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Developing Developing eHealtheHealth Strategies to Strategies to
Deliver an Effective EHR SystemDeliver an Effective EHR SystemIndia Case StudyIndia Case Study
Gaur SunderMedical Informatics Group
C-DAC, India
AgendaAgenda
• Introduction & Background
• Issues & Challenges
• Strategies
INTRODUCTION & BACKGROUNDINTRODUCTION & BACKGROUND
Indian Healthcare ScenarioIndian Healthcare Scenario
• Tiered Rural and Urban Healthcare System
• Doctor Patient ratio at 1:2000 (average)
• Robust network of private healthcare providers and ancillary services
• Private sector share a large load and service profile (about 50%~70%)
• Majority of medical graduatesare provided by public system(about 80%)
EHR/EMR Systems in IndiaEHR/EMR Systems in India• Scant but few at District level and above have
some HIS/HIMS or system
• Most public/private large setups have functional HIS/HIMS, some of them have internal EMR/EHR capability
• There is no mandated functional interoperable EMR/EHR at any level
• There are several Telemedicinesetups but mostly withoutEMR/EHR constructs
Building National EMR SystemBuilding National EMR System
• Union Ministry of Health has started
consultation for building National EHR System
• Few steps already taken:
– National EHR Standards Committee by MoH&FW
– Technology Prototype for scalable, reliable
healthcare repository by MoC&IT
– National Knowledge Commission
project iHIND
ISSUES & CHALLENGESISSUES & CHALLENGES
EHR Data SourcesEHR Data Sources
• Application Communication Protocol
• Device Communication Protocol
• Database Schemas
• Structured Data Transmission
• XML Mapping Schemas
• Medical Informatics Standards
Medical Standards: Current ScenarioMedical Standards: Current Scenario
• EHR Standards
– EHR Content Standards
– Content Exchange Standards
– Codes, Terminologies, Vocabularies
• “Proprietary” Data Representation
– Local Data Formats
– Local Clinical Data Standards
– Local Codes, Terminologies
Problem of PlentyProblem of Plenty
• No single comprehensive Standard,
Terminology, Coding System
• Content-based selection of Standards
• But Standards change too!
– Dependency on evolution, changes in Standards
– Localization of existing Standards, Terminologies,
Codes
– Change in version also costs to implement/adopt
Regulatory EnvironmentRegulatory Environment• No regulation towards enforcing selected eHealth
Standards
• Comprehensive mechanism for regulation of healthcare, etc. but none for eHealth
• Work on since 2003 by IT Ministry and Health Ministry to find an acceptable set of standards
• ICT penetration, where available, in Healthcare is focused on operations and not clinical information
• Unfortunately, most of HIS/HIMS in useare not designed to maintain clinical data,most don’t follow any establishedeHealth standards
Identification & Duplication Identification & Duplication • India has begun to allot Unique National
Identification Number – Aadhar, to citizens
• There are plethora of IDs given by Government Agencies at Rural, District, State, National, and Service levels
• All Healthcare system have their own ID assignment policy
• Due to illiteracy and time-constraintsduring data-entry, the demographicrecords captured are unreliable orduplicated
STRATEGIES TOWARDS BETTER STRATEGIES TOWARDS BETTER
HEALTHCARE SERVICESHEALTHCARE SERVICES
Identification & DuplicationIdentification & Duplication• Where UID available, system should readily use it
• Where not, then you have plethora of IDs but
– IDs are by nature unique
– Degree of Uniqueness varies on Zone of system implementation
• Maintain a ID Relationships to match records
• Search and Identify possible duplication, and:
– Preferably, prevent duplication
– Or allow merging of records by records keeper
Learn from National EHR ProgramsLearn from National EHR ProgramsCountry National EHR Program
Australia HealthConnect
Austria ELGA
Canada EHRS Blueprint
Denmark MedCom
England Spine
Hong Kong eHR Infrastructure
India *Recommendation Stage*
Netherlands AORTA
Singapore NEHR
Sweden National Patient Summary (NPO)
Taiwan Health Information Network (HIN)
United States of America EHR Meaningful Use
Need of the HourNeed of the Hour
• Building today’s Model
of EHR
• Multiple Data Source
integration
• Many Standards,
Multiple data formats,
Single Solution?
HL7openEHR DICOM CCR
CCD
EHR
*
Addressing ProblemsAddressing ProblemsConcerns Solution Approach
Multiple patient identities Maintain ID Relationships
Incomplete EMR/EHR Cover complete EHR phases/artefacts
Geographical spread Design for single/distributed/cloud environment
Solution Scalability Highly scalable architecture
Multiple Standards Multi-standard support
Fail-safety/Redundancy Distributed/Clustered design
Performance Efficient operations
Design and Integration Flexibility API for integration with healthcare applications
Security Integrate Security Framework
Large Data-set Efficient storage management
Vendor Lock-in Build on Open systems
DHS: Overall System ArchitectureDHS: Overall System Architecture
OfferingOffering• Highly redundant, fail-safe, secure system framework
• Works as EHR integrator from various sources
• Requires little or no change in your current systems:– Only add as additional underlying layer
– If schema is shared then non-standard system could be supported
– Requires NO change in workflow, database, application logic
– If not supporting certificates, then stop-gap arrangement is possible
– Will require marginal change in User management part
– Users are obvious to addition
– However, tighter integrations are possible using EHR-API
• Can be used for Interoperability, Telemedicine, Referrals, Emergency
• Any number of consumer application can be built on top
• Can be extended further to meet specific requirements
• OLAP services can be build on top
ChallengesChallenges
• Integration of existing health data in
proprietary format into the Distributed
Store
• Evaluating the Distributed Healthcare
Information store in diverse conditions
• Absence of Unique Patient/Citizen
Database
• Willingness of Medical organization /
individuals in participating
• Adoption by
ISV/OEM/Applications/Services
Proposal: Get it workingProposal: Get it working• Work towards promoting eHealth standards
• Increase ICT penetration:– Government Programs, Incentives, Regulations
– Support with affordable technologies
– Utilize available affordable hardware
• Bring in regulatory/control body for managing National Health Repository (NHR)
• Incentivize interoperability and connecting to NHR
• Promote interoperability between Private-Private, Private-Public referral system
• Demonstrate in public healthcare system and invite all to join; start with Hospitals, migrate to ancillary providers
Thank YouThank You