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

gaurs@cdac.in