12th Year of eHealth

Time to Think of Healthcare Beyond Hospitals

O P Yadava
CEO and Chief Cardiac Surgeon, National Heart Institute, New Delhi

The 21st century has seen us become a knowledgebased society and the world has shrunk into a global village with erudite, better informed and connected citizens — all meriting a re-think in the way we govern ourselves. There has, therefore, been a clarion call and a felt need for a change from the archaic, bureaucratic and governmental control to a more user-friendly, simplified and single window systems. Over the last 70 years, physical governance has failed and is now slowly but surely witnessing a paradigm shift towards electronic (e) governance or e-Governance. Not only it offers the ease and convenience of delivery, but it also reaches out to the masses at their doorsteps in the remotest corners of the country with efficiency, rapidity, transparency and in a cost effective manner, besides providing a single window opportunity. One can seek services from the comforts of ones home and vice-e-versa deliver the same through smaller well kept offices rather than the conventional, shabby, dingy, dilapidated, ill-lit and unkept premises of a typical Sarkari building.


This assumes special significance in a vast country like India, which is seventh largest in the world with topography ranging from sprawling deserts to the high peaks of Himalayas, dense jungles and a huge ocean front. Moreover, India has developed strong capabilities in Information and Communication Technologies (ICT) and mobile telephones have reached and being used by even the poorest of poor in the country.

Though the first national e-Governance plan was launched in 2003, its actual growth started with the establishment of National Informatic Centre (NIC) in 1977 and the launch of NICNET in 1987. However, these disjointed standalone efforts needed to be integrated to provide an all encompassing model of e-Governance. Projects like Unique Identification Number and Aadhar Card and linking of these to the PAN card are important landmarks in this journey. E-Governance must encompass the entire society from the individual level to the collaborative bodies of corporates and the government. It is only then that this metamorphosis of the governance would truly be called revolutionary and disruptive.

The proof of concept is already there in the form of initiatives like Bhoomi Centres of Karanataka for land revenue records, building plan sanctions in Delhi and the Gyan Doot project for the tribals in Madhya Pradesh. Smart Government of Andhra Pradesh is another such glowing example of success of e-Governance. This can even take place at micro level as shown by the project SARI (Project Sustainable Access in Rural India) delivered through public access internet kiosks run and established by certain enterprising IT professionals in a small village near Madurai.


This is one valid and effective way of addressing the issue of corruption, which has been the biggest bane for development in our country. It would also facilitate a push towards Digital India and cashless economy.

E-Governance in medical sciences is virtually in its infancy and could range from single window permission and sanction of licenses for medical institutions to monitoring of vital statistics like birth and death rates, and delivery of healthcare services through concepts like e-ICUs. According to EU, E-Health can be described as the application of information and communication technologies across the whole range of function that affect the health sector, from the doctor to the hospital manager, via nurses, data processing specialists, social security of administrators and “ of course “ the patients. It encompasses tools like web-based libraries, electronic medical records (EMR) and electronic health records (EHR), continuing medical education (CME) programmes, inventory control; hospital information system (HIS), computerised prescriptions, medical and nursing audits, quality assurance tools, finance modules, image capture, storage and transmission tools like PACS and tools for doctor-patient communication.

In a country like India, where nearly two-third of vulnerable population is based in rural areas, the concept of a village e-health centre via online video conferencing can be attractive and effective method of healthcare delivery. Personal health records can be made available on CD Roms and smart cards. Tele-health and medical informatics are new frontiers at present in India and are likely to see spiralling growth in near future. Medical transcription can even drive growth and economy. Some of the current examples of successful telehealth initiatives include the Wipros HIS system for Delhi Municipal Corporation, Tata Consultancy Services EMR system for Tamil Nadu and 21st Century Health NET in Goa.

National Health Portal launched on 14th November 2014 too is a worthwhile single point initiative for authentic health information for general public, trainees, professionals and researchers.

In fact, the next major disruptive change in health sector could well be the analysis of a huge amount of data available through various devices like ventilators, ICU monitors as well as wearable devices, which a large section of Indias population is using. While the data is being captured and stored effectively, it is not being analysed to improve health outcomes of an entire community.

Remote sensing of health parameters and early institution of therapy to prevent hospitalisation will not only reduce morbidity and mortality of life threatening conditions but also would become cost effective solution to the health problems of any nation. Most diseases today are lifestyle related and have behavioural factors as their root cause. E-Governance through mobile telephony and internet services can be used to bring about a paradigm shift in these behavioural parameters affecting health, thus contributing to primordial and primary prevention. People in far flung areas, with limited access to quality healthcare, can be given access to the best medical services anywhere through e-Governance. Tele-robotics can be used effectively to deliver therapeutic services.

