Disruptive Digital Health - Hastened by the Covid-19 Pandemic
In wake of the Covid-19 pandemic (Coronaviral disease 2019, a Severe Acute Respiratory Syndrome – SARS – caused by the novel Coronavirus called SARS-Cov2), digital health interventions have garnered a sudden increase in demand. The inherent nature of a pandemic makes digital health a viable solution as digital healthcare inter alia allows; firstly, the doctor and the patient to avoid meeting in person and secondly digital health interventions aid in gaining and tracking information regarding spread of the pandemic. In other words the voice for legitimizing such interventions has been driven by necessity. There has existed a vacuum regarding governmental policies related to them, which the government is trying to redress by rolling out the Guidelines for legally practicing Telemedicine[i] and implementing the National Digital Health Mission.[ii] Through the instant piece we seek to address twin questions (A) How digital health interventions have gained an urgent legitimacy due to the ongoing pandemic? (B) Are these interventions transient in nature, endemic only to the looming pandemic?
Defining Digital Health
Digital Health has been defined by the World Health Organization (“WHO”) as “use of information and communication technologies for health.“[iii] The European Commission provides a more comprehensive definition of digital health and care as “tools and services that use information and communication technologies (ICTs) to improve prevention, diagnosis, treatment, monitoring and management of health and lifestyle.”[iv] Thus, the European Commission aimed at stipulating the specific areas for which digital health interventions can be used. Both, the WHO and the European Commission’s definition of digital health help us understand that digital health is not just a necessary requirement during a pandemic rather it can become a necessary cog of the healthcare system of a country.
India’s Tryst with Digital Health Policy
To understand the traction gain regarding legitimizing digital health interventions, it is pertinent to trace the trajectory of the relevant digital health policies of the past. The bedrock of digital health is data; therefore, the government has tried to push for a legislative framework for safeguarding such data. The Digital Information Security in Healthcare Act “DISHA” (draft legislation) was aimed at filling this legal vacuum. However, the aforementioned legislation would be formally subsumed by the newly drafted Personal Data Protection (PDP) Bill.[v]
The call for establishing a robust digital health framework started with The National Health Plan (“NHP”) released by the Ministry of Health and Family Welfare (“MoHFW“), which recommended establishing the National Digital Health Authority (“NDHA”) to regulate and foster digital health across the country.[vi] Further on, the NITI Ayog in its strategy paper[vii] recommended establishing a National Health Stack (“NHS”). The Health Stack was suggested to be a “nationally shared digital infrastructure” for Ayushman Bharat and health programmes across India.[viii]
The National Digital Health Blueprint (“NDHB”) was released by the MoHFW for providing an implementation framework for the NHS.[ix] The NDHB accounting for the vast size of India, stipulated that holistic, comprehensive and interoperable digital architecture is required across the country.[x] The NDHB proposed the setting up of a National Digital Health Mission (“NDHM”) which would implement the NDHB.[xi] The role of the NDHM was to provide data to “different components of the health eco-system to work together and also provide the technological infrastructure for collection and storage”[xii] of data through registries.
Despite the attempt to provide a legal framework for digital health, there have been very bleak legislative developments. The fact that the pilot Telemedicine project was first initiated in the year 2001,[xiii] and it is only now that Notification to regulate it is out, highlights the limited attention that the government has given to digital health.
Abrupt Changes in Wake of Covid-19
Largely attributed to Covid-19, digital healthcare interventions are being widely practiced not only in India, but also globally. According to a Bain survey, 24% of the Chinese people surveyed had used telemedicine; however, 64% were expected to use telemedicine in the next five years.[xiv] Similarly in England, in March, the registrations for the National Health Services App (provides consultation with health professional through an online form, order repeat prescriptions etc.[xv]) increased by 111%.[xvi] Following a similar trajectory, in India startups like Practo, Portea, and Lybate (facilitate remote medical checkup) witnessed a spurt in demand during Covid-19 as people were trying to access doctors even for mild symptoms.[xvii]
Though telemedicine was being used in India before Covid-19; the Guidelines were released only on March 25, 2020. This was duly notified through the Extraordinary Gazette of India dated 12th of May 2020 thereby amending the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 and allowing consultation through Telemedicine by the Registered Medical Practitioner in accordance with the Telemedicine Guidelines.[xviii] The Indian government launched the Arogya Setu application, a contact tracing application, aimed at monitoring Covid-19 and informing people about the potential risk of Covid-19 infection.[xix] Similarly, various States have been using various digital healthcare interventions to monitor and manage Covid-19 patients. In Tamil Nadu, geo fencing was used by the government to ensure compliance of quarantine.[xx] The sudden issuance of the Telemedicine Guidelines in wake of Covid-19 can be attributed to manage the spurt of patients who would have otherwise flocked the hospitals, thus, risking the healthcare workers and increasing the burden on the hospitals and clinics. Additionally, telemedicine also mitigates the risk of contamination as patients would not be exposed to high risk contagion places, like hospitals and clinics.
Similarly, it is only in the form of relief package for Covid-19 that the government has directed setting up of the NDHM, which would be a culmination of the NHS and NDHB.[xxi]
Due to the lockdown and the risk of infection even traditional sectors have been forced to shift their workings to digital medium. The Supreme Court of India has been forced to publish Guidelines for hearing matters via Video conferencing.[xxii] Even the judges in various High Courts have been using various video conferencing applications for various matters. Similarly, many private sector jobs which were conventionally desk jobs have been shifting to work from home. The University Grants Commission (UGC) has recommended shifting to online mode of education to continue with classes for the students.[xxiii] Therefore, necessity has indeed driven the need for innovation. However, the moot point to be addressed is regarding the transient nature of such developments; that whether such changes are endemic only in light of Covid-19. The following question plagues the measures being taken to adopt digital health too. The answer to that would be that such changes are enduring in nature and are bound to become necessary cogs for the digital health machinery. The reasons for the same would be the following:
The nature of digital healthcare is such that it helps penetrating the remotest of places, where it is logistically burdensome to reach. Considering the demography of India, it becomes even more critical as it provides inclusivity, thereby helping India reach closer to its universal health coverage goal.
Telemedicine aids in relieving the burden on patients as it mitigates the time and expenses incurred in travelling and waiting at hospitals.
Digital health mitigates the workload on medical practitioners as they get the aid of digital health records to monitor a large swathe of patients.
Remote patient monitoring aided through wearable tools that “track metrics such as blood pressure, weight and oxygen saturation”[xxiv] help the medical practitioners to cut down on the readmission rates of the patients.
Provider-to-provider Telemedicine[xxv] aids the medical practitioner in getting the second opinion of the expert medical practitioner regarding the medical ailment. Such advice is sought through sharing of health data of the patient through digitized modes.
In light of Covid-19 the world has become cognizant about the risks with a communicable disease and how it severely affects the healthcare professionals. Therefore, to mitigate the impact on the healthcare professionals, during pandemics or epidemics, digital health can be a sine qua non so as to prevent personal contact between patients and health practitioners, and to monitor data related to such disease.
The setting up of a Coverage and Claims platform as envisaged by the NHS[xxvi] will help in cutting down the costs for claims and aid in providing personalized health insurance due to transparency regarding the individual’s health and claims history.[xxvii] However for creating such a mechanism a strong willed legislative push is required to adopt for digitization of health records by the hospitals.
Big data can be used to understand the impact of disease on the different parts of the country, and to identify patterns and clusters of the infected. Such data can be used for Targeted client communication, which entails transmitting health related information to specific segments of population (through SMS alerts etc).[xxviii]
Thus, the awareness created by Covid-19 can help in boosting the adoption of digital health interventions, including digital symptom checkers, remote patient monitoring, tele-ICU, smart-phone enabled digital disease management.[xxix] However, as a caveat it is pertinent to mention that with increasing digitization of health sans an adequate data protection regime, the health record of the people would be in a precarious position. Welcome to the post-pandemic era of digital health![xxx]
[i] Telemedicine Practice Guidelines Enabling Registered Medical Practitioners to Provide Healthcare Using
Telemedicine, Ministry Of Health and Family Welfare,2020.
[ii] आत्मनिर्भरर्ारत, Part 5: Government Reforms and Enablers, Health Reforms & Initiatives, Pg5.
[iii] WHO Guideline recommendations on digital interventions for health system strengthening, Executive Summary, pg3
[iv] eHealth: Digital Health and Care Preparing for the future, European commission, Pg1
[v] Data Transfer of Digital Health Records, Ministry of Health and Family, 2019 accessed at Welfarehttps://pib.gov.in/PressReleaseIframePage.aspx?PRID=1578929
[vi] National Health policy, 2017, Ministry of Health & Family Welfare Government of India Pg. 28, para 23.
[vii] National Health Stack Strategy and Approach, NITI Ayog, 2018.
[viii] Id Pg 17.
[ix] National Digital Health Blueprint, Ministry of Health & Family Welfare Government of India, 2019, Pg 5.
[x] Id Pg. 1.
[xi] Id Pg. 37.
[xiii] Vinoth G. Chellaiyan et.al, Telemedicine in India: Where Do We Stand?” Journal of Family Medicine and Primary Care 8, no. 6 (June 2019): 1872–1876.
[xiv] Kevin Chang, As the Coronavirus Spreads, Healthcare Goes Digital, Bain &Company, February 26, 2020 accessed at https://www.bain.com/insights/as-coronavirus-spreads-healthcare-goes-digital-snap-chart
[xvi] NHS Digital, Coronavirus (COVID-19) increase in use of NHS Digital tech accessed at https://digital.nhs.uk/coronavirus/nhs-digital-tech-analytics
[xvii] NHS Bureau, COVID-19 push to tele-medicine, geo-fencing and surveillance, National Herald, 25 Apr 2020 accessed at https://www.nationalheraldindia.com/india/covid-19-push-to-tele-medicine-geo-fencing-and-surveillance.
[xviii] Indian Medical Council (Professional Conduct, Etiquette and Ethics)
(Amendment) Regulations, 2020 accessed at http://egazette.nic.in/WriteReadData/2020/219374.pdf
[xix] Aarogya SetuFAQs’ accessed at https://static.mygov.in/rest/s3fs-public/mygov_159056978751307401.pdf
[xx] Vijay Kumar, Coronavirus Tamil Nadu to geo-fence thousands of quarantined people, The Hindu accessed at https://www.thehindu.com/news/cities/chennai/state-to-geo-fence-thousands-of-quarantined-people/article31157934.ece
[xxi] SupraNote 2.
[xxii] UGC Guidelines on Examinations and Academic Calendar for the Universities in View of COVID-19 Pandemic and Subsequent Lockdown, April 2020, pg 3.
[xxiii] UGC Guidelines on Examinations and Academic Calendar for the Universities in View of COVID-19 Pandemic and Subsequent Lockdown, April 2020, pg 3.
[xxiv] Calvin Hennick, How Remote Patient Monitoring Programs Are Beneficial, Healthtech, April 27,2020 accessed at https://healthtechmagazine.net/article/2020/04/how-remote-patient-monitoring-programs-are-beneficial
[xxv] WHO guideline Recommendations on Digital Interventions for Health System Strengthening, Executive Summary, Definitions of included digital health interventions pg. vii accessed at https://apps.who.int/iris/bitstream/handle/10665/311977/WHO-RHR-19.8-eng.pdf?ua=1
[xxvi] National Health Stack Strategy and Approach, NITI Ayog, 2018 pg. 23.
[xxvii] Ayush Rathi, Is India’s Digital Health System Foolproof?, Economic&PoliticalWEEKLY Vol. 54, Issue No. 47, 30 Nov, 2019 engage accessed at https://www.epw.in/engage/article/indias-digital-health-paradigm-foolproof
[xxviii] WHO guideline Recommendations on Digital Interventions for Health System Strengthening, Executive Summary, Definitions of included digital health interventions pg. viii accessed at https://apps.who.int/iris/bitstream/handle/10665/311977/WHO-RHR-19.8-eng.pdf?ua=1
[xxix] Andrew Matzkin, How COVID-19 Could Impact Digital Health, Health Advances Blog, April 1,2020 accessed at https://healthadvancesblog.com/2020/04/01/how-covid-19-could-impact-digital-health/
[xxx] Sarbadhikari SN, Corona#Covid 19# # NEW NORMAL # Cinema for a Cause # https://www.youtube.com/watch?v=qk9D_XHDfvQ&list=LLYFQQt7bMesVqFQBit4eq_w&index=2&t=0s
By Prof. S N Sarbadhikari, Independent Consultant for Digital Health, New Delhi, and Shrey Nautiyal, Editor, RSRR.