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Summary of the Draft Implementation Strategy of the National Digital Health Mission

The National Health Authority (NHA) last month released the Draft Implementation Strategy for the National Digital Health Mission (NDHM), laying out the government’s plans to implement the objectives of the NDHM. This crucial document was listed for merely a week of public consultation between March 22 to March 29 and it flew under the radar as it was listed as a submenu link on the NDHM website without any other intimation. Following the end of the consultation period, the link to the document has been removed from the site.

Background: The Narendra Modi government launched the National Digital Health Mission on August 15, 2020, with the aim of creating a digital health ecosystem by issuing unique Health IDs to citizens, maintaining interoperable electronics records of patient history, creating a digital repository of doctors and health centres across the country, and providing any other digital service that makes health services more accessible, inclusive, efficient, and affordable. Later in the year, the Centre approved the Health Data Management Policy, which governs the collection and use of personal health data.

To know more about the goals of NDHM, read our previous article on All You Need To Know About The National Digital Health Mission.

What are the guiding principles for the NDHM?

NDHM will follow the guiding principles set out by the National Digital Health Blueprint:

Business Principles: 

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  • NDHM will be designed to be inclusive and will strive to reach out to those who are currently unconnected such as the digitally illiterate and people who live in remote, hilly, and tribal areas.
  • NDHM will enable seamless portability across the country through the Health ID and other supporting blocks such as the Health Information Standards
  • NDHM will adopt a minimalistic approach for designing each building block following the idea of “think big, start small, scale fast.”

Technology Principles:

  • The design of the building blocks of NDHM will adopt the Agile India Enterprise Architecture Framework (Agile IndEA) notified by the Ministry of Electronics and IT (MeitY).
  • The building blocks of the NDHM will be interoperable, conform to open standards, and abide by the Open Standards and Open Source Software policy put out by MeitY.
  • Furthermore, the blocks will adopt the Open API Policy notified by MeitY and will have security and privacy designed into the development of these APIs.
  • Legacy systems will be assessed for conformance to NDHB principles such as the Agile IndEA, and systems that pass will be integrated. If not, useful data contained in legacy systems will be leveraged and utilized.
  • NDHM will follow a federated architecture. Except for certain Core Blocks that will be maintained centrally, all other building blocks will operate as regional, state-level and institution-level platforms. This allows the system to function independently but in an interoperable manner.
  • All the registries and master databases will follow the single source of truth architecture and will be backed by strong data governance established at the State and Central levels.

What are the building blocks of the NDHM?

The draft document defines a building block as a package of functionality defined to meet certain needs. Apart from being useful in a standalone case, each building block will also be interoperable, cross-functional, standards-based, and designed to scale. The building blocks for NDHM have been categorized into two main types: Core and Reference; and two additional types: Infrastructure and External Solution.

Core Building Blocks: These are components required by multiple applications and systems. The government sets the standards for these blocks and has strategic control over them in the form of ownership or control over the third-party licensee that operates them. The Core Building Blocks are:

  1. Health ID: A unique ID for identifying individuals, authenticating them, and capturing their health records (with consent) across multiple systems.
  2. Healthcare Professional Registry (Digi Doctor): A comprehensive registry of health care professionals across various domains and working at all tiers of the public and private sector.
  3. Health Facility Registry: A repository of the health facilities in the country describing the specialities and services they offer.
  4. Security Operations Centre (SOC): The SOC is tasked to prevent, detect, and respond to any kind of cyberthreats targeting the digital health ecosystem.
  5. Privacy Operations Centre (POC): The POC is tasked with ensuring that there are necessary privacy safeguards in place for a person’s health data and all stakeholders are in compliance with these privacy safeguards.
  6. APIs: Building blocks should be able to interface with other blocks using open APIs and must be implemented as workflow-based modules.
  7. Drug Registry: A registry to smoothen the inventory flow throughout the drug supply chain and reduce counterfeit medicines. The registry will also capture details of all drugs sold in India.
  8. Health Analytics: This block analyzes the aggregated anonymized data and provides decision support to the various stakeholders of NDHM.
  9. Health Data Fiduciary Registry: A registry of entities who determine the purpose and methods of processing of personal data. Health Information Providers and Health Information Users are such entities in this context.

