Health Ministry that brings together various regulatory bodies for drug research, the Department of Pharmaceuticals, the Department of Biotechnology, the Department of Industrial Policy and Promotion, the Department of Science and Technology, etc. would be desirable. Innovative strategies of public financing and careful leveraging of public procurement can help generate the sort of innovations that are required for Indian public health priorities. Drug research on critical diseases such as TB, HIV/AIDS, and Malaria may be incentivized, to address them on priority. For making full use of all research capacity in the nation, grant- in- aid mechanisms which provide extramural funding to research efforts is envisaged to be scaled up.

25.2 Drug Innovation & Discovery: 
Government policy would be to both stimulate innovation and new drug discovery as required, to meet health needs as well as ensure that new drugs discovered and brought into the market are affordable to those who need them most. Similar policies are required for discovering more affordable, more frugal and appropriate point of care diagnostics as also robust medical equipment for use in our rural and remote areas. Public procurement policies and public investment in priority research areas with greater coordination and convergence between drug research institutions, drug manufacturers and premier medical institutions must also be aligned to drug discovery.

25.3 Development of Information Databases: 
There is also a need to develop information data-bases on a wide variety of areas that researchers can share. This includes ensuring that all unit data of major publicly funded surveys related to health, are available in public domain in a research friendly format.

25.4 Research Collaboration: 
The policy on international health and health diplomacy should leverage India’s strength in cost effective innovations in the areas of pharmaceuticals, medical devices, health care delivery and information technology. Additionally leveraging international cooperation, especially involving nations of the Global South, to build domestic institutional capacity in green-field innovation and for knowledge and skill generation could be explored.

Comments: For health research and innovation the government’s role of encouraging Standards for interoperability and allowing open data for analysis will go a long way.
Apart from the NHP-2017, there are certain existing legislations that affects the adoption of digital health in India. The first and foremost is the 2012 Amendments of the Clinical Establishments Act 2010. The other guidance comes from the Constitution of India. Both of these are discussed below.

Clinical Establishments (Registration and Regulation) Act (CEA): 
In 2012, the MoHFW amended the CEA (2010) and added Clause “9 (iv): the clinical establishments shall maintain and provide Electronic Medical Records (EMR) or Electronic Health Records (EHR) of every patient as may be determined and issued by the Central Government or the State Government as the case may be, from time to time”.

Comments: The Act has taken effect in the four states namely, Arunachal Pradesh, Himachal Pradesh, Mizoram, Sikkim, and all Union Territories since 1st March, 2012 vide Gazette notification dated 28th February, 2012. The states of Uttar Pradesh, Uttarakhand, Rajasthan, Jharkhand, Bihar and Assam have adopted the Act under clause (1) of article 252 of the Constitution. 

The Ministry has notified the National Council for Clinical Establishments and the Clinical Establishments (Central Government) Rules, 2012 under this Act vide Gazette notifications dated 19th March, 2012 and 23rd May, 2012 respectively.

The Act is applicable to all kinds of clinical establishments from the public and private sectors, of all recognized systems of medicine including single doctor clinics. The only exception will be establishments run by the Armed forces.


The good point is the enactment of the necessity for EMR / EHR. The Ministry of Health and Family Welfare has been notifying Standards for EHR since August 2013 and the second edition of the Guidelines were notified in December 2016. That is the right way to move forward. However, Health being a State subject, not all the states are equally keen to adopt it.


Concurrent List: The seventh schedule of the Constitution of India lists “Health” (Public health and sanitation; hospitals and dispensaries) under the Item 6 of List-II (State list). As expected, like the Union ministry, health ministers of various states have also agreed to equipping PHCs and CHCs with latest technology.

Comments: However, as seen in the previous section, the CEA has not yet been adopted by most of the states of India. Therefore, although the CEA mandates EMR / EHR, most of the states are not yet bound to follow it. Since Health is neither in the Union list, nor in the Concurrent list, it may be prudent to include it in the Concurrent list. In that case adoption of digital health would be much smoother.

Conclusions:
While the NHP-2017 is bold in its thoughts and foresight, for facilitating digital health, the ground realities don’t appear to have been considered well enough. Early setting up of a functional NDHA is essential for India to avoid a digital health mess in future. Inordinate delays might make us deal with non-interoperable legacy systems. The first job for the proposed NDHA will be to formulate a robust National Digital Health Strategy / Policy, in consultation with all the stakeholders. 

Caution needs to be exercised before cross referrals and sharing disparate information among different systems of medicine. Health informatics education must be embedded as an integral part for health and hospital management. Since Health is neither in the Union list, nor in the Concurrent list of the Constitution of India, it may be prudent to include it in the Concurrent list. In that case adoption of digital health would be much smoother. 

