Information and Communication technology has revolutionized the way medicine is practiced and the way healthcare information is documented, archived and retrieved at the point of care. While information technology is facing challenges of adoption, communication technology is striving to create health information exchanges for connecting providers within multi-org environments and across disparate geographical boundaries, using secure and fail-safe internet connectivity for high speed data, voice and video communication.

This article on National IT Backbone is a synthesis of diverse but related issues that facilitate access to clinical information at the point of care promptly and securely.

Dr. Ajit K. Nagpal
MBBS (AIIMS), MHA (AIIMS), MPH (Harvard)

Convener, Task Force on Health Sector Reforms, J & K State
Chairman, CII Healthcare Committee on Public Private Partnerships

Group Chairman, Wellogic Information Technologies, USA
Chairman, Healthcare Advisory Council, Feedback Ventures, India

Framework:

National IT Backbone is essentially a broad band, ultra high speed, multi-protocol, multi-gigabit per sec internet connectivity with nation-wide network topology, multi-nodal distribution system and multiple points of presence. It is a security-enabled cohesive framework that provides security services like authentication, data confidentiality, integrity, and non-repudiation with the best cryptographic techniques available.

Therefore, National  IT Backbone must offer a comprehensive and integrated framework to enabling models that address today’s business demands and economies of scale with higher speed links, carrying more traffic at substantially lower costs with integration of several sub-networks, providing secure and private means of data transport, with effective, time sensitive and distributed voice, data and video applications.

Objective:

The objective of the National IT Backbone for Healthcare is to facilitate secure and reliable exchange of clinical and health related information amongst public & private hospitals, clinics & ambulatory care centers, clinical laboratories, imaging & diagnostic centers, pharmacies and drug store, and insurers, payers and third party administrators; and most significantly empower the policy makers and regulators to capture statistical data and trends, assess epidemiological and economic burden of disease, facilitate prospective planning, and take public policy initiatives to reform the health sector to incentivize investment in healthcare infrastructure and to achieve technical efficiency, clinical effectiveness and quality in the delivery of healthcare.

Standards for Interoperable Framework:

Standards for creation a reliable interoperable framework include data security standards, data communication standards, data archiving and retri standards, and precise reconciliation rules to avoid data duplication and redundancies.

Standards for data exchange in healthcare include classification of disease like ICD 9 and ICD 10, catalogues for procedural terminologies including CPT, LOINC, SNOMED, and data communication standards such as HL7 and CDA protocols.

While barcode scanning and biometric systems are used for maintaining data security, CPOE, Care Plan alerts and CCR are used as standards for data integrity. Further activity logs, audit trails, and data recovery are used as standards for data archival and retri.

The Healthcare Information Technology Standards Panel (HITSP) which is a cooperative partnership between the public and private sectors of healthcare industry was constituted for the purpose of harmonizing and integrating standards that will meet clinical and business needs for sharing information among organizations and systems.

HITSP is engaged in developing standards with specifications for interoperability in the areas of lab results browsing, emergency responder, consumer empowerment for access to clinical Information, quality of care, medication management, personalized healthcare, consultations and transfers of care, immunizations and response management, public health case reporting, patient-provider secure messaging, remote monitoring, and clinical research.

National Information Data Bank (Central Data Repository)

Non-availability of essential clinical information at the point of care is the most leading cause of Medical Errors. While HIPAA guarantees strict handling of sensitive personal information, Master Patient Index (MPI) with a reconciliation logic process based upon good factors and identifiers is the hallmark of successful development and maintenance of MPI at regional and national levels.

One-patient-one record created and reconciled on the basis of factors such as name, date of birth, address, associated with public identity using smart cards, driving license etc, and biometric identification including finger print and retinal image help relate the patient to their health record for accurate accessibility at the point of care.

Access to Clinical Information:

Patient Records include patient demographic and clinical data including sensitive information. Patient data archive, retrieve and exchange within and across organizational and geographical boundaries depends upon data content, formatting standards, and data exchange mechanism.

It is therefore essential to define the role relationship of the authorized users through consent management protocols, and freedom to access sensitive information through break-glass functionality.

In this process the defined role privileges with right to access patient record for view, add , edit and delete functions must also be defined on the basis of role relationship between the patients and the providers of care, as primary, attending and consulting physicians, nurse practitioners, technicians or pharmacists, the administrators, and the patient’s relatives and care takers.

Patient Confidentiality in a Multi-Org Environment:

Environments where instant access to clinical information of patients is available at the point of care, the Care Providers have the opportunity to make critical clinical decisions, and multiple organizations within communities can collaborate with each other to provide better care services

The ICT technology has the challenge to create these milti-org environments with option to share or restrict information between and within communities based upon personal preferences and HIPAA compliance.

The following Figure 1 shows the components and stakeholders of the National IT Backbone.

Solicited and Unsolicited Transactions:

The clinical information exchanged between various stakeholders fall into the categories of solicited and non-solicited transactions. Solicited transactions are explicitly requested transactions with known origins, workflow and destinations, which may or may not be stored within the Central Data repository (CDR). These transactions include lab and diagnostic imaging requests and results, Rx orders and status updates, community-wide referrals, and import of patient record from the Health Information Exchange (HIE).

The un-solicited transactions also include explicitly requested transactions based on timed events/data received routed to known destinations such as medication histories and discharge summaries, etc.

The following figures show the components and stakeholders of the solicited and un-solicited transactions.

Summary & Conclusion:

Healthcare information technology has had a late start in its adoption by healthcare delivery networks and most organizations in the private as well as the public sector of healthcare industries have either home grown of basic IT solutions addressing backend functions with some front desk applications for appointment scheduling, admission/discharge/transfer functions, and billing and claims management.

Since healthcare industry has seen a substantial growth during the past decade and the pace of development is growing rapidly, there is an increasing awareness of the role of information and communication technology in facilitating better clinical care and enhancing efficiency and quality in the delivery of care.

While the healthcare industry is taking major initiatives in upgrading their IT platform, the ICT industry has to respond urgently and aggressively to meet the challenges of IT adoption and upgradation.
It is in this context the role of National IT Backbone assumes great significance in creating accredited and certified multi-org environments to facilitate adoption of ICT through the establishment of health information exchanges and central data repositories within communities.

While there are many impediments to rapid adoption of information and communication technology in healthcare, there are indications that the Central and the State Governments are engaged in taking public policy initiatives to incentivize investment in this sector and facilitate establishment of Regional IT Backbones for flow of clinical information across disparate geographical boundaries for access to patient record by authorized users at the point of care.

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