Digital Health Ecosystem in India Journey So Far and Way Forward

Rajib Kumar Sen, Shrestha Hazra & Vaishnavi Iyer

The term digital health - defined by the World Health Organization as "a broad umbrella term encompassing eHealth, as well as emerging areas, such as the use of advanced computing sciences in 'big data', genomics and artificial intelligence" - primarily refers to the applications emerging out of the interaction between healthcare and technology. The phenomenon of digital health is commonly described as a "cultural transformation of how disruptive technologies that provide digital and objective data accessible to both caregivers and patients leads to an equal level doctor-patient relationship with shared decision-making and the democratization of care." The notion of digital health or eHealth brings to the forefront the power of Information Communication Technologies (ICTs) in the healthcare sector, making it better-equipped with cutting-edge resources to ensure efficient management and optimal diagnosis - over and above everything, better patient care. The innovative outcomes of digital health include a host of areas, right from doctor-patient communication, to research and hospital management. The digital health initiative has played a pivotal role in ameliorating health care services, thereby bringing communities closer to seeking health care needs through all feasible modalities.

Digital Health Ecosystem: Emerging Necessity and its Proven Advantages

The proliferation of global population at a rapid rate has made it all the more difficult to bridge the gap between healthcare system and patients, resulting in increased cost for accessing healthcare services. Simultaneously, the rising incidence of lifestyle or noncommunicable diseases, increase in population belonging to the senior category, and growing health awareness among the wealthy upper class are some of the prominent contributing factors towards the increasing demand for healthcare services. The scarcity in human resources and inadequate infrastructure to cater to the growing demand has added to the pressure of developing better alternatives to the existing healthcare system. Investment in technology for leveraging the health-care delivery services in a more efficient manner was a muchneeded stimulus.

Traditionally, healthcare practices have remained restricted to diagnosing, treating ailments, and prevention based on the expertise level of the healthcare professionals. The advent of technologies in the arena of healthcare, has made the healthcare delivery a precise customized process, which does not necessarily entail the intervention of a healthcare professional at a given point of time to address any kind of emergency. The emergence of digital health technology has acted as a pillar in strengthening the delivery of healthcare across the world.

The world has witnessed a rapid boom with respect to the availability of healthcare technology products in the market in the form of wearable monitoring devices, teleconsultation practices, e-pharmacies etc.. Continuous efforts have been made in integrating advanced technologies such as robotics, Artificial Intelligence (AI), blockchain technology with pharmaceuticals and healthcare services. Research and development in these areas have also received a boost in recent times. The incorporation of ambient computing techniques into the traditional course of healthcare delivery seeks to bridge the gap in supply. Innovative solutions imparted by the digital health revolution is a boon to people, and has helped in achieving improved standards of healthcare to people worldwide, by increasing their access to services through a window of potential opportunities, with the goal of promoting and protecting their health and well-being.

Digital health encompasses a wide spectrum ranging from apps teaching Yoga to the wristband that measures heart rate to exploring medical practitioners and scheduling consultations. The most notable applications in digital health include telemedicine, Point-ofCare Diagnostics, m-health, Medical Virtual Assistants, selfmonitoring healthcare devices, Electronic Health Records (EHR), the use of big data and blockchain technology in healthcare, e-pharmacy, and elearning in healthcare sector, among many others.

The advanced technologies used for developing these applications include, among many others, Internet of Things (IoT), big data, AI, Block Chain, Chatbots, and Virtual Reality. The interlinking of each of these features has further enhanced the scope of service delivery in digital health. For instance, while IoT is crucial for equipment such as inhalers and audiometers, and minimizes the likelihood of incorrect diagnosis in such cases, big data allows analysis at a macro level for tailored treatments besides helping in detection of risk factors and potential side effects of drugs on patients. AI and blockchain enables healthcare professionals to make wiser decisions in treatments and renders administration more effective. Chatbots are one of the most popular tools used for faster communication. The use of Virtual Reality is limited to mostly patient rehabilitation and treatment in case of psychological disorders, but has nevertheless made a significant contribution in this domain.

