“We recommend that NDHM should be flexible and open from the start, with the private sector allowed to undertake development of UHI gateway,” Bishakha Bhattacharya of Amazon Internet services submitted in response to the National Health Authority’s consultation paper on the Unified Health Interface (UHI).
On September 2, the NHA made public the submissions by various health service providers and digital health stakeholders on the proposed UHI and other components of the National Digital Health Mission. This included cloud services provider and, e-commerce giant Amazon’s subsidiary, Amazon Internet Services (abbreviated as AWS).
The NDHM envisages a layered digital health infrastructure comprising Health IDs, healthcare facilities registry, health professionals registry, teleconsultations, etc. Launched last year by Prime Minister Narendra Modi and with a pilot already underway in 6 Union Territories, the NDHM has gained steam with over 11 Crore Health IDs already issued.
AWS’s submissions are an important indicator of how the private sector views the proposed NDHM layers. AWS was also involved in the creation of the Ministry of Health and Family Welfare’s vaccine registration platform CoWIN.
AWS comments on Unified Health Interface
NHA: Suggestions were invited on changes needed to the teleconsultation policy for wider adoption.
1. Telemedicine gateways
AWS suggested that state governments set up state-wise telemedicine gateways which will be interoperable with each other.
AWS sought clarification on how telemedicine gateways will be implemented including private players.
2. Medical Practioner verification and validity
AWS sought clarification on:
- If the Registered Medical Practitioners (RMP) will now be identified through the healthcare professionals registry under NDHM.
- If that is so, will such a registry be made only by the central government or will state governments also be allowed to make them and later integrate with the central system?
AWS suggested that with different communication channels and platforms for sharing medical data being made available, the telemedicine guidelines should emphasise health data privacy and management practices. “Tools like consent management as a service may be considered, both as an integral part of the platform or as a standalone offering,” it said.
AWS sought clarification on:
- Telemedicine application data standards and interoperability guidelines.
- The use of anonymisation systems to utilise telemedicine data for analytics and policy-level decision making.
4. Teleconsultation data
AWS sought clarification on:
- The process of adding data under teleconsultation to the health record of an individual.
- The sharing of data from remote medical devices (e.g., remote android based sugar monitor, mobile-compatible BP monitor), etc. using AI/ML/IoT for telemedicine purposes.
- With regards to doctors having to retain the teleconsultation patient data, AWS asked if each RMP will thus have to become Health Information Provider and Health Information User under the NDHM? If not, it asked if the Health Information Service is expected to be made available as a service on the cloud or separate products can be conceptualised?
5. Opportunities for private sector
AWS suggested that the guidelines ‘allow and encourage’ private sector aggregators to develop and offer telemedicine-as-a-service platforms that can onboard government authorities as well as private practitioners.
AWS sought clarification on:
- The process and opportunity to create a telemedicine sandbox by a private sector in partnership with NDHM.
- The permissions for the private sector to create service mechanisms and platforms for validating medical prescriptions’ authenticity.
- If the health ID was going to be mandatory for teleconsultation and if so, would the states/private entities be able to create products and integrate with NDHM services for health ID?
- Would state government(s) be able to create/expand on their state-level health IDs and integrate with health ID under NDHM – that will be used for teleconsultation?
6. Course for doctors
AWS suggested that the online course, mandatory for doctors looking to provide tele-consults, should include:
- Minimum safeguards to be put in place for the healthcare provider to safely deliver consultation and treatment planning.
- Modules on how the healthcare provider includes the service into their practice – dedicated tele-consult clinics, versus on-demand physical vs virtual patient waitlists
- Assist the healthcare provider in setting up and monitoring the efficacy of their telemedicine capability, patient outcomes, and satisfaction scores.
7. Code of conduct
AWS suggested that the Indian Medical Council Regulations, 2002 and the IT Act, as well as any healthcare professional regulatory body, should describe the practice of telemedicine and establish the associated healthcare professional conduct.