Seeking comments on the Draft Bill DISHA (Digital Information Security in Healthcare Act) is a good start.

References:
[1]: Ministry of Health and Family Welfare, Government of India, National Health Policy 2017: https://www.nhp.gov.in//NHPfiles/national_health_policy_2017.pdf (Accessed 19th February 2018)

[2]: Ministry of Health and Family Welfare, Government of India. Situation Analyses: Backdrop to the National Health Policy – 2017, New Delhi. Available from : https://mohfw.gov.in/sites/default/files/71275472221489753307.pdf

[3]: Sundararaman T, National Health Policy 2017: A Cautions Welcome, Indian J Med Ethics. 2017 Apr-Jun;2(2):69-71

[4]: Sarbadhikari SN. A farce called the National Board of Examinations. Indian J Med Ethics. 2010 Jan-Mar;7(1):20-2

[5]: Thomas G, Medical education in India – the way forward, Indian J Med Ethics. 2016 Oct-Dec;1(4):200

[6]: Government of India, The Gazette of India, dated 31/01/2017: http://www.cdsco.nic.in/writereaddata/Medical%20Device%20Rule%20gsr78E(1).pdf (Accessed 19th February 2018)

[7]: Government of India, The Gazette of India, dated 19/8/2010, Clinical Establishments (Registration and Regulation) Act 2010:
 http://clinicalestablishments.nic.in/WriteReadData/969.pdf  (Accessed 19th February 2018)

[8]: Government of India, The Gazette of India, dated 23/5/2012, Clinical Establishments (Registration and Regulation) Act, (Amendments) 2012:
http://clinicalestablishments.nic.in/WriteReadData/386.pdf (Accessed 19th February 2018)

[9]: Ministry of Health and Family Welfare, Government of India.  http://clinicalestablishmentstraining.nic.in/cms/Home.aspx (Accessed 19th February 2018)

[10]: National Health Portal, Ministry of Health and Family Welfare, Government of India, EHR Standards: https://www.nhp.gov.in/electronic-health-record-standards-for-india-helpdesk_mty (Accessed 19th February 2018)

[11]: Government of India, The Constitution of India  http://lawmin.nic.in/olwing/coi/coi-english/coi-4March2016.pdf  (Accessed 19th February 2018)

[12]: Press Information Bureau, Government of India, Shri J P Nadda chairs 12th Conference of the Central Council of Health and Family Welfare to discuss Draft National Health Policy, dated 27/02/2016: http://pib.nic.in/newsite/PrintRelease.aspx?relid=136961 (Accessed 19th February 2018)

[13]: Ministry of Health and Family Welfare, Government of India. https://mohfw.gov.in/newshighlights/comments-draft-digital-information-security-health-care-actdisha (Accessed 28th March 2018)

[14]: National Health Portal, Ministry of Health and Family Welfare, Government of India, EHR Standards: https://www.nhp.gov.in/ehr-standards-helpdesk_ms (Accessed 28th March 2018)

Author
[tab]
[content title="About Prof. Supten Sarbadhikari"]
Prof. Supten Sarbadhikari
Digital Health Influencer & Project Director at Centre for Health Informatics of the National Health Portal; President IAMI (2016)
Connect with me
[/content]
[content title="Latest Articles"]
[/content] [/tab]
Read more »

Clinical Decision Support Systems: Resolving the “Build or Buy” Dilemma - Part 2 by Dr. Ujjwal Rao, @drujjwalrao


The 2 part paper: Discusses the key role of evidence-adaptive clinical decision support systems (CDSS) in the healthcare system of the future. Weighs the pros and cons that hospitals should consider when deciding to buy or build such decision support tools


Healthcare providers today face the challenge of delivering up-to-date, evidence-based care given the ever burgeoning pool of medical evidence, which is not only prone to inconsistencies but also take an average of 17 years to make their way into routine clinical practice. 

Coupled with the hassle of meeting advance electronic health record (EHR) platform integration requirements, Dr. Rao proposes that buying knowledge-based CDSS is increasingly more favorable and the way forward. 

A number of major initial and ongoing hurdles with home-grown solutions – including the significant time and effort needed to constantly update evidence – could overwhelm and overburden healthcare organizations, taking time away from delivering standardized and evidence-based care. 

Dr. Rao offers five ways on how these challenges can be avoided with the purchase of third-party CDSS platforms.


