Available Online at http://www.recentscientific.com
International Journal of Recent Scientific Research
Vol. 6, Issue, 5, pp.3881-3886, May, 2015
ISSN: 0976-3031
International Journal
of Recent Scientific
Research
RESEARCH ARTICLE
MOMENTUM IN PENETRATION OF TECHNOLOGY IN INDIAN HEALTHCARE: A WAY
FORWARD
Manoj Kumar Gupta, Veena R and Chandraprabha
1,2Institute
3Institute
of Health Management Research (IIHMR) Bangalore
of Medical Sciences (IMS), Banaras Hindu University (BHU), Varanasi
ARTICLE INFO
ABSTRACT
Article History:
The epidemiological transition, in the form of rapid structural changes in disease patterns and global flow
of patients across borders in the form of ‘medical tourism’ have changed the patterns of demand and
supply of healthcare services in the country and insisted for reshaping the Indian health care delivery
system. Considering the fast pace of innovations and rapid growth of technology, healthcare providers
started inclining towards the technological aspect of healthcare delivery. Telemedicine, mHealth,
Electronic Health Record (EHR) / Electronic Medical Record (EMR), Health/Hospital Management
Information System (HMIS) and Digital Health Knowledge Resources (DHKR) are some of the
technologies, gained wide acceptance in the sector. This progressive reshaping of healthcare industry has
increased the demand for deployment of robust IT infrastructure, trained healthcare personnel, informed
decision makers and better financial management in the country to reduce the challenges for better
utilization of HIT potential. In this regard, beside existing efforts by Government and private sector, there
is urgent need of capacity building of health professionals on available tools and incorporate the IT
component in medical curriculum.
nd
Received 2 , April, 2015
Received in revised form 10th,
April, 2015
Accepted 4th, May, 2015
Published online 28th,
May, 2015
Key words:
Health IT, Telemedicine, EHR,
EMR, mHealth, HMIS
Copyright © Manoj Kumar Gupta et al., This is an open-access article distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Background
Healthcare is one of the largest and fastest growing service
sectors in India. The epidemiological transition, in the form of
rapid structural changes in disease patterns because of rapid
changes in lifestyle and global flow of patients across borders
in the form of ‘medical tourism’ have changed the patterns of
demand and supply of healthcare services in the country and
insisted for reshaping the Indian health care delivery system.
Considering the fast pace of innovations and rapid growth of
technology, healthcare providers started inclining towards the
technological aspect of healthcare delivery to standardize the
quality of service delivery, control cost and enhance patient
engagement. Gradually this penetration of technology in
healthcare started taking momentum. Telemedicine, mHealth,
Electronic Health Record (EHR) / Electronic Medical Record
(EMR), Health/Hospital Management Information System
(HMIS), Digital Health Knowledge Resources and PRACTO
are some of the technologies, gained wide acceptance in the
sector and demanding the deployment of robust IT
infrastructure in Indian healthcare organizations.
These swift changes in the scenario of Indian healthcare
industry market started attracting attention of private players,
especially profit making organizations for the investments.
*Corresponding author: Manoj Kumar Gupta
Institute of Health Management Research (IIHMR) Bangalore
Foreign investors also consider India as a strategic location for
conducting profitable international business and to exploit the
benefits, started investing in Indian healthcare industry in the
form of Foreign Direct Investments (FDI). Healthcare sector in
India has progressed at an impressive pace over the past five
years and during this decade (2011-20), the market is expected
to record a Compound annual growth rate (CAGR) of 17
percent. Healthcare revenue in India is set to reach USD160
billion by 2017 and USD 280 billion by 2020 (Frost & Sullivan
2014). The Planning Commission has allocated USD55 billion
under the 12th Five-Year Plan to the Ministry of Health and
Family Welfare, which is about three times the actual
expenditure under the 11th Five-Year Plan. In-spite of India
being the hub of the IT enabled services, the use and growth of
Healthcare Information Technology (HIT) is very low.
