“Doctors are worried about the sanctity of their consultative discussions, the patient data, and afraid of poaching of patients by the telemedicine etc. service providers and that remains one main cause of hesitancy to get onto one of the commercial offerings (of telemedicine),” Federation of Indian Chambers of Commerce and Industry (FICCI) told the National Health Authority in their comments on the consultation paper for the Unified Health Interface (UHI).
The comments received from four industry bodies – FICCI, Internet and Mobile Association of India (IAMAI), Confederation of Indian Industry (CII), and National Association of Software and Service Companies (NASSCOM) on the Unified Health Interface consultation paper were published by the NHA earlier this month.
The proposed UHI lays down how third-party applications will interact with the government’s National Digital Health Mission (NDHM) – a multi-layered digital health infrastructure that looks to digitise sensitive health data for citizens.
The four organisations reviewed and suggested changes to the proposed UHI and its End User Applications, pricing mechanism, enlisting of various healthcare providers, method of verification, and so on. Members in these organisations range from health tech apps like 1MG and Practo to service providers like Amazon Internet Services, Tata Consultancy Services, etc.
What was said about the UHI?
NHA: It asked stakeholders about the benefits and risks anticipated in an open network approach to digital health services. The NHA has proposed an Open protocol-based UHI with standards that offer interoperability between various stakeholders.
- The core products’ (like registries and health IDs) dependency should not be restricted to NDHM only and instead, state governments should be allowed to implement/expand their systems while complying with NDHM standards.
- It also pointed out that the open network approach and its implementation would require significant effort into setting the mandated data modelling and messaging standards, as well as gaining alignment throughout the whole healthcare network on agreed nomenclatures.
- Organisations compliant to NDHM /UHI through sandbox should be promoted/incentivised by NDHM for on-ground implementation of interoperability standards.
NASSCOM suggested that a clear action plan be laid out by the MoHFW for encouraging wider adoption of a standard (or a set of standards) for interoperability under the NDHM. It noted that interoperability may be difficult if a hospital or health service provider is using a more advanced health information service than an End User Application. In this case, they would not be able to communicate, share health records and other information.
- SNOMED CT should be used for standardisation of health data. It is a suite of medical clinical terminology that is used by the US government for its own interoperability standards under the U.S. Healthcare Information Technology Standards Panel.
- Only a unique identifier should be used to pass on information through the Health Service Provider’s application as it could otherwise risk passing sensitive information through multiple hands, including the sales and marketing departments.
FICCI sought clarification on:
- Whether the UHI will be internationally interoperable?
- The timeline for the deployment of standards and tools if they are to be made from scratch?
- If the Open Standards will be mandatory for all Healthcare Service Providers or Vendors?
- Who will be maintaining this ecosystem and the infrastructure?
- Action plan on open Network and protocol’s security concern
- List and details of Standard compliances expected to be followed
- Information on Code level details for integration
Incentives, disincentives and how to mitigate them
NHA: It asked for a list of any incentives and disincentives for stakeholders, along with ways to mitigate them, that haven’t been covered by the consultation paper.
1. For private sector
NASSCOM, IAMAI, and CII suggested that the UHI allow End User Applications to select doctors from their own networks, based on experience, and other criteria as this creates a unique patient experience. The UHI currently asks End User Applications to list all healthcare workers listed in the health professionals registry.
FICCI disagreed with this, and instead asked for a regulatory system for such platform operators that use their own mechanisms to verify doctor credentials, which it says, leads to ‘arm twisting of (health) service providers’, and ‘an atmosphere of distrust’.
CII suggested incentives/capabilities for private sector entities in its individual submission:
- Allow them to build reference apps (So far the UHI has restricted this to the government/NDHM) and sandboxes.
- If the UHI is open, then Health ID and registries like Healthcare Professionals Registry should also be ‘open’ like in the Unified Payments Interface – which has a different ID for the same person in different applications.
- That prior approval be taken from a hospital, if a healthcare worker’s name appears in its database as well as in the individual database signalling private practice.
CII also said that disincentives may not only be monetary. Instead, it could include “additional workload, liability, clinical safety, concerns over continuity of care, plus for aggregators, challenges of size, scale, adoption, no guaranteed return on investment,” it said.
FICCI suggested that ‘health benefits’ be added to the UHI, as health data exchange is happening on an open network, so that data could be productively used. According to FICCI, the platform is only seen to be helping in booking appointments and making payments.
2. For health workers
CII suggested holding consultations with healthcare workers like administrative managers, ASHA, ANW administrators, etc. to help understand their incentives, disincentives, etc.
NASSCOM suggested that an incentive programme be introduced by the government to give financial benefits encouraging health service providers to adopt digital systems that can create and manage electronic health records.
3. Concerns about business viability
CII, NASSCOM, and IAMAI raised concerns about the monopolies and oligopolies that could emerge in the current model of End User Applications’ interaction with the Unified Health Interface. According to them, the current model allows any app with a large consumer reach to have a gateway to the UHI, and thus the NDHM; regardless of whether they have experience in the healthcare sector. This can discourage smaller businesses and investors, they said.