Read more »

Clinical Decision Support Systems: Resolving the “Build or Buy” Dilemma - Part 1 by Dr. Ujjwal Rao, @drujjwalrao

The 2 part paper: Discusses the key role of evidence-adaptive clinical decision support systems (CDSS) in the healthcare system of the future. Weighs the pros and cons that hospitals should considered when deciding to buy or build such decision support tools


Healthcare providers today face the challenge of delivering up-to-date, evidence-based care given the ever burgeoning pool of medical evidence, which is not only prone to inconsistencies but also take an average of 17 years to make their way into routine clinical practice. 

Coupled with the hassle of meeting advance electronic health record (EHR) platform integration requirements, Dr. Rao proposes that buying knowledge-based CDSS is increasingly more favorable and the way forward. 

A number of major initial and ongoing hurdles with home-grown solutions – including the significant time and effort needed to constantly update evidence – could overwhelm and overburden healthcare organizations, taking time away from delivering standardized and evidence-based care. 

Dr. Rao offers five ways on how these challenges can be avoided with the purchase of third-party CDSS platforms.


Read more »

How do we value your #startup?  Part 2 by Arpit Agarwal, @arpiit



How do we value your startup? — Part 2

In the previous post we talked about how VCs perceive valuation and how to broadly deal with it. It was aimed to dispel some misconceptions most first-time entrepreneurs may have about this very important aspect of our business. This posts builds on that and another and gives you actual numbers to play with. Before you go on, it maybe a good idea to take a look at the way I define stages of a startup.

Round sizes and dilution benchmarks in India

Now that you know the only two thing that matters to a VC is the stake she’s getting and the amount she’s investing, it is best that you play accordingly. If you’re seen as obsessed too much about valuation, you’re likely to be considered a hard-nosed founder. So be smart and play for ‘lower dilution’ instead. In case you argue that these are one and the same thing, think again :)
The table below presents a broad structure of startup funding in India today. This is what is considered ‘average’ in our industry. Please note that all these numbers are only representative in nature and deals frequently happen on both sides of these extremes. Also, like any well-functioning market, these prices represent only a momentary equilibrium and this changes over time:

© Blume Ventures, 2018 — Please don’t republish without permission. Write to [email protected]
What are the Terms and Conditions?
  1. At any stage of investment, the investor is making a forward judgement on the exit outcome. Hence, it is common for investors to bake the exit scenario in the way you are being valued. For example, if a Series A investor, who’d typically expect a startup to exit at $500M, may value a startup which may exit at only $250M (in their minds) much more harshly than a startup which could easily build a $1B or more as an outcome.
  2. All the rules of the market —namely, demand and supply — still apply. It is not uncommon for serial/exited entrepreneurs to raise money at 5–10x valuation than first-time entrepreneurs.
  3. Valuation remains the last step. Hence, if you don’t pass any of the filters a VC has in their model, your willingness to price yourself very attractively doesn’t count.

How can you use this information?

First, it is always a great idea to know what’s the playbook on the other side. At the same time, smart people would know that such discrete classifications can’t be taken for granted. Second, whenever you have term-sheet on offer, you should know that valuation is largely formulaic for a VC, hence pay immense attention to the terms that come along with it. That’s the detail most first-time entrepreneurs struggle with!
Finally, as most experienced entrepreneurs will tell you,
forget valuation and focus on creating things of value.
If there’s value, valuation cannot be far behind. And creating anything of value is incredibly hard in any economy, doubly so in India. Once you are past your curiosity about valuation, you’d notice that life after raising VC money becomes much harder. In fact, the more you raise (by corollary, the higher your valuation) the more complicated it will get!

What’s more?

Hope these two posts satisfy a lot of your curiosities. As you can imagine, the art of valuing a startup is much deeper than what we covered here. Do post your responses and ask me if I skipped a step in my explanation.

The article was first published in the Arpit's Medium Blog here,  and has been republished here with the Author's permission.
Author
Arpit Agarwal
Arpit has been involved with promotion of startups and ecosystem since 2006 when he co-founded Headstart Network, today India's largest early stage entrepreneurs' network with over 20 city chapters.

Arpit has been with Blume for last four years as a Principal, responsible for scouting science-led and hardware businesses, apart from managing a portfolio of about 15 companies, which include companies in a variety of sectors ranging from used goods market to IOT to Healthcare to Enterprise services.