Emergence of Telemedicine
Telemedicine is a fast emerging sector in India because of its
strengths to bridge the rural-urban divide in terms of increase
accessibility of medical and diagnosis facilities and extending
low-cost consultation to the remotest of areas via high-speed
internet and telecommunication. During its inception in 1999, it
was considered as ‘futuristic’ and experimental’, and since
then, Department of Information Technology, Ministry of
Health & Family Welfare, State Governments and premier
medical and technical institutions of India have been involved
Manoj Kumar Gupta et al., Momentum in Penetration of Technology in Indian Healthcare: A way forward
in implementing telemedicine with the aim to provide quality
health-care facilities to the rural and remote parts of the
country. Many major hospitals like Apollo (pioneer in
telemedicine), Fortis, AIIMS, Aravind eye care, Sankara
Nethralaya, Escorts Heart Alert and Narayana Hrudayalaya
have adopted telemedicine services and entered into a number
of Public Private Partnerships (PPPs) (IRDA 2014, Bhowmik
D et al. 2013). Government of India (GoI) has also adopted
telemedicine into the National Rural Health Mission (NRHM).
In 2012, the telemedicine market in India was valued at USD
7.5 million, and is expected to rise at a CAGR of 20 per cent, to
USD 18.7 million by 2017 (IRDA 2014).
In patient perspective, telemedicine has been proved
advantageous in reducing the time and costs of the patient
transportation from far-off places by facilitating care access
to specialized health care services and specialists and aiding in
early diagnosis and treatment. Thus it is helping in reducing the
financial burden on the families and increasing the patient
satisfaction. Sanjay Gandhi Post Graduate Institute of Medical
Sciences’ (SGPGIMS) tele-follow up program survey for the
patients of Odisha state has revealed that majority (99%) of the
patients were satisfied with using telemedicine technology, as
they do not have to travel 1500 km to show their diagnostic
reports to their doctors (Bhowmik D et al. 2013). A number of
recent studies also support the view that telemedicine-based
interventions can result in comparable outcomes to traditional,
in-person meetings, while at the same time offering the
potential for cost savings and other efficiencies (Ebad R 2013).
Because of the variety of applications of telemedicine in patient
care, education, research, administration and Public health
through tele-health care, tele-consultation, tele-education and
tele-home healthcare, health care providers are utilizing
telemedicine in range of medical specialties and home health
care (Bhowmik D et al. 2013, Jacobs K et al. 2012). For the
healthcare service providers, the instant access to computerized
comprehensive data of patients (both offline & real time),
improved diagnosis and better treatment management, quick
and timely follow-up of discharged patients, reduction in the
patient load, monitoring home care through improved
communication and Continuing Medical Education (CME) and
trainings are some of the beneficial aspects of telemedicine
(Bhowmik D et al. 2013). Besides that increased staff
productivity and economization of resources are other added
advantages. Telemedicine is also an important tool in
epidemiological surveillance, disease prevention, interactive
health communication and disaster management.
Telecommunication is the backbone of telemedicine. A typical
telemedicine centre requires satellite units that must run on the
state-of-the art technology with high bandwidth, dedicated
servers, high capacity routers and networking equipment to
make the telecommunication network one of the robust
solutions (Ebad R 2013). But there has been apprehension
about safety and confidentiality of data transferred, so, security
and reliability of telecommunications networks is a critical
factor for introducing telemedicine applications that
eventually impacts both economic and practical viability.
Furthermore, there is a need for modifications to allow
encryption so that the communications are compliant with the
Health Insurance Portability and Accountability Act (HIPAA).
A common solution to this is built-in videoconferencing unit
encryption and/or establishing a virtual private network (VPN)
tunnel. As Internet networks has become more reliable and are
able to provide more bandwidth, telemedicine programs are
more frequently using the Internet with either encryption or
VPN (Ebad R 2013). In developing countries like India,
nonexistence or obsolete infrastructures for telemedicine and
inadequate transmission capacity are also the major challenges.