Reference Building Blocks: These are components that most stakeholders will use for designing, developing, and delivering their services. The Reference Building Blocks are:

  1. Personal Health Record (PHR): An electronic record of health-related information of an individual drawn from multiple sources and that conforms to prescribed standards. The information contained as part of this record is under the control of the individual.
  2. Electronic Medical Record (EMR): An electronic record of a patient’s medical history from a single health facility. Allows clinicians in a facility to efficiently track data over time.
  3. Health Information Exchange (HIE): This exchange will be responsible for facilitating the exchange of data between applications in the health ecosystem using Open APIs. HIE will also enable the creation of an interoperable Health Record for each individual by prescribing the standards.
  4. Consent Manager: The role of a consent manager will be to ensure that a patient is in complete control of what data is collected and how/whom it is shared with and for what purpose.
  5. Record Locator Service: A service that will help you query records across the system using specified search criteria.
  6. Anonymizer: Anonymisation of data will be performed by commercial off-the-shelf products.
  7. Health Locker: A standards‐based interoperability specification that enables the creation of digital health record repositories that allows medical records to be shared with others through a reference link.
  8. Tele-Medicine: NDHM hopes to provide health care services to inaccessible areas and regions with a low doctor‐population ratio through telemedicine facilities.
  9. Health App Store: A store like Google Play Store or Apple App Store where all applications developed by the NDHM will be uploaded and made available to the public.
  10. Disease Registry: A database containing information about people diagnosed with a specific type of disease classified into hospital-based and population-based.

Infrastructure Building Blocks: These blocks will support core and reference blocks. Examples include cloud infrastructure, network security, identity access management, visualization services, services access and delivery channels, and IT infrastructure at the health facility.

External Solution Building Blocks: These blocks will be developed by ecosystem participants using the open architecture developed by NDHM. Examples include wellness apps, offline tools, social media, IT support, Unified Health Communications Centre, and secure health networks.

What training approach will be used for the various stakeholders?

The platform is expected to be user-friendly and simple to use for citizens, but healthcare professionals and administrators will require some minimum training to use the tools provided by NDHM. These stakeholders will be provided training in a cascading manner, where a select number of master trainers will be trained in workshops and provided with course material, training manuals, and system user manuals.

The training workshops will be conducted face-to-face as well as through online channels depending on the subject matter. Onsite training will primarily be carried out for large healthcare centres that require specialised training and for stakeholders who play a significant role in the onboarding. Online training, on the other hand, will enable self-learning through a comprehensive web-based e-learning platform.

The training program will be designed into the following types:

Basic training: As part of this, trainees will be given an introduction to the mission and a run-through of the basic processes pertaining to the NDHM ecosystem. This training will also be scheduled to announce new initiatives, mandates, guidelines

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Advanced training: At this level, more detailed and complex topics will be presented to an audience that has the domain expertise to comprehend them.

Functional training: Functional specialists will be trained to understand workflows and processes for end-users, based on their functional role and responsibilities.

Technical training: A team of experts will train the IT staff on the technical aspects of the NDHM building blocks.

NDHM roll-out strategy

The NDHM roll-out is currently in a pilot phase. As part of this phase, five building blocks have been designed and implemented across six Union Territories (UTs). The blocks that have been rolled out in these UTs are Health ID, Healthcare Professional Registry (Digi Doctor), Health Facility Registry, Personal Health Record, and Electronic Medical Record.

The overall roll-out follows two approaches:

  • Technology roll-out strategy: As part of this strategy, a Managed Service Provider (MSP) will be onboarded to transition the existing five building blocks onto the technology platform that will be adopted for all other building blocks. The MSP will then develop the remaining building blocks and test out the product in select public and private institutions. The blocks will finally be deployed once they pass the performance and security requirements. A repository of standards, API’s, metadata and data dictionaries will also be established as part of this strategy.
  • Adoption Strategy: The adoption strategy is divided into three phases.
    • Phase 1: As part of Phase 1, the existing building blocks developed in the pilot phase will be transitioned by the MSP. Following the transition, emphasis will be placed on increasing the adoption of the various NDHM platforms and conducting capacity building for the various healthcare stakeholders.
    • Phase 2: In Phase 2, the government will roll out building blocks developed and launched in the UTs to other states. NDHM will work with dedicated teams in each state for the integration, onboarding, and roll-out of NDHM in the concerned State. State authorities will be allowed to assume a leadership role in the implementation and can design a state-specific approach to the roll-out.
    • Phase 3: Following an all-India rollout, the final phase will focus on the operation and maintenance of the building blocks, and making changes and enhancements based on the feedback from various stakeholders.

Furthermore, to spread information, education, and communication (ICE) about the mission, NDHM will conduct campaigns and workshops for doctors and healthcare facilities, partner with NGOs to drive awareness campaigns, conduct training workshops for health care workers, and run promotions and public and private hospitals.

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