The pandemic made digital health care an integral part of our lives in various forms, including teleconsultations, exchanging digital records and now linking health outcome (vaccination) to identity, anywhere, anytime, through the Co-WIN site, which can also, inter alia, be accessed through the Aarogya Setu app. Now, visualise an ecosystem where, just like vaccination, all the medical tests and procedures related to an individual were stored in the cloud, available, anywhere, anytime, whenever demanded by the individual or someone authorized by the individual. That is the goal of a personal electronic health record (EHR) linked to a unique health ID – currently termed the Ayushman Bharat Health Account (ABHA) number.
The thrust of this policy brief focuses on the various aspects of human interface with the EHR ecosystem, presents possible challenges to implementation, and possible actions to overcome those challenges.
Accessing the ABHA – The basic details necessary to create an ABHA account are name, date of birth, gender and a mobile number. One can use the Aadhaar number or driving licence to create an ABHA number but it is not necessary. The vaccination record in CoWIN is a good example of how ABHA is supposed to work. First, it is accessed through an OTP on your mobile or through a login and password. The user has to remember her ABHA number or ID (similar to an email ID) and the linked mobile number and have access to the linked mobile number (in case a password is not being used). A critical difference is that multiple ABHA IDs are permitted. To quote the Ayushman Bharat Digital Mission (ABDM): “ABDM believes that users are rightful custodians of their data, and can make rational decisions associated with its use. Given that healthcare is a sensitive subject, ABDM does not want to restrict users from linking different sets of health data with different ABHAs. For instance, if a user wants to use a separate ABHA to access data related to their sexual history, ABDM will allow for such use. However, in order to establish a better continuum of care, it is recommended that users create & use only one ABHA.” In addition, the login process requires information on date of birth as well as the ability to navigate a captcha. The existing process of accessing ABHA will need assistance, especially for digitally challenged persons, who may be a large share of the older, less literate persons seeking care. This assistance could compromise privacy. Other access methods, e.g., autoscanning of QR codes could retain privacy if physical possession is with the patient.
The adoption of EHR is about collecting, storing, transferring, and analysing patient data over a period of time in order to improve health outcomes. This does not mean only IT adoption, or computerising records, but signals fundamental behavioural changes among the stakeholders involved, structural changes in institutions and legal frameworks, and a shift in how policymakers think about health as a subject, from providing facilities to managing care. Adoption of EHR in countries like the United States and United Kingdom is also driven by efficiency outcomes, i.e., improving health outcomes in an economically efficient manner. This is not currently the priority in India, where it is perhaps accurate to say that the focus of the effort is to expand access as widely as possible. For example, it can help improve maternal and child health care provided by ASHA workers, tuberculosis management, etc. – interactions where patient information is collected but an accessible EHR may not be created. Insurance providers affect the use of EHR in determining the course of treatment in two main ways – first, by suggesting procedures to avoid allegations of malpractice, and second, hospital administrators may want to assure themselves that the care being is covered by insurance. Some large corporate hospital systems who have implemented EHR have indicated that the absence of standardised patient treatment protocols in India has meant that EHR has not been used to suggest treatment options to doctors, thereby obviating the risk of alert fatigue (at possible cost to quality of treatment), though this does not mean that data is not analysed and shared with physicians periodically (not real time), who may then adopt changes to their regime. So, even for those who are already part of the formal medical system, EHR could also improve outcomes.
This paper can be accessed by clicking here.
This article is authored by Neharika Rajagopalan.