In order to address these issues on standardisation of the
telecommunications infrastructure, technical and legal
requirements, ensure the storage and confidentiality of the data
and various matters of telemedicine, the "Committee for
Standardization of digital information to facilitate
implementation of Telemedicine systems using information
technology (IT) enabled services” formulated by the
Department of Information Technology (DIT), Ministry of
Communications and Information Technology (MCIT) with the
support by
a Technical Working Group (TWG), has
formulated the ‘Recommended Guidelines & Standards for
Practice of Telemedicine in India’ (Recommended Guidelines
& Standards for Practice of Telemedicine in India 2003).
National Task Force on Telemedicine was constituted in
September 2005. Presently, Satellite Telemedicine Network is
working in India through Indian Satellite System (INSAT) in
439 nodes across the country through 17 mobile vans (Panth M
et al. 2015).
Lack of focus on training of the technical staff and lack of
domain knowledge of the policy makers on the subject has also
been a big hindrance in evolution of telemedicine in India
(Suresh S 2015). The private doctors sometime fear that
telemedicine is likely to reduce their practice. Hence, there is a
need to sensitize the government decision makers, health and
telecommunication professionals, concerned communities and
users that telemedicine enhances their reach and exposure and
not meant to replace the physician or human intelligence
(Bhowmik D et al. 2013).
M Health (m-health)
Health care stakeholders are aware that there is a need to
reshape the existing health care delivery system for efficient
delivering, consuming and paying for care (Ernst and Young
2012). mHealth has been considered and identified as one of
the five key trends reshaping the future of health care viz. new
accountability concepts, changing channels, virtual care models
and tele-health, vertical integration, diversification and
emergence of health care conglomerates and mHealth (Jain AK
et al. 2014). Mobile phones have been found to be an
appropriate and very promising tool for disease control
interventions in developing countries like India, where its use
has been done in key diseases like HIV/AIDS by way of bulkSMS (push& voice) messaging and this is found to be well
accepted by the population (Déglise C et al. 2012). Currently,
there are over 20 mHealth initiatives in the country for
spreading awareness about various health issues (IRDA 2014).
Some of the projects in India have been successful and
continue to develop into long-term services. Freedom
HIV/AIDS in India - a mobile games to promote HIV/AIDS
awareness, Handhelds for Health in India-uses mobile
technologies (instead of pen and paper) to collect field data on
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disease or public health are such examples. Boston Consulting
Group has made striking prediction that two years can be added
to the average life expectancy in India by reducing perinatal
and maternal mortality if m Health is widely deployed as this
can increase the flow of information (prenatal advice) to
pregnant women at every stage of their gestation through SMS
campaigns. SMS-based reminders can also improve patients’
drug compliance by between 30 and 70 percent and thus can
help in minimizing the risk of the disease spread and in
ensuring that patients complete their treatment especially in the
case of Tuberculosis. As a result, by 2025, use of mobile
healthcare techniques could lead to the cure of 1.1 million
tuberculosis sufferers in India (The Socio-Economic Impact of
Mobile Health 2012).
Emergency and Non-emergency help lines by government and
private setup, Apollo Aircel mobile health care, Apollo
M.I.N.D line, Apollo prism, Apollo Munich, ICICI Lombard
health insurance companies, Med India website, mobile clinics,
heart help lines and Dr SMS are some of the examples of
efforts made by Indian health care industry in the direction of
m Health. Besides that, the Governments of India (GoI),
Ethiopia and the United States together with UNICEF launched
the Call to Action for Child Survival and Development in 2012
to focus on accelerating the achievement of Millennium
Development Goals 4, 5, 6 and 7 in 200 underperforming
districts in India. M Health can further improve public health
system of India through providing help in remote data
collection, communication and training for healthcare workers,
real-time monitoring of patient vital signs, mobile
telemedicine, remote patients management, public health
surveillance, patients education and awareness (IEC and BCC
Messages), disaster warnings (Disasters Management),
communicable diseases management, etc (Davey S 2013).
