Task-shifting, Technology, and Training (3T) in Healthcare
Year 1: To identify the institutional voids in the health system that would inform key outputs of this project in its first year, the team undertook an extensive reconnaissance exercise of current initiatives in India, including site visits to Telangana, Karnataka, rural (tribal) and urban Maharashtra, Uttar Pradesh, and Delhi.
The team introduced a digital epidemiological surveillance tool at the Malvani Urban Health Center in collaboration with KEM Hospital and Seth G.S. Medical College, Mumbai, to begin mapping the diurnal and seasonal variations in presentations to the clinic. Based on these data, the project identified the top 10 diseases for which to develop clinical protocols and began developing protocols for these diseases. The team also mapped workflow and data flow at Malvani and an additional health center in Mugalur in collaboration with St. John’s Research Institute, Bengaluru, to begin the design of an “EHR-lite,” a plug-and-play digital health ecosystem. In collaboration with SJRI’s scientists, the project also finalized a partnership with the Government of India’s Non-Communicable Disease (NCD) Program to establish a Center of Excellence in Digital Health Innovation, at two PHCs and ten sub-centers in T. Narsipur, close to Bengaluru.
In February 2018, the project responded to the call for public review of the White Paper on Data Protection released by the Government of India’s Srikrishna Committee through a Lens on Health Data. In July 2018, the team was invited to present their work jointly to the Government of India’s NITI Aayog, the Ministry of Health and Family Welfare, and iSPIRT, to present the paper “Reimagining Health Data Exchange: An API-enabled Roadmap for India.” The project team was also invited to a Working Group constituted by Aayushman Bharat to implement the proposed architecture.
Year 2: In its second year, the team proceeded with the development and implementation of an API-enabled PHC health platform to track epidemiology, demography, and practice patterns. This prototype for an EHR-lite was designed in collaboration with SJRI and implemented at the Mugalur site with the goal of presenting an early prototype at a conference of key stakeholders (chemists, labs, other hospitals) in Bengaluru. After the pilot stage of implementation at Mugalur, the project set out to improve the usability of the tool and test the interoperability of the EHR-lite system at the PHC level with community-based tools through a Federated Personal Health Record architecture. The team also started a preliminary analysis of backend usability data at the Mugalur clinic and conducted focus group discussions with health workers and community to optimize the UI/UX of the EHR system and identify potential issues prior to integration with the larger set of tools available at the PHC.
In April 2019, the project brought together over 40 stakeholders from across the public and private sector in India to present the early prototype of its work at the “Powering the PHR” conference, and learn from the several initiatives across the country that are building components of what may ultimately become India’s health-tech grid. Key outputs from the workshop included a roadmap for collaborative work between invited entities to accelerate current technical and regulatory efforts by fostering synergies between implementing agencies, scientists, and regulators. The project was able to map a) technical preparedness and needs, b) regulatory needs to support such exchange and access, and c) financial needs.
Following the conference, in May 2019 the team began conceptualizing a large-scale study to expand on the EHR-lite work at Mugalur, with the aim to understand provider perspectives toward digital health technology through a nationwide, 10,000-person survey. In October 2019, the team received ethical approval through the Institutional Ethics Committee at SJRI.
In collaboration with the Government of India’s NCD Screening and Management program, the project also began the migration of the prototype for a Center for Digital Health Innovation as planned in Year 1, and designed a three-arm Quasi-experimental study in Karnataka to facilitate an evidence-based, stepped-wedge rollout of digital health tools for Comprehensive Primary Health Care across the state. In October 2019, the project received provisional approval of its study through relevant Institutional Ethics Committees and prepared for collaboration with key stakeholders to begin implementation across PHCs in the State in 2019-2020.
In July 2019, the Government of India released a blueprint for a nationwide integrated e-Health system under National Digital Health Blueprint; if executed thoughtfully, the NDHB has the potential to improve medical practice by making it more transparent and accountable, to strengthen the care delivery by making it more responsive, to accelerate medical research by providing contextually rich and valid data, and to enrich the healthcare experience for over a billion people. In response to this blueprint, the project team at Harvard and SJRI, supported by the Tata Trusts, were provided with the opportunity by the Ministry of Health and Family Welfare and the Satyanarayana Committee to review the NDHB. 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—the most substantive response that the GoI received from any group in India.
In addition to the above publications targeted at Government stakeholders, the project closed out Year 2 by summarizing the work over the last two years through a series of three technical papers targeted at academic journals highlighting the proposed data architecture, a third policy paper surveying the policy guidelines or big data health exchange in India, and an academic blog article, “Will AI help universalize health care?”
Year 3: The final year of the Tata Trust 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.
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 Years 1 and 2. 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 health workers. 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).
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.
In July 2020, the government finally allowed hospitals to monitor COVID-19 asymptomatic and mild symptomatic patients from home. This allowed the team 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 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 our 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.