Ayushman Bharat Digital Mission (ABDM – renamed from earlier called ‘National Digital Health Mission’), launched in August last year, works to bring together, the various stakeholders in the Indian healthcare ecosystem through digital means. The mission, under which citizens can get a unique 14-digit health identification (ID) number, will create a digital health ecosystem with a personal health ID for every individual, unique identifiers for doctors and health service providers, and personal records. ABDM makes both the opt-in and the opt-out of the database decisions at the user’s discretion.
As we know, but do not pay enough attention to — Paper-based medical records like prescriptions, lab reports, hospital records, discharge summaries, and health insurance papers may get torn, faded, misplaced, etc. It is far better to keep digital record of these.
As a necessary evolution due to the covid pandemic, two unassociated projects — online healthcare and creating a Unique Health ID (UHID) — propelled the possibility of creating a single digital locker to store health records. The UHID network will operate like UPI which created a payment system that was not dependent on the banking system; helping users to receive and send health reports and access doctors, labs, etc. of their choice
Typical Health journey
The typical healthcare journey of any individual has the following components: symptoms, diagnosis, treatment, support for treatment, post-treatment care, health records for follow-up visits. The ecosystem includes patients/doctors/hospitals/clinics.
During the COVID panic, we saw citizens using mobile phones and video conferencing to access doctors and healthcare. With access to internet data and mobile telephony available across India, every small town or village can benefit from telemedicine and e-pharmacy as a first step. Primary Health Centers at most of these places either has no doctor (for reason of shortage or delay in replacement staffing) or a less experienced doctor, who may or may not be able to address all queries. Even in the case of the doctor with relevant skills being available, in case (s)he needs to refer the case to a specialist, where and how does (s)he refer? Integrated e-healthcare can reduce the cost of medical access to the patients, and also save time and travel.
Learnings from other nations’ attempts
Various countries had attempted e-health initiatives and it has been a mixed bag of outcomes.
The UK’s National Health Service (NHS) was one of the first to deploy a digital system to make patients’ records accessible to doctors across the UK. The attempt failed as it did not address data confidentiality concerns as well as the trust of the medical community.
Both the US and Australia attempted free-markets driven digital healthcare system, with multiple layers of complex healthcare insurance covers. The US has not been able to have inclusive coverage of its entire citizenry in the e-health care process. A study shared that over 90 percent of US patients complain about the lack of data sharing and that faxes and phone calls remain the communication means of choice in health departments across the country that invented the Internet. To address this problem, interoperability rules were introduced in 2020. However, as of July 1, 2021, only two of the policies from the May 2020 Interoperability and Patient Access final rule had come in effect.
In a data-centric world, India seems to be leading the game with policies like ABDM. Evolving a language of communication in the digital health ecosphere could pose unforeseen problems in India given the country’s diversity and its chronic shortage of doctors, especially in public health centres — the main source of medical care for a vast number of people in the country. Poor internet speeds could make data entry an onerous proposition for rural healthcare providers.
Size & complexity
ABDM is often being compared to the Unified Payments Interface (UPI), a platform that financial services companies use for transactions. Under the Mission, a user can, in the same way, that they use Paytm or Google Pay, choose from several private health care providers and personalised offerings. The UHID network will operate like UPI, which disconnected the payment system from the banking system. There will be a protocol for the transfer of health-related information transfer, quite like money transfer. Like the virtual payment address in UPI, there will be a virtual health address in UHID. On top of that will be patient-facing apps and below the gateway will be service providers. It will be guided by patient demand.
The National Health Stack, on which the ABDM will function, is designed to generate vast amounts of data, thus making it one of the largest health databases in the world. Around 24,000 hospitals are already empanelled with ABDM. India has generated around 14 crore health IDs. Already 80,000 out of the 1.5 lakh primary health centres are connected. The major challenge for the mission will remain convincing private health care providers to come on board, as it is purely voluntary for them to share information for this digital repository.
Startups/businesses in this space should be excited unless they were relying solely on the data collection and repository as a good business model. India has 5,295 health tech startups. The market size is expected to expand to USD 10 billion by 2025. Telemedicine as a sector is expected to cross USD 5 billion by 2025.
Concerns: Data governance, Cyber Security & privacy
Data Governance is the process and procedure organisations use to manage and protect their data. In this context, data can mean either all or a subset of a company’s digital and/or hard copy assets. In the healthcare industry, that data is patient records, blood test results, EKGs, MRIs, billing records, drug prescriptions, and other private medical information. Data governance in healthcare is all about the individual pieces of data like the patient ID number, blood pressure reading, etc.
The Nation Health Authority (NHA) has put out the National Health Data Management Policy, which aims to govern how the data will be handled in the ecosystem that ABDM aims to establish. The famous Puttaswamy Judgment held that informational privacy is a fundamental right, which includes health data. The proposed Personal Data Protection bill categorises health data as sensitive personal data, which would mean that there are enhanced protections in place that would seek more obligations from the data fiduciaries. The data will be anonymised, to protect the privacy of people. The government will not have access to data or own the data. It will be guided by data-protection laws.
There is a cry for using Blockchain in this endeavour. Blockchain is a powerful technology for enabling secure data sharing and access between multiple parties. This is a major challenge in digital health, where the privacy and security of medical data is paramount. On a blockchain, the Health ID can work as a private key used to encrypt and decrypt data shared between a sender and receiver. The private key will enable patient anonymity on the Public Health Registry (PHR), which can be on the blockchain. Authorisation for the government or private entities to use the data can be granted using these private keys, by the patient.
Blockchain can help digital health by making it easier to share data securely, with patient consent, across very fragmented healthcare systems. It can aid in building transparency across the entire supply chain, verification of credentials across the chain, facilitate efficient remote monitoring of security, insurance claim, and other supply chain settlements that can be easily validated and authorised.
Health data, which is considered ‘Sensitive Personal Information’, is prone to cyber threats. Once data protection law is in place, adequate security framework can enhance user trust in the system. Between October 1 and November 25, 2020, over seven million cyber-attacks were recorded in the Indian healthcare sector, including vaccine makers and hospitals, according to a report by the CyberPeace Foundation.
In the long run, the creation of a health record system could improve public health monitoring & with data sciences application, even help in advance forecasting and allow for proactive data-based policymaking, than mere precedence-based current methods. But as with every new idea, we have to sweat the details. And getting carried away by the sheer idea alone is scary, especially when it has to do about data privacy and overcoming the lethargic healthcare industry which has not shown its objective to being patient-centric.