The guidelines should also lay out what kind of services are appropriate for telemedicine. For example, road traffic accidents would not be an appropriate use of telemedicine but headaches, coughs, colds, and rashes may be appropriate.
It further suggested that there should be guidelines on enlisting the telemedicine support of an RMP/specialist so that referral to, or secondary opinion seeking from another provider is based on expertise, skill, specialty instead of leading to inappropriate referrals.
8. Grievance redressal mechanisms
AWS suggested that to provide guidance and confidence to the users, there should be guidelines that outline escalation points for any complaints related to the healthcare service.
AWS later also asks for a grievance redressal mechanism to be constituted under the UHI at large as well.
NHA: It asked stakeholders about the benefits and risks anticipated in an open network approach to digital health services.
1. Standardise existing health IT systems
AWS suggested that the core product’s (like registries) dependency should not be restricted to NDHM only and instead State governments should be allowed to implement/expand their systems while complying with NDHM standards. It also pointed out that the open network approach and its implementation would require significant effort into getting the mandated data modelling and messaging standards, as well as gaining alignment throughout the whole healthcare network on agreed nomenclatures.
AWS suggested that organisations compliant to NDHM /UHI through sandbox should be promoted/incentivised by NDHM for on-ground implementation of interoperability standards.
NHA: Comments were invited on the comprehensiveness of objectives listed for the UHI, the methods to achieve them, as well as any other objectives that should be included.
AWS suggested including Key Performance Indicators answering questions of improvements to expect, impact on disease incidence and patient experience, etc.
NHA: Any other stakeholders in the UHI that the NHA hasn’t mentioned in its consultation paper?
AWS suggested adding two more stakeholders to the list made for the Unified Health Interface:
- Private sandboxes
- Other healthcare workers: It asked for the inclusion of stakeholders who take ownership of components required for UHI. Examples included ASHA (Accredited Social Health Activist), ANW (Anganwadi Worker) administrators, and administration managers. AWS also stressed the need to include operating theatre functions, medical device manufacturers, etc.
Included health services and their phasing
NHA: How digital health services should be phased in the UHI?
AWS suggested that the NDHM do a cost-benefit analysis of sorts of the system to decide the phasing and services.
The Authority can decide low hanging fruit against minimal return, versus, longer term success, but less short-term projects. Depending on the architecture approach, and the willingness of the authorities to program manage multiple projects, change management, care delivery disruption as SME is required to volunteer time to help design, build, configure, test and deploy capability, taking them away from their normal duties, the demand on the care system will be great. — AWS elaborated.
Incentives, disincentives, and how to mitigate them
NHA: It asked for a list of any incentives and disincentives for stakeholders, along with ways to mitigate them, that haven’t been covered by the consultation paper.
1. For private sector
AWS suggested incentives/capabilities for private sector entities:
- Allow them to build reference apps (So far the UHI has restricted this to the government/NDHM) and sandboxes.
- If the UHI is open then Health ID and registries like Healthcare Professionals Registry should also be ‘open’ like in the Unified Payments Interface – which has a different ID for the same person in different applications.
AWS noted that disincentives may not only be monetary. Instead, it could include “additional workload, liability, clinical safety, concerns over continuity of care, plus for aggregators, challenges of size, scale, adoption, no guaranteed return on investment,” it said.
2. For health workers
AWS suggested holding consultations with healthcare workers like administrative managers, ASHA, ANW administrators, etc. to help understand their incentives, disincentives, etc.
Pricing and search discovery
NHA: Suggestions were invited on alternate models of discovering health service providers on the UHI as well as alternate models to price these services.
AWS suggested multiple UHI gateways. Gateways are entry points in the UHI for third-party health service providers or end user applications to join the NDHM ecosystem. Adding to this, it said that the discovery should also bring up results of nursing and allied Health professionals.
AWS sought clarification on how the NDHM would balance the expectations of the customer with the success rates of services. For example, providing services with high success rates at cheap prices.
UHI Governance, management, development
NHA: Views and suggestions were invited on approaches for governing and managing the UHI Gateways, along with allowing multiple gateways. It also asked for comments on charges it can levy for use of the Gateway in a few years and how it should be evolved.