Real-Time Biosurveillance Program (RTBP) can reduce
expenses, introduce benefits, and improve the efficiencies in
disease surveillance and mitigation in India (Waidyanatha N et
al. 2010).
The steering committee on health said that in the 12th plan
(2012-17), all district hospitals would be linked to leading
tertiary care centers through telemedicine, Skype and similar
audio visual media. mHealth will be used to speed up
transmission of data in this. By 2017, mobile health can
become a 3000 crore market in India and mobile health market
opportunity for India will be around 8% of the total AsiaPacific opportunity (Davey S et al. 2013). Although mHealth is
viewed as a promising tool in developing countries patient
satisfaction, clinical efficacy and sustainability is really
questionable. Besides that, language, timing of messages,
mobile network fluctuations, lack of financial incentives, data
privacy, and mobile phone turnover are primary barriers in m
health. So despite all these developments, more evaluations of
current interventions need to be conducted to establish stronger
evidences (Déglise C et al. 2012, Gurman TA et al. 2012).
Electronic Health Record (EHR) / Electronic Medical Record
(EMR)
Healthcare organizations have made significant investments in
HIT tools, and EMRs and EHRs are major technological
advances (Mane RR et al. 2012). The EHR/EMR is being
implemented to improve patient care, reduce health care
expenses and fundamentally change the way of practicing
medicine (Accenture 2010). Substantial improvements have
been made in the cost and quality of care in developed
countries since the introduction of the EHR/EMR, although the
same cannot be said in resource-constrained settings (Walker J
et al. 2005). Replacing paper-based medical records with the
electronic version assists the entire healthcare delivery process
in reducing cost and maximizes the profit. It helps in efficient
management of the medical data in the form of timely and easy
retrieval of robust patient data anytime and anywhere,
automation and streamlining of hospital and clinical workflow,
better clinical decision making by monitoring the condition of
the patients, hospital order management, creation and
maintenance of data set needed for medical audit, quality
assurance, disease surveillance and security of the medical data
(EMR Market in India 2011, Parkhi S 2013).
Medical tourism, telemedicine and health insurance have also
played role in pressing the healthcare organizations to adopt
EHR/EMR as an integral system of HMIS. Among other
technology based applications in healthcare (EMR/EHR,
mHealth, telemedicine and web-based services), EHR/EMR
has highest penetration in India. It is growing by 13.5 per cent
in the last five years, and it is expected to have the same rate of
increase due to improving uptake and upcoming hospital
projects (Jha BK 2013). In India, Apollo Hospitals, Fortis
group of hospitals, Max healthcare, Sankara Netralaya, Satya
Sai Hospital etc., are few big names who have implemented
EMR in their organizations. There has been an increase in the
use of electronic systems for capture of data in clinical research
and trials in the country (Mane RR et al. 2012). Yet, conclusive
data regarding adoption rates of EHR/EMR in India are not
available and this lack of data can be attributed to challenges
such as long implementation time, security and privacy issues,
user resistance to adoption, complex organizational
environment, overpopulation, and lack of resources and
infrastructure (Mane RR et al. 2012, Sood SP et al. 2008,
Scholl J et al. 2011).
In order to have a uniform system for maintenance of
EHR/EMR by the hospitals and healthcare providers in the
country, GoI had set up an Expert Committee which has
developed Standards for adoption / implementation of
EHR/EMR in the country which have been finalized and
approved by the Ministry of Health and Family Welfare, after
due consideration of the comments received from the stake
holders and general public. This will definitely help the
healthcare organizations to understand the bare minimum
standards of technology, infrastructure and application for the
implementation of HMIS, EHR/EMR (EHR Standards for India
2013).
