Task-shifting, Technology, and Training (3T) in Healthcare
When it comes to health information in India, the majority of recorded data are stored and transferred on paper, causing significant overlap and making the validity of such data questionable, while also presenting a substantial challenge toward a seamless and effective exchange of health information. The 3T project is building scientifically proven clinical pathways that are aimed at optimizing digital tech and achieve the ideal combination of task-shifting, technology, and training in the Indian setting.
Informing National Policy:
While the original 3T project set out to develop the “model” prototype for a primary care center, the launch of HWCs, and Ayushman Bharat’s invitation to the team to join a Working Group, and the collaboration with Social Alpha positions the project uniquely to scale its ideas at a national level. The project built rich partnerships with the public and private sector at the state level as well, allowing to leave behind a team that will maintain and continue to develop the prototypes to ensure sustainability. It has helped shape national policy debate in this space, through the following tangible and highly influential outputs:
- The conference “Powering the PHR,” organized in New Delhi in 2019, brought together over 40 participants across the public and private sector (representatives from The Rockefeller Foundation, ACCESS Health India, Social Alpha, state governments of Rajasthan and Gujarat, NITI Aayog, National Health Authority, among others).
- In 2019, the team worked with domain experts from medicine, law, digital health technology, health administration, public health, non-governmental organizations, and industry to publish a Response to the Invitation for Public Comment to the National Digital Health Blueprint (NDHB) – the most substantive response that the GoI received from any group in India. The team, in its response, had emphasized the creation of regulatory sandboxes in health as a controlled testing environment within which existing regulations may be temporarily relaxed to allow experimentation. In January 2020, the team received approval from the Government of Karnataka to develop these sandboxes as “Digital Health Innovation (DHI) Hubs” across two districts in the state. Subsequently, in August 2020, the Prime Minister announced the National Digital Health Mission (NDHM), and the National Health Authority (NHA) launched the NDHM Sandbox, allowing integration and validation of third-party software by partnering with NDHM APIs.
- In Bengaluru, in collaboration with the SJRI, the project completed the feasibility analysis of using open-source EHR platform in small to medium size health care enterprises.
- On July 15, 2020, the team from Harvard and SJRI was invited to an online stakeholder discussion chaired by National Health Authority, aimed at providing the basis for the development of technological modules for the National Digital Health Mission. Team members drew from best practices in their work implementing digital data collection platforms for community health and contributed to the discussion outputs.
The final year of the Tata Trusts supported project was to see the development of prototype Digital Health Innovation Hubs. The pandemic-related lockdowns and suspension in India required that the team take its learning and pivot to meet the pressing challenges posed by the pandemic.
Success with Bahmni (open source EHR developed by ThoughtWorks)
- Based on the implementation instance at Community Health & Training Center (CHTC) Mugalur, recommendations were provided to the St. John’s Hospital Management to use Bahmni EHR to digitize records at newly started St. John’s Health Center at Kanakapura. Bahmni was implemented & customized in the Kanakapura health center from March to September 2020, applying implementation lessons from the past years.
- To sustain training and onboarding at the CHC, the permanent community health workers were successfully empowered to train the rotating residents and interns that transiently passed through the health center for a brief period of weeks and months. Training has now completely been transitioned over to the healthworkers.
- External organizations visited the site to observe and learn from the Bahmni implementation, and included the CF-SHORE Hospital Rajnandgaon Chattisgarh, a rehabilitation center; and The Association of People with Disability (APD).
- In July 2020, the 3T team provided technical guidance for incorporation of the telemedicine options into the Bahmni EHR, which are now available at all institutions using Bahmni, since September 2020.
- In early 2021, the project provided technical assistance to ThoughtWorks to incorporate Vaccine Record Management in the latest release of Bahmni update.
- Recognizing the need for community-based vulnerability mapping, during the pandemic, the 3T team provided technical guidance from May 2020- Jan 21 for a household based survey targeting 20,000 persons across 7000 households in 35 villages. In addition to creating a baselined record health conditions in the community, the survey allowed ascertainment of the prevalence of disability in the locality, to design and provide rehabilitation services.
3T Application for COVID Home-Monitoring Solutions at SJRI
- In July 2020, the government finally allowed hospitals to monitor COVID-19 asymptomatic and mild symptomatic patients from home. This allowed to combine the principles of Technology (telemedicine), Task-shifting, and Training to provide COVID-19 home-monitoring services at St. John’s Research Institute. Patients were triaged by Family Medicine physicians and if eligible, were monitored daily by nurses via a video calls; supervision was provided by physicians. If patients were admitted, they continued to be assisted by the monitoring team to ensure continuity of care, and liaison with specialists including endocrinologists, nutritionists, and physiotherapists. 60 patients were enrolled in the service from Sept 2020 to Jan 2021, until the second surge. The services are now institutionalized since April 2021 and more patients are being served currently through this second surge. This telemedicine solution is now institutionalized as the main platform for tele-consultations at St. John’s Medical College Hospital from March 2021 and is used by clinicians from more than 10 specialties.
- The project team also worked with Ubiqare Pvt Ltd, a third-party solution incubated by Social Alpha, to develop rapid iteration and feedback cycles prior to integration into its home-monitoring solution, with the goal of improving UX and care quality. The solution is still being used in daily monitoring of COVID patients registered with the hospital.