He's based in Delhi, in an MBA from IIT Bombay and holds a BTech from NIT Trichy
Read more »

How do we value your #startup?  Part 1 by Arpit Agarwal, @arpiit



This is the favorite topic of every single startup entrepreneur in early stages of their evolution. It also incites an academic curiosity in a large number of people who, like the 3 adorable dads in this video, have a highly misplaced notion about it. A big reason why this happens is because we don’t write about it so often in India and, perhaps, everyone understands this quite well in US or China.
Read more »

5 product management hacks to build great products by Subhadeep Mondal, @smondal1008

In the past 5 years, I had the opportunity to build and ship great consumer products which touches the lives of millions of people around the world. Recently, Branchmetrics invited me to share some of my learnings at Innov8 CoWorking Space along with speakers from UrbanLadder, HeadSpin, Branch.io and Glispa Global.
Read more »

Vision 2025: What Health Care Could Look Like a Decade from Now by Dr. Vicky Parikh, @ParikhVicky

Value-based care, coordinated care, information technology integration . . . healthcare is undergoing transformation.

Sweeping changes are putting pressure on the entire system, particularly from an administrative standpoint. With all the paperwork and logistics to worry about, it's easy to grow frustrated and lose sight of what we are working to achieve: economically viable solutions for providing the highest level of care to all our patients.
Sometimes it helps to take a step back, to forget the red tape and day-to-day grunt work of overhauling a 2.8 trillion dollar industry. For a moment, let's allow ourselves to focus only on the possibilities. Looking ahead, we'll explore one patient's journey through health care in the not-so-distant future. This is a story about health care in the year 2025.
Introducing Mr. Average Patient
Our patient - we’ll name him Philip - is a 35-year-old man in average health. Like many Americans, Phil tries to eat right and exercise, but enjoys rich foods, fails to sleep adequately, and relies on calorie-laden designer coffees, energy drinks to keep him energized. For months, he's been ignoring symptoms of frequent urination, fatigue, and dry mouth. But when Phil’s smartwatch repeatedly alerts him of high blood pressure readings, he decides to speak with a doctor.
This is 2025, so Phil won’t be taking any time off work for an office visit. Instead, he logs into his personal health management system - a cloud-based program accessible via web browser or specialized app - for a video chat with a member of his care team (let's call her Dr. McCoy).
While Phil describes his symptoms, the user interface provides Dr. McCoy an overview of his medical history. Phil’s vitals have been uploaded from his smartwatch and 20 pounds of weight gain have been registered by his smartscale over the past year. Dr. McCoy notes a family history with genetic predisposition of heart disease and diabetes, and that Phil's most recent blood work, drawn over a year ago, showed an elevated blood glucose level.
Suspecting diabetes as the source of Phil’s woes, Dr. McCoy uploads an order for a CBC and A1C while sending Phil instructions for scheduling his outpatient appointment.
Exploring the untapped potential of mobile health
In this scenario, two trends diverge with promising results. First, we are taking advantage of the increased popularity and decreased cost of the Internet as a way to passively monitor patient health. Familiar devices already track heart rate, sleep quality, activity levels, weight and BMI for non-clinical purposes. Before long, these technologies will advance, allowing us to discreetly record temperature, blood pressure, pulse oximetry, and maybe even blood chemistry. Like crash avoidance systems on a car, these devices can act as early warning systems, alerting patients of brewing health problems and encouraging them to contact a health professional.
Secondly, we are combining this with the growing availability of “doctor on demand” services. Telemedicine companies such as Teladoc have seen exponential growth in recent years, largely fueled by changing reimbursement schedules. Currently, this low-cost alternative to traditional office and urgent care visits is limited to addressing the most common of health concerns (runny noses, etc). But, we envision telemedicine as an integral part of coordinated patient care. An on-call doctor with access to telemetry from wearables and a complete medical record could remotely diagnose and manage a wide variety of medical issues. In this futuristic system, patients benefit from convenience, doctors from increased efficiency and reduced overhead, and payers from lower costs.
Mr. Average Patient skips the waiting room
After Dr. McCoy signs off, Phil follows the link she sent him to make his outpatient appointment. Scrolling through the list of available providers, he sorts by location, price, patient ratings, and earliest availability. He chooses a location near his home and schedules a same-day appointment. Before logging off, he pays his copay and downloads directions to his phone's GPS.
At the outpatient clinic, Phil checks in by tapping his smartphone to the reception kiosk. It provides him on-screen directions to the lab. There, he is greeted by his nurse who performs a quick physical examination before drawing Phil's blood. All told, the appointment takes no more than 30 minutes out of our patient's day.
How patient self-service benefits everyone
Consumers today are accustomed to booking airline flights, hotels, rental cars, even haircuts online. There is no reason health care providers shouldn't benefit from this same technology. Early adopters have discovered that online appointment scheduling simultaneously reduces administrative burdens (and associated costs) while increasing patient satisfaction. The Oregon-based Zoom+ health system, for example, has established a positive reputation for itself by providing on-demand health care services with transparent pricing and online appointment scheduling. As more patients and providers join in, we foresee sites like ZocDoc evolving into Expedia-like clearinghouses complete with payment and review functions.
Further automation will take place on-site at medical centers. Already, some hospitals have discovered that both patients and staff enjoy the shorter lines and reduced wait times that check in kiosks accommodate. In our scenario, these kiosks have evolved to incorporate technology borrowed from modern mobile payment systems. With a tap, encrypted information is exchanged between the patient's smartphone and the provider's practice management system: uploading doctor's orders, insurance authorizations, patient records, and payment information. The result is a near instantaneous check-in, freeing up staff, virtually eliminating paperwork, and dramatically speeding up appointment turnover. Once again, patients benefit from convenience while providers increase the number of patients they can see in a day, which lowers per-patient costs for payers.
Mr. Average Patient learns about self-care
The day after his appointment, Phil receives an email notification that his test results have come back. The email contains a link for another video chat with Dr. McCoy. She informs Phil that his labs indicate diabetes; she'd like to have a nurse practitioner come visit with him, or, if he'd prefer, she can schedule an appointment with his PCP. Phil opts for the nurse practitioner.
When Beverly, our local nurse practitioner, receives Dr. McCoy’s order, she calls Phil to schedule their face-to-face meeting. She brings with her his new medications and supplies (including a bluetooth-enabled glucose meter which will automatically record readings in Phil’s health management system). Together, she and Phil develop a care plan that includes follow up labs and visits with his GP. They set up reminder texts that help Phil remember to take and refill his medications on time. Phil also agrees to use his smartwatch to better manage his activity level and a nutrition diary to help him (and his care team) watch his caloric intake. Before leaving, Beverly leaves behind her contact information and informs Phil she’ll be checking in with him by phone once a week for the next several weeks.
Furthermore, Phil's diagnosis automatically adds him to an email list for patients with diabetes. Unless he opts out, Phil will receive daily educational emails with informational articles, videos, healthy recipes, as well as lifestyle tips and challenges. He’s invited to attend local diabetes classes and to join an online forum for diabetics and their families.
Personal attention keeps patients out of hospitals
Patient non-compliance is currently costing the American health care system an estimated $290 billion every year. That number will only grow unless we improve patient engagement in self-care. Many factors have been identified as contributing to patient non-compliance. In this scenario, we tackle several of these issues.
Poor communication between patient and provider has been identified as one component in patient non-compliance. This is why we have given our patient a choice between visiting his GP or meeting a nurse practitioner in an environment where he feels more comfortable. The nurse practitioner serves the dual role of educating the patient and providing one-to-one support for someone who has just received a life-changing diagnosis. By staying in touch over time, she fosters a positive patient/provider relationship that can lead to greater trust and hence greater compliance.
Next, we are making sure to involve our patient in his own care planning. He is provided tools such as electronic reminders and an app-based nutrition diary to help him stay on track. By monitoring medication usage, diet, and exercise via the health management system, Phil's care team is able to intervene if he is not following his care plan.
Finally, we are taking full advantage of modern multi-media resources for educational purposes. Being well-educated about one’s condition, medications, and long-term prognosis can help patients stick to their care plan. Since not all patients absorb information in the same way, our scenario uses a mix of articles, videos, game-like challenges, live classes, and online interactions with peers to keep him motivated.
The future of health care
Health care is looking to technology to boost efficiency and thereby lower administrative costs. Some in our industry worry this will detract from doctor/patient relationships, forcing doctors to spend more time staring at computer screens and less time interacting with patients. However, our scenario demonstrates how technology can actually increase personalization, contributing to higher patient satisfaction and better clinical outcomes. Nothing presented in our story is far-fetched; in fact, most of these technologies are already in use or under development in pockets across the nation. Our challenge is to identify and proliferate those innovations that most benefit the health care system as a whole: patients, providers, and payers alike.

The article is republished here with the authors' permission. The article was first published here
Author
Dr. Vicky Parikh
Healthcare Executive who combines clinical, public heath, and data management knowledge and success, transforming healthcare systems and improving delivery and quality. Leads continuous improvement processes, creating fundamental change in healthcare industry with new value-based care delivery systems, innovative collaborations, and partnerships for a sustainable healthcare model. Strives to improve quality of healthcare while lowering costs. Specializes in advancing efforts in population health and care delivery models, addressing increased healthcare costs and improving quality of patient care.
Read more »

Popular Posts