The establishment of a digital channel of communication between patients and doctors has made it much easier to ensure real-time monitoring of patients and track their progress. Through guide books, prevailing best practices, social media, and local popularity, the digital revolution in the health sector has provided patients with more information, such that they can make better health decisions and are empowered to manage their own health. It has transformed the manner in which health professionals deal with a disease. Technology is often more useful in identifying the right kind of treatment for an illness and also its detection at an early stage. Moreover, portal technology benefits both serviceproviders and service-seekers. Through access to the medical records and online interactions, it empowers patients on the one hand to be more responsible about their health and the medical professional on the other hand to have a better perception about the historical pattern of health status of an individual.

The last decade has seen a huge leap in the sphere of digital health. With increasing smartphone prevalence and the ubiquitous use of "Apps" gaining dominance, more than 4 billion downloads have been recorded for healthcare apps alone, and are paramount in the healthcare system. Mobile app-based healthcare services figure among more than 60,000 such healthcare-related apps on Android and iOS. This appears to be a promising scenario for the digital health ecosystem in India, given that the share of population using an internetenabled smartphone is rising with every passing day.

Where does India Stand?

Like most other nations, India’s contribution in the digital health revolution has been noteworthy. The Government of India launched the flagship programme Digital India Campaign in 2015 which included public health initiatives geared towards adoption of digital technologies for penetration of healthcare services in rural areas. The National Health Policy 2017 envisages a Digital Health Technology Ecosystem, which through a nodal implementing authority serves the needs of all stake-holders and improves efficiency, transparency, and citizen experience. Consequently, the Ministry of Health & Family Welfare formulated the National Digital Health Blueprint in October 2019, based on the National Health Stack proposed by NITI Aayog in 2018. The blueprint has been designed as a layered framework, with a vision and a set of principles at the core, surrounded by layers relating to digital health infrastructure, data hubs, building blocks, electronic health records standards, regulations and an institutional framework for its implementation. The Prime Minister announced the implementation of this framework as the National Digital Health Mission (NDHM) on 15 August 2020. Presently, this endeavor has evolved into the Ayushman Bharat Digital Mission (ABDM).

The ABDM seeks to establish a federated health information architecture, health information exchanges, and a national health information network by 2025, that will make the healthcare system secure and interoperable enabling easier accessibility and portability of anonymized health records across public and private healthcare institutions. The ABDM is based upon five main components - Health ID, Health Facility Registry, Healthcare Professionals Registry, Health Records, and Consent Manager. The other entities in the ecosystem include ABDM Sandbox, Health Information Providers, Health Information User, Health Repository Provider, and Health Lockers.

Alongside the efforts of the Government, independent players also have a significant role in improving the healthcare landscape in the country through innovations in wearable technologies, telemedicine, AI, virtual reality, genomics, etc. Digital health technology has brought about enhancements to revamp the delivery of value-based care, to the continuum of healthcare services in India. The adoption of intelligent solutions will help in setting aside the inequalities arising out of the barriers that have existed between healthcare system and patients historically, in not just improving the service availability, but also adding to service quality to cater to patient satisfaction, particularly with respect to hospital care and services, even in Tier II and Tier III cities in India.

While the groundwork in digital health was being laid since the last decade and its interventions have made provision for achieving desirable outcomes in maternal health, cessation programs, and mental health among others, the COVID-19 pandemic demonstrated the capability, outreach and functionality of its application - the most prominent outcome was witnessed during the Government's COVID-19 management through roll-out of the CoWIN dashboard for operationalization of the Covid vaccination programme and Aarogya Setu mobile app to aid contact tracing. These initiatives in essence have proved to be a testing ground for implementation of the large-scale, nation-wide Digital Mission programme. Notably, focus has shifted from lifestyle enhancement devices and digital services to critical medical and emergency services. The target population has moved from the urban wealthy to an allencompassing population

Challenges of Implementing a Digital Health Ecosystem in India

The NDHM envisages to "create a national digital health ecosystem that supports universal health coverage." Towards this goal, a robust capacity building system, which takes into consideration both the intrinsic and contextual factors, is required without which the exercise would be rendered inefficient in terms of acceptance, usability, and data aggregation. Recent studies uniformly confirm the view that strong governance is the key to the success of digital health. However, digital governance needs careful optimization, across various levels of healthcare for a holistic digital health ecosystem in India. The operation of digital platforms in silos owing to limited interoperability, noncompliance to standards, and lack of data governance frameworks, coupled with the absence of trained workforce is detrimental, and therefore, an optimal data governance mechanism would need to be put in place. A specific health data protection law or guidelines is essential to prevent misuse of personal information.

The responsibility of onground implementation in matters of health lies with the States/UTs. Although in most of the cases, policy prescriptions are centrally directed, federal structure of the system entitles the states to differ from central health perspectives, thereby giving rise to precarity in alignment across the nation. A roadmap may be developed, recognizing common challenges and offering broad solutions in this regard, which may be implemented by states in a tailormade and suitable manner.

The biggest implementational challenge that has been daunting the healthcare sector in India for quite some time is ensuring timely capacity building of the human resources, which in turn hampers leadership and management capacity. Concerted efforts from the Centre and States/UTs would be required to close these gaps.

Given India's demographic and socio-cultural diversity, it is extremely important to understand the usability of digital applications from the user's perspective and thereby integrate existing portals in India to offer a seamless experience. This calls for a collaboration among interface designers, administrators, the end users, such that a participatory codesign approach is adopted while designing it. High patient load and poor participation from private health-care providers towards health data aggregation are also some of the key challenges.

While smart phone penetration rate has increased over time, it is important to note that there is a stark difference across geographical locations, especially rural and urban. Therefore, low digital literacy and the vast digital divide among the Indian population are some of the barriers that needs to be overcome.

Opportunities Ahead

Despite implementational challenges, the technological revolution has started making an impact on the healthcare system in India. Digital health poses immense potential to transform the delivery of health services in the near future for better patient care. In the post-pandemic era, when the world is struggling to recover, the emphasis lies on recalibrating the public health strategies towards digital tools, especially when it comes to "preventive" care. Tools and innovations that are easy to use and affordable are likely to be the most-demanded product in future, especially for women, marginalized and vulnerable groups with greater focus on ensuring accessibility, affordability and quality services.

Based on a latest report by India Health, telemedicine can reduce the consultation time by 10 to 15 minutes in both rural and urban areas. This ensures optimal utilization of doctors and by avoiding the need to travel to a clinic or hospital, it will cut down the out-of-pocket expenditure for availing healthcare services. AI has a big role to play in improving clinical outcomes as increasing amounts of health data becomes more available and analysis techniques improve. Smart health monitors have the ability to collect personalized vital signs and test results in real-time, which may aid the rapid diagnosis, timely and proper treatment at an early stage, eliminating travel and wait times for diagnosis. It also increases operational efficiencies for doctors and assures patients with improved support and feedback. Mobile-based health apps have immense potential for preventing serious diseases by increasing patient engagement, providing health education, and expert guidance from healthcare providers.

In India, start-ups in the digital healthcare arena are eventually turning out to be a vibrant ecosystem, in the backdrop of the need for viable solutions. As per a 2018 report, there are 4,892 startups in the Indian health-care space, that goes beyond a specific disease, domain, geography, product, service or business model. Digital start-ups have introduced novel technologies to the Indian healthcare system. Especially with respect to non-communicable diseases (NCDs), the digital platforms have provided requisite structure for capturing the chronic patient pool. Most importantly, it has enabled the capturing of non-clinical data, which forms an integral part in preventing NCDs. Conventionally, most start-ups seek to provide administrative solutions such as automating internal processes, digitization of health records and other such. While most start-ups typically cater to the metro cities, the urban-rural divide is gradually reducing given the proliferation of the internet coupled with improving connectivity. With the adoption of a multidisciplinary approach, there is scope for improved in-depth clinical focus in service delivery. A professionally diverse team consisting of medical professionals and product engineers, might be a potential remedy.

Social media has also been a major driver in the development of digital life. Exclusive social media platforms catering to patients with similar health concerns will not only help connect them and exchange information, the data collected by the platform can be used to improve health care services and devices, which ultimately improves people's lives.

The ABDM is a much-needed strategy to build the digital health ecosystem in the country and thereby encourage innovation in the health sector, which bring together public-private partner-ship. Efforts until now have laid the path for a strong digital health ecosystem in India in the right direction towards increa-sing access to equitable health services and thereby improving health outcomes. A promising future is awaiting to be witnessed.

(Rajib Kumar Sen is Senior Adviser, NITI Aayog. Shrestha Hazra and Vaishnavi Iyer are Young Professionals, NITI Aayog).

Views expressed are personal.