An Approach Towards Health Systems Design in India, Information technology for Primary Healthcare in India, Johns Hopkins University, March 2020, 13 citations - [Streveler and Gupta, 2019] - Health Systems for New India - Niti Aayog Book published in Nov 2019, eObjects - eClaims, eDischarge, ePrescription, eEncounter, eReferral,

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Information Technology for Primary Healthcare in India
Preprint · March 2020
DOI: 10.13140/RG.2.2.25513.13925
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2. Information Technology for Primary Healthcare in India
Nachiket Mor
March 7, 2020
Abstract
Comprehensive primary care is an essential part of all high-performing health systems. Only way
developing countries like India, will be able to provide such services within their available-resources
envelope is by fully harnessing the power of technology. However, to be truly effective, these solutions
will need to have several key components which help providers with serving their patients directly,
managing internal operations, and handling referrals.
1 Introduction
There is good evidence that health systems that effectively address sources of ill-health, and identify and
treat diseases early in their life-cycles, deliver far better health outcomes (Starfield, Shi, and Macinko, 2005;
Levine, Landon, and Linder, 2019) for the same level of expenditure, than do others which leave people to
their own devices until they are really sick, and then use hospital based approaches to address the problem
(Mor, 2019). Countries such as the United Kingdom (Cylus et al., 2015) and France (Dumontet, Buchmueller,
Dourgnon, Jusot, and Wittwer, 2017