Post fulfillment features: Pricing, ratings, etc.
NHA: Suggestions were invited on alternate models of discovering health service providers on the UHI as well as alternate models to price and rate these services.
1. On discovery
CII and NASSCOM suggested multiple UHI gateways. Gateways are entry points in the UHI for third-party health service providers or end user applications to join the NDHM ecosystem. Adding to this, it said that the discovery should also bring up results of nursing and allied health professionals.
2. On Ratings
FICCI suggested that the rating mechanism should not be included. This is because healthcare service providers are uncomfortable with them. However, in case there is a rating mechanism, FICCI said that HSPs should also be allowed to rate patients instead of just the other way around.
CII suggested that there be a way to change ratings once a patient’s grievance is addressed or clarified by the Health Service Provider.
3. On Pricing
CII, IAMAI, and NASSCOM raised concerns that the current model of payments was restricting the business model of End User Applications like Practo and 1MG who help customers discover Health Service Providers online by allowing pricing to only be transactional. According to them, healthcare pricing can be more subscription-based, or have package plans to be more effective.
CII and IAMAI suggested that End User Applications should be given the freedom to have their own models of pricing.
FICCI suggested that insurance claim settlements and direct payment clearance should be added to the payment mechanism.
NHA: Any other stakeholders in the UHI that the NHA hasn’t mentioned in its consultation paper?
CII suggested adding two more stakeholders to the list made for the Unified Health Interface:
- Private sandboxes
- Other healthcare workers: It asked for the inclusion of stakeholders who take ownership of components required for UHI. Examples included ASHA (Accredited Social Health Activist), ANW (Anganwadi Worker) administrators, and administration managers. CII also stressed the need to include operating theatre functions, medical device manufacturers, etc.
FICCI suggested that the following should be included:
- Organisations like National Medical Council and various Dental, Nursing, Physiotherapy, Pharmacy councils, etc be made a part of the list of stakeholders.
- Health service aggregators which offer services to end users- like Practo, DocOnline, etc.
- Insurance companies as Health Service Providers so they can access health data for seamless reimbursements and claim settlements.
Digital health services and their phasing
NHA: How digital health services should be phased in the UHI?
FICCI suggested that the UHI should be rolled out keeping in mind the promotion of good health, diagnosis management before, during, and after pandemic or epidemic care.
- The NDHM should go forward after doing an analysis of the areas with the most deficit, the largest populations, as well as the services which are easiest to deploy.
- It could deploy the NDHM phase-wise as well – in different parts of the country.
UHI Governance, management, development
NHA: Views and suggestions were invited on approaches for governing and managing the UHI Gateways, along with allowing multiple gateways. It also asked for comments on charges it can levy for use of the Gateway in a few years and how it should be evolved.
- Private players be allowed to create their own UHI Gateway
- A timeline be laid down for the NDHM to phase out the UHI Gateway years after its full operationalisation.
NHA: Comments were invited on the comprehensiveness of objectives listed for the UHI, the methods to achieve them, as well as any other objectives that should be included.
CII suggested including Key Performance Indicators answering questions of improvements to expect, impact on disease incidence and patient experience, etc.
FICCI suggested that a health-tracking platform should be added, wherein, patients can track their health over a period of time.
This pertains to suggestions and comments on matters other than those explicitly mentioned in the questions asked by the National Health Authority.
1. On data sharing
FICCI suggested that ‘best’ international models be referred to for open source-based health data exchange models, instead of building it from scratch.
2. On services available on the UHI network
FICCI suggested that the availability of beds including categories like regular and critical care should be included among the services available on the UHI network.
3. Use of Health-IDs
FICCI asked for clarification on why Aadhaar could not be used as an identifier instead of Unique Health IDs.
Interestingly, CII’s submission on the Telemedicine Guidelines mirrored the suggestions given by Amazon Internet Services (AWS) on the same issue.
Comments and consultations so far
At an Open House held for consultation on three NDHM components – UHI, Health Professionals’ and Facilities’ registry- last week, the NHA revealed that it had received 329 comments so far.
Out of this:
- 48% were on the Health Professional’s Registry
- 33.4% were on the UHI
- 18.5% were on the Health Facilites’ Registry
Further by area of concern
- 23.4% were on implementation – as in how the concepts would be implemented across the country, in areas where other infrastrucure is weak.
- 25.3% were on policy – such as data sharing mechanisms, data regulations, etc.
- 51.1% were on product- Such as the design principles as well as technological aspects of the building blocks
During the Open House, it also noted that this marked the fourth stage of its consultative process on different parts of the NDHM. Previously it had conducted consultations on the
- NDHM draft implementation strategy,
- NDHM blueprint,
- NDHM data policy,
- Sandbox framework guidelines, and others.
- NDHM Consultation: Practo says UHI could enable healthcare monopolies
- Open House on National Digital Health Mission: Stakeholders want no liability for data, fair discovery, and more.
- Why did RS Sharma bring up UPI and Account Aggregators in an event on digital health?
- Unified Health Interface: IT For Change warns against oligopolies, raises privacy concerns
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