In-spite of the advantages with the use of EHR/EMR, the rate
of adoption of the technology is very low owing to many
hurdles and challenges in implementation. Successful adoption
of such systems depends on a combination of people,
technology, and processes. Attitude towards IT adoption,
obsolete healthcare infrastructures, lack of technical standards,
issues related to security and privacy of data, difficulty in
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Manoj Kumar Gupta et al., Momentum in Penetration of Technology in Indian Healthcare: A way forward
transferring paper based information into electronic format,
lack of user friendly interface, long implementation time,
untrained healthcare workforce, lack of availability of training
facilities for healthcare workforce, paucity of funds and inertia
in taking appropriate initiatives from public health governance
authorities are some of the challenges for progression of
EHR/EMR in the country (Mane RR 2012, EMR Market in
India 2011, Sood SP et al. 2008, Athavale AV et al. 2010).
Clinical documentation and health information portability also
pose unique challenges in urban and rural areas of India
(Radhakrishna K et al. 2014). The EMR in most of the
implemented organizations is limited to the patient’s key health
parameters, laboratory results, and discharge summary, if
admitted to the organizations. In many of the implemented
organizations, the patient data is interoperable within the closed
system of the network and is not exchangeable across different
healthcare organizations in India. Besides that, the doctors also
find it difficult sometimes to spare extra time to enter the data
into the system because of their non-adaptation to the use of
technology and their perception about affecting the doctorpatient relationship if they spend more time in data entry than
communicating with the patients (EMR Market in India 2011).
Health Management Information System (HMIS)
HMIS is the key component of any health program and
provides new opportunity to link information and
communication technology to healthcare. It is primarily a tool
of policy and strategy making at national level, monitoring and
managing the program at state and district level and gathering,
aggregating and analyzing the information, and generation of
reports for taking actions to improve performance of health
system at the sub-district level (Panth M et al. 2015, LaTour
KM et al. 2013). With the rapid change in the disease profile,
medical technology, regulations, healthcare standards and
competition among healthcare providers, the administrators are
constantly relying on their information system for effective
decision making. Because of revolutionary progress in the IT
sector and its integration into the HMIS system, there is speedy
access to even micro-level data. So, in developing countries
like India, donors and investors are increasingly linking release
of funds and investments to performance based indicators
through HMIS. In this regard, the information provided by this
system should be adequate, reliable, and accurate and updated
so that the decision makers and investors are equipped
adequately and timely.
Increasing competition among private players for healthcare
excellence, ever-increasing healthcare data volumes, advent of
electronic health records (EHR) and changing ways for
disseminating information using IT has propelled the medical
world for a slow transition from paper-based records/files
maintenance to Electronic form of information management
system (Jha BK 2013, De RM et al. 2012). With emergence of
customized solutions, the market for HIS & HMIS is growing
fast and Indian healthcare is now more receptive for that (Das S
2013). The HMIS web portal launched by the Ministry of
Health and Family Welfare (MoHFW) on 21st October, 2008,
with the objective to enable capturing of public health data
from both public and private institutions in rural and urban
areas across the country was a bold and innovative step in this
direction. Web-based HMIS helps in easy aggregation of data,
reduces workload on field staff, strengthens decentralization,
and hence, improves the planning ability by formulating 18
national, 52 state/district, 51 facility, and 18 community
indicators (Panth M et al. 2015, Fox LA 2005).
With the growing importance of health in the global agenda, it
has been tried to streamline the HMIS of public health system
in India in the form of development of structured data
collection formats and provision of computer and internet
facility even to the Primary Health Centers (PHCs). But issues
like non-availability of data entry operators at the PHC level,
untrained staff to handle the computers and lack of steady
internet functioning are some of the issues which need to be
addressed. Moreover, the present health information systems in
the country are not sufficiently equipped and often fail to
respond adequately to the complex epidemiological transition
and growing medical tourism market. This implies a need for
the health system to go beyond the existing routine HMIS
system and require accelerated efforts to meet international as
well as country specific needs (Pandey A et al. 2010,
AbouZahr C et al. 2005).
In hospital sector implementation of HMIS is more a voluntary
process than a mandatory imposed act. As a result not many
hospitals are either keen on implementation or implemented
HMIS only for certain aspects of hospital operations.
Inadvertent intrusion of technology in the health system is also
a major challenge for the hospitals in incorporating HMIS.
Most care delivery organization’s decision makers, clinicians
and bureaucrats are not experts in IT component (Garets D et
al. 2005). Considering the inundation of types of HMIS
software, assessing the right type of software, identifying the
right vendor, software package and customization of the
available software are major hurdles in taking decisions.
Besides that, complexities of the functioning of the healthcare
organizations, lack of dedication and financial support from
management, expectation of early return on investment, unmet
need for customizations, non-user friendliness of the software,
lack of training of the staff on the usage of the software are also
some of the challenges being faced in implementing HMIS in
India (Vishweshwara R 2009).
Digital Health Knowledge Resources (DHKR)
The various categories of healthcare providers, both private and
largely public, are to be equipped with the right
information/resources on wide range of health topics of need to
the community. Some of the information/resources that the
healthcare providers require are grey literature, government
reports, Internet-based publications, meeting abstracts,
industrial effluent data, laws and regulations, legislative issues
updates, forms and formats for the submission of the data,
vaccination guidelines, action-taken guidelines for outbreaks
and emergencies, etc. In this regard, there is a need for health
knowledge resources to be made readily available and easily
accessible to the healthcare providers. The best way to make
these resources available is in the digital form. Hence, there
evolved the concept of Digital Health Knowledge Resource
(DHKR) or the digital medical library, where the health
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International Journal of Recent Scientific Research Vol. 6, Issue, 5, pp.3881-3886, May, 2015
information is collected and stored in the digital formats and
accessible through internet from the individual’s computer.
The advantages of DHKR are easy and timely availability of
the information to address the needs of wide range of users,
like clinicians, health professionals, healthcare consumers,
medical researchers and students (Sharma K 2012). But there
are some challenges in providing comprehensive, coordinated,
and accessible information to meet the needs of the diversified
public health workforce. Majority of times the information
seeking is situational, contextual, and unique to the information
seeker
and
time,
resource
reliability
and
trustworthiness/credibility of information are some barriers for
information access. Hence there is need and scope to design the
DHKR through the development of evidence-based decision
support systems and human-mediated expert searching; and
this should be well supported by trainings in the use of
information retrieval systems (Sharma K 2012, Revere D et al.
2006, Revere D et al. 2007).
5.
6.
7.
8.
CONCLUSION
9.
It is undisputed that HIT can lead to better and promising
results and is capable to bring out a better future of the Indian
healthcare industry. Despite having a lag in adoption and usage
during previous years, the penetration of technology has gained
momentum in Indian healthcare delivery system in the form of
telemedicine, HMIS, Picture Archival and Communications
System (PACS), EHR/EMR, mHealth and web-based services
and has started changing the face of Indian healthcare industry.
This reshaping has increased the demand for deployment of
robust IT infrastructure, trained healthcare personnel, informed
decision makers and better financial management in the
country to reduce the challenges for better utilization of HIT
potential. In this regard, beside existing efforts by Government
and private sector, there is urgent need of capacity building of
health professionals on available tools and incorporate the IT
component in medical curriculum. But, patient safety and
satisfaction are also important factors to deal with, as human
factors are more difficult to overcome, rather than the
technological ones.
10.
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How to cite this article:
Manoj Kumar Gupta et al., Momentum in Penetration of Technology in Indian Healthcare: A way forward. International
Journal of Recent Scientific Research Vol. 6, Issue, 5, pp.3881-3886, May, 2015
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