On July 26, the Internet and Mobile Association (IAMAI) organized its first Digital Health Summit. One of the topics heavily discussed at the conference was India’s digital health infrastructure initiatives, namely, the Ayushman Bharat Health Account (ABHA) and Ayushman Bharat Digital Health Mission (ABDM). Digital health industry experts talked about the reasons why private hospitals are reluctant to use ABHA, issues of data security, and the utility of the ABDM system.
Some context please:
Ayushman Bharat Digital Health Mission (ABDM)—previously called National Digital Health Mission or NDHM—is a project aimed at bridging “the existing gap amongst different stakeholders of the healthcare ecosystem through digital highways.” The building block of this project is ABHA, a 14-digit unique identification number that identifies you as a participant in India’s digital healthcare ecosystem. This can be linked to an ABHA address that allows one to access all their health records digitally.
ABDM started as a pilot project on 15 August 2020 in Andaman & Nicobar, Chandigarh, Dadra & Nagar Haveli and Daman & Diu, Ladakh, Lakshadweep, and Puducherry. A year later, in 2021, it was launched nationwide.
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But do people really see the benefit of ABHA?
Speaking about the milestones of the ABDM Joint Director of National Health Authority (NHA), Vikram Pagaria said that as of now “about 40 crore people have ABHA IDs and around 200,000 facilities and 200,000 health professionals are on our HPR [Healthcare Professional Registry] and HFR [Healthcare Facility Registry].”
Ironically, the panel right before Pagaria’s highlighted ABHA’s limited reach in metropolitan cities. Speaking in a panel discussion about technology and innovation in healthcare, Suhel Bidani, Lead, Digital Health at Bill & Melinda Gates Foundation, India, asked a room full of health tech professionals (and journalists like yours truly), “Can I just, [find out] by raise of hands, how many of you have ABHAs?” Roughly 15 people raised their hands (for reference, based on my estimation around 50-60 people were in the room at the time. We have reached out to confirm this estimate with the event’s PR team and will update the story if and when we receive a response.)
He then asked another interesting question, “Once you have created an ABHA, how many of you have seen the utility of an ABHA?” and about 7 people raised their arms this time. “Reluctant hands,” Bidani said, adding that “that’s [using the ABHA] the next step, there’s no point having these ABHAs, there’s no point having these ABDMs or ABHA-linked records unless and until it translates to getting that information on a health locker [a cloud-based platform that allows users to upload, save, and share their medical records digitally],” and urged people to create these lockers with any one of the many health locker providers available in the market.
Why is the private sector shying away from National Digital Health Mission?
“The main mission [of NDHM] is to create a national digital health ecosystem and to promote interoperability. One of the main use cases that we want to implement using ABDM is that when a patient goes to a hospital and the doctor over there asks, Can I see your past records? And if the patient says yes, then all the past records, all the longitudinal health records, or all the medical records that are there, immediately come on the screen of the doctor, and the patient is not required to carry that polythene or bag of records,” Pagaria said.
This, based on my understanding, would mean that you could go up to any hospital (public or private), irrespective of whether you have been treated there before or not, and the hospital will be able to access your health records. But to do so, all hospitals would have to agree to share the health records of their patients with the ABDM ecosystem.
Pagaria said it has been challenging to work with the private sector—which accounts for 70% of the healthcare in the country— on establishing this interoperability. “Narayana Hrudayalaya, Manipal Hospital, and Fortis Hospital, Max Hospital, Medanta Hospital, we had a series of conversations, but they say that NHA is about interoperability, and if we promote interoperability, then the patient would never come back to the same hospital,” Pangaria explained (emphasis ours).
But there are other concerns with interoperability as well and one such concern was highlighted by Praveen Bist, CIO of Amrita Hospitals during the final panel of the day. When asked how cyberattacks (like the one attempted on AIIMS) can be prevented, Bist said, “If we don’t have a good consolidation of data, then the threat is very low because what will they do? Even if they get access to the data, there is hardly much there.”
NHA’s targets for the future:
Pagaria said that the NHA was currently focusing on populating the registries of healthcare professionals (HPR) and healthcare facilities (HFR) to create the building blocks of the digital health ecosystem. “ In COVID time, there were a lot of requirement of the number of health care professionals, the number of health care facilities, and India, unfortunately, did not have very credible data. We had some data, but that was also not updated,” he said explaining why the NHA is focusing on populating these registries.
He also said that the NHA wants to promote the use of these registries in the private sector as well. He mentioned that the authority wants to create something similar to the know your customer (KYC) system: “So know your customer services through AADHAAR, you give your OTP and you are identified. Similarly, we are trying to promote the use of KYD, know your doctor, and KYF, know your health care facility services,” he said.
Pagaria gave the example of the healthcare platform Practo, saying that when Practo onboards doctors it has to ask them for their professional credentials, leaving room for fudging of documents. “What we are building in ABDM is these digital public goods [HPR and HFR] which are for use for the entire country. So any private company which wants to use our identification services for doctors or for a health facility, we have our APIs which are open and any company can utilize those,” he said adding that this will make it easier to identify who’s a real doctor and who’s a quack.
Tackling issues of data security:
“Our mission’s [ABDM’s] main feature is its federal data architecture. Federal data architecture means that [if] I go to Apollo Hospital, my report is with Apollo Hospital. It is not with the government,” Pagaria said, talking about the data safety measures present in the ABDM system. He further explained that under the ABDM system if a hospital asks a patient for their lab reports and the patient says yes, the report would travel from the lab straight to the hospital’s records. “So the government is not storing any record. It is just facilitating the exchange. And this exchange also happens only when consent is given,” he added.
“We also have a health data management policy which we follow. We are increasingly in touch with the Ministry of Electronics and Information Technology so that the recent personal data protection bill if it gets passed, it would be very convenient and it would be very beneficial for the entire health ecosystem as it would give clear-cut directions on data privacy,” he mentioned.
It is worth considering that earlier this year, the data of the NHA-run COVID-19 vaccination portal, CoWIN, was reported to have been breached. This breach highlighted that there are holes in the digital healthcare infrastructure which need to be addressed. But this remained missing from the topics brought up at the summit.
Plans for the ABHA dataset:
When asked what NHA is doing with the ABHA data, Pagaria replied, “As of now, we have not gone ahead and done anything about data.” Further, he added that they have planned to provide hospitals with data aggregation and anonymization tools. “ So for example, Apollo Hospital, we will give an anonymizer. At the end of the day, they would send us the details of the number of, say, persons who came through Apollo hospitals, their age groups, the diseases that they report. So if that data comes, then we will aggregate it all and show it on the [Indian] map,” he explained.
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