On September 27, Prime Minister Narendra Modi launched the Digital Health ID project (DHID), generating debate on issues related to the use of technology in a broken health system. In an interview, R S Sharma, the architect of DHID, stated that the key objective of DHID was to “improve the quality, access and affordability of health services” by making the service delivery “quicker, less expensive and more robust”. The ambition is undoubtedly high. Given that health systems are highly complex, would DHID be able to address some of the issues plaguing it? What are the pros and cons of DHID?
The use of technology for record maintenance is not just inevitable but necessary. Its time has certainly come. A decade ago, the process to shift towards electronic medical records was initiated in the private sector. It met with limited success, despite the strong positives. With DHID, the burden of storing and carrying health records for every visit to the doctor is minimised. Besides, the doctor has instant access to the patient’s case history –the treatment undertaken, where and with what outcomes — enabling more accurate diagnosis and treatment. As the DHID enables portability across geography and healthcare providers, it also helps reduce re-testing or repeating problems every time a patient consults a new doctor. That’s a huge gain, impacting the quality of care and enhancing patient satisfaction and confidence.
Second, digitisation of medical records is another important positive, given the problems related to space and retrieving huge databases. Well organised repositories that enable easy access to records can stimulate much-needed research on medical devices and drugs. This storehouse of patient data can be invaluable for clinical and operational research.
Third, DHID can have a transformative impact in promoting ecosystems that function as paperless facilities. Years ago, I visited one such “paperless” hospital in Thailand where before the patient reached the doctor, the doctor had already gone through the patient’s record and the pharmacist had the drugs ready by the time the patient reached the pharmacy counter. This was possible due to the direct electronic linkages between the patient registration process, doctor, laboratory and pharmacy that enabled use of relevant information before the patient’s arrival, reducing delays and enhancing efficiencies. All administrative procedures were also computerised. Given our population, would this be an idealistic expectation? Or is such automation necessary in reducing some of the chaos at our facilities? We need to conduct pilot studies to assess the use of technology for streamlining patient flows and medical records and thereby increase efficiencies across different typologies of hospitals and facilities.
While technology helps smoothen processes and enhance patient experience, there is a cost attached. Investments have to be made upfront. In the immediate short run, DHID will increase administrative costs by about 20 per cent, due to the capital investment in hardware and software development, technical personnel and data entry servers. Amortised over the long run, the additional cost to care is expected to be about 2 per cent. Studies of such reform undertaken in the US in 2009 showed that small and medium hospitals were generally reluctant to adopt EMRs, partly because of the upfront investments that they were required to make. This resulted in the federal government providing subsidies of about $30 billion as an incentive. Clearly, any scaling up of this reform would require extensive fiscal subsidies and more importantly providing techno-logistical support to both government and private hospitals.
The costs in the Indian context can be high and that should lead to a careful assessment of the project. A large majority of facilities do not have the required physical infrastructure — electricity, accommodation, trained personnel. Cards getting corrupted, servers being down, computers crashing or hanging, and power outages are common in India. The inability to synchronise biometric data with ID cards has resulted in large-scale exclusions of the poor from welfare projects. Such a scenario is not inconceivable and in the case of health, may cause immense hardship to the most marginalised sections of our population. Besides, the efficacy of the DHID hinges on the assumption that every visit and every drug consumed by the patient is faithfully and accurately recorded. With the digitised records virtually “speaking” for the patient, information gaps can be problematic.
Moreover, while electronic mapping of providers may enable patients to spot a less busy doctor near their location, it is simplistic to assume that the patient will go there. Patient preference for a doctor is dependent upon perception and trust. Likewise, teleconsultations need a huge backend infrastructure and organisation. Teleconsulting has certainly helped patients access medical advice for managing minor ailments, getting prescriptions on the phone and even getting drugs delivered home. But in handling chronic diseases that necessitate continuity of care, teleconsultations have been problematic and cannot be substituted for actual physical examination. Continuity of care is central to good outcomes in patient management of chronic diseases. The one serious shortcoming of using teleconsultation for such management is the high attrition rate of doctors within the context of an overall shortage of doctors. Technology can be of little use in the absence of doctors and basic infrastructure.
Most important is the issue of privacy, the high possibility of hacking and breach of confidentiality. The possibility of privacy being violated increases with the centralisation of all information. Though it is said that the patient is the owner of the information, how many of us deny access, as a matter of routine, when we download apps or programmes that seek access to all our records? How far is this “consent” practical for an illiterate, vulnerable patient desperate to get well? So, taking refuge behind a technical statement that access is contingent on patient consent is unconvincing. What is needed is building very robust firewalls and trust. Seeing the frequency with which Aadhaar cards have been breached and the gross limitations of the Aarogya Setu and CoWin, it is not unreasonable to be concerned with this issue and the implications it has at the family and societal levels. For this reason, instead of a big bang approach, it is better to go slow and steady, testing the waters as we go along to make DHID sustainable and acceptable with the aim to achieve this aspiration within the next decade or two. That’s the only way to ensure that a good policy does not die along the way due to poor implementation.
This column first appeared in the print edition on October 6, 2021 under the title ‘Digitise healthcare slowly’. The writer is former Union health secretary