AWS suggested, once again, that private players be allowed to create their own UHI Gateway. This would allow Health Service Provider Applications a choice s to decide if they want to onboard with the Government UHI gateway or “one of the options of a feature-rich private sector built UHI gateway.”
AWS comments on Health Facility Registry
Right off the bat, AWS recommended the use of cloud-native design and hyperscale cloud hosting services for the NHA’s Health Facilities Registry. The HFR would contain details of potentially all health facilities in the country including hospitals, clinics, labs, pharmacies, etc.
Further, it had the following questions and suggestions.
On integration of various databases
NHA: The health authority invited suggestions on how should a Health Facility Registry organisation/programme be integrated with the HFR.
AWS suggested that highly scalable Application Program Interface (API) services be leveraged to support the large number of transactions expected in a national system. It also asked that compliance requirements with reference to data processing, data privacy and security of data be clearly outlined and be aligned with the upcoming Data Protection legislation.
AWS sought clarification on:
- How data from HFR will flow back to the registries (National Identification Number, Registry of Hospitals in Network of Insurers, National Health Resource Repository, Pradhan Mantri Jan Aarogya Yojana) in their respective professions.
- How the existing registries of the States expand to be NDHM HFR compliant
- How Aayush facilities will be integrated into the HFR.
On included data fields
NHA: Comments were invited on the sufficiency of data fields the HFR consultation paper lists for the registering facilities along with suggestions for what more could be added.
AWS suggested that the HFR should keep a provision to add more data fields so that more data can be captured as the ecosystem develops.
On Health Facility verification
NHA: Suggestions were invited on alternative models of verification of health facilities.
AWS suggested that the NDHM should publish a list for all certifications/audits/compliance checks that different types of facilities have to do – hospitals, clinics, pharmacies, labs, diagnostic centers, etc. For example, it says that compliance to health data standards – e.g. LOINC, ICD 10/11 or SNOMED-CT should be suggested for facilities.
On Application Program Interfaces
NHA: Suggestions were invited on any other APIs that should be included in the HFR.
AWS suggested that the existing Sandbox APIs should be expanded and details of all respective APIs should be provided. It also asked for a dedicated team to help those aspiring to use NDHM onboarding. According to AWS, this will improve the adoption of HFR.
On the use of HFR for verification
AWS sought clarification on:
- If the HFR can be used in the future as a verifier of other new or existing registries including certifications/ audits/ compliance/ license/ permit/ empanelment checks.
- How agencies already empaneled with government health and insurance programmes will be treated and any other exemptions.
AWS comments on Healthcare Professionals Registry
AWS only sought clarifications on the HPR which would potentially be a registry of all healthcare professionals like doctors, nurses, midwives, paramedics, health service managers, etc.
The clarifications are:
- Status of HPR with respect to Medical Council of India/National Medical Commission registries to avoid duplication and also allow integration of existing data.
- Modes of eKYC that may be adopted to avoid data duplication and misuse/unauthorised access of profiles. “For example – If place of practice is optional, can the same health professional be able to create multiple profiles with different locations. Also, post an approval of HP at an HF is done, security parameters need to be defined to ensure that the credentials of HP are not being used by others,” AWS said.
The consultation process so far
So far, the NHA has conducted consultations on the Healthcare Professionals Registry, Health Facility Registry, NDHM draft implementation strategy, NDHM blueprint, data policy, sandbox framework guidelines, and others.
In July, it held public consultation meetings on the Healthcare Professionals Registry and Health Facility Registry. It had conducted consultations on the draft implementation strategy and Health Data Policy consultation last year as well and is expected to release several other papers for further consultation.
- Unified Health Interface: IT For Change warns against oligopolies, raises privacy concerns
- RTI: Over 11 Crore Unique Health ID’s issued through CoWIN says Health Ministry
- At UHI consultation meet, NHA reveals details on NDHM governance, roll-out, and more
- Summary: Consultation paper on UHI shows what NDHM could look like
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