Its time to think of healthcare beyond hospitals and to look at newer models like digital health. Health applications can be used to provide medical care and help prevent diseases. These can also help harness the power of artificial intelligence, point of care diagnostics, genetics and other affordable emerging technologies. Home health care, delivery of telemedicine and the use of healthcare analytics with medical grade wearables are going to bring, and are in fact they are already bringing, a paradigm shift in the way we deliver healthcare and look beyond hospitals. Patient data portability and laying down of the e-health standards, however, are certain issues that need to be addressed soon.

To err is human but to reduce that err is now the domain of e-health. It helps break the silobased outdated healthcare delivery systems and help integrate various legacy systems like the private sector with the government and the nongovernmental organisations; social care with hard core medicine; and acute hospital care with primary and primordial care. Even within the hospital, various departments can be integrated.

It helps reduce clinical errors, adverse drug reactions, implementation of evidence-based decisions and transparency of route to decision. One can identify the patient and community needs and, thus, help in efficient allocation of resources. It helps in acquisition of accurate and relevant data, its storage in a durable fashion, its retri and transmission at will and in its efficient analysis with a view to innovation.

Even the productivity will go up as no time is wasted in standing in the queues. Besides contributing to such mundane parameters like the Gross Domestic Product (GDP), even more ephemeral parameters like the Gross Happiness Index, Satisfaction, Peace of Mind of the general public will improve with such measures thereby reducing the stress levels and may even translate into reduction of man made diseases like hypertension, diabetes and metabolic syndrome. A paperless hospital will not only be cost effective but also efficient and environmentally friendly with less chances of inadvertent errors, besides improving patients satisfaction, all of which contributing to the productivity and acceptability of the institution. E-Governance also ensures accountability and outcomes analysis which should now become the buzz word in every field of service delivery, more so in medicine.

Just as the benefits are humongous, there are countervailing panoply of challenges. These are related foremost to changing the mind-set of the bourgeois class and training the 50 years plus, who still have a morbid fear of these services; providing good connectivity to remote areas, specially the Himalayas “ where physical barriers of mountains may affect satellite connectivity; and confidentiality and security of information and transactions. Rules concerning cyber frauds and hacking need to be made more stringent and e-policing too needs to have its Is dotted and Ts crossed.

Challenges extend to creating an infrastructure to support the IT network in terms of power and physical creation of Internet kiosks etc which indeed is an Herculean task. The middle and upward classes may have their personal computers but for the people in the lower rung of the societal hierarchy, public access internet system would have to be created even though mobile telephony have percolated more than PC based services. Bridging this digital divide will require mobilization of resources. Also, besides Hindi and English, vernacular language applications too need to be developed as the dialect and language change in our country every 100 kilometers. It is heartening that the apex committee for the national e-Governance plan chaired by the cabinet secretary has approved the inclusion of health as a mission mode project. It will ensure easy access to public services and equitable distribution of economic growth. In health, it has been used effectively for monitoring the mother and the child health services and for management of the National Rural Health Mission Programme, but can also be used for HIS and for the supply chain management for drugs and vaccines. The challenges could be the maintenance of these services, in light of the past experiences of major equipments in hospitals remaining dysfunctional with a very long down time. Literacy of the users, their willingness to use and the mind-set and intent behind non-use of these services will all need to be addressed. The issues concerning security, privacy and confidentiality and the menace of spam and the fear of hyper-surveillance by an over-arching, all prevailing and pervading watch dog “ government and its bodies “ are issues which may derail the e-Governance story unless addressed in the earnest. Even trust of the lay man needs to be built.

Another limitation could be that medicine, as against other fields, is not a precise science and is highly subjective and therefore developing protocol based applications is not valid in all clinical scenarios. Therefore, some level of human interface with provisioning of override has to be built in e-Governance. There are certain protocols that are nearly mathematical and can be easily delivered, at least at the initial stages, through these e-Governance modules. Even diversity in food habit, life style and ethnicity of various population groups in our country as also the wide spectrum of health related issues ranging from communicable to noncommunicable lifestyle disorders pose a formidable challenge.

The biggest barrier of e-Governance in medicine are the doctors, nurses and other healthcare professionals, who are hostile to new ICT applications, partially because of their mind set, but also at times, because of ulterior motives of loosing their control of the patient and the clientele.

For these e-Governance initiatives to succeed, a high powered and enabled team headed by an intellectual and a kind of top-down approach should first give a thorough and meticulous look at the process engineering required prior to the actual launch of the services. Setting up of an over arching, high powered body with a secretary level officer and a minister in charge may indicate the seriousness with which these measures are meant to be implemented – a message to the public as well as to the bureaucracy.

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