Representative photo: Owen Beard/Unsplash
- India hasn’t mandated healthcare digitisation, and muddles along with antiquated legacy systems.
- Under the UK’s National Health Service, 94% of patients have some kind of electronic medical record.
- Digitisation can eliminate errors and waste, and is a highly desirable public good.
Digitisation has transformed large swathes of the economy. As consumers, we enjoy the benefits when we bank or shop. Healthcare, with all its complexity, human touch points and inconvenient process hand-offs should be ripe for the adoption of digital tools. But it stubbornly resists. Your doctor still writes out your prescription in longhand, and you must be an obsessively organised filer if you can find your cholesterol level reports from two years ago. Even the byzantine processes of the Income Tax department have been digitised. But healthcare’s love for the fleeting paper trail remains strong.
It is not as if digitisation cannot work in healthcare. Ninety-four percent of patients covered by the National Health Service in the UK have some kind of electronic medical record (EMR). But the NHS is a monolithic, government-run system where coercion by fiat can prevail. In a laissez-faire healthcare system like in the US (which more closely resembles what we have in India), doctors have had to be persuaded with financial subsidies, to go electronic. In India, digitisation has not been mandated, and we muddle along with our antiquated legacy systems.
Digitisation can eliminate errors and waste and is a highly desirable public good. It is therefore a puzzle why it has not found widespread acceptance in healthcare. Doctors are portrayed as tradition-bound and resistant to new technologies. But, the manner in which hospitals are packed with glitzy technologies puts paid to this notion. Indeed, the medical profession often stands accused of an over-eager acceptance of new drugs and devices. So, what is it that makes the uptake of digital tools so slow in healthcare?
The pace of adoption of new technologies in medicine is driven by how doctors perceive its benefits, first to themselves and then to the patient. digitisation improves the efficiency of medical care – this is a benefit for the patient, in the form of convenience or improved clinical outcomes (because of fewer errors). For the doctor, digital tools like EMRs are seen as an unwelcome imposition. It forces her to spend extra time completing the EMR without a corresponding increase in income. Digital records contain more information and can be stored, retrieved, and shared very easily, unlike paper records.
This ease also means that digital records enable a level of transparency that paper records do not. This level of transparency can be uncomfortable for providers used to operating under the guild like opacity of traditional medical practice. While these factors may account for the smaller doctor-owned and operated facilities resisting digital tools, what accounts for the slow adoption of EMRs in professionally managed corporate hospitals, including Government-run hospitals?
There is a steep upfront cost to digitisation that low-cost providers are not willing to fund. Apart from this the fragmented nature of healthcare delivery in India (the largest hospital chain Apollo operates less than 1% of all hospital beds in India (3)) also retards the adoption of digital tools. Unless the entire ecosystem operates on the same standards and the digital documents are easily portable, the benefits are not fully available. If I visit Apollo hospital today, and tomorrow I visit Fortis, I cannot simply provide an electronic link to my Fortis doctor to access my past medical records. So, electronic data, when it exists, does so in silos that defeats the entire purpose of digitisation.
Finally, the IT engineers – the proverbial barbarians at the gates of healthcare – must also share blame for their inability to storm healthcare with their magical solutions. Health are, unlike other sectors, works according to different rules. And rule no: 1 is – if a new solution cannot be proven to improve clinical outcomes doctors can and will resist its use. Tech companies with their outside-in perspective are learning this the hard way. While in a sector like banking, simply improving ease of banking is sufficient justification to deploy a solution, tech solutions in healthcare must, at the very least, show that they do not negatively affect clinical outcomes. And doctors, either due to their genuine concern for the patient or concern for their own autonomy, cannot be persuaded to adopt a solution without a clear demonstration that it is neutral or positive for patient clinical outcomes.
Addressing the fragmented healthcare ecosystem also calls for crafting solutions that work seamlessly across multiple contexts and providers. Many small IT companies have been unable to foster such solutions, and even the larger players have failed to cooperate to establish a common set of standards to ensure seamless interoperability.
So, what is the solution? Simply put, it is the government.
The government has a key role to play as an orchestrator and intermediary using two powerful handles that only it can use. The first handle is to establish standards for interoperability in cooperation with healthcare providers and IT companies. The second handle is to mandate universal adoption of these standards, perhaps by linking adoption to a licensing scheme for healthcare providers. However, these handles have the potential to squelch innovation.
To avoid this, the government should also operate sandboxes for new technology development where, within a controlled environment (healthcare does require some guard railing), new ideas can be developed and scientifically evaluated against each other to select winners for large-scale use. And the sandboxes should not simply be virtual conglomerations. They should be brick and mortar innovation parks where a hospital, an incubator for start-ups, research facilities, offices and the government-appointed regulator who can oversee the development and clinical trials of digital tools are co-located.
For too long, the Indian government has stood back from its role in developing the digital economy in the healthcare sector, under the facile, and very wrong, assumption that leaving it to private players in the market as in other parts of the economy would work. Loose confederations of private players when attempting change in healthcare have quickly fallen apart as the conflicting interests of the players pull the agenda in different directions. The Swasth Alliance, an amorphous grouping of hundreds of well-meaning people cobbled together at the peak of the pandemic, has produced underwhelming results, if one is to go by the press releases on their website.
Enlightened government oversight may be an oxymoron, but it is the only way to succeed in developing a coordinated approach that can nurture and grow this sector. The partnership between the digital startup Babylon and the National Health Service in the UK is a model for how governments and private players can and should work together.
Healthcare is quite unlike other parts of the economy where market forces can be relied upon to select the winners. Healthcare is also the part of the economy where digitisation is sorely needed. A proactive approach led by the government is the only way that digitisation of healthcare can proceed apace. Healthcare consumers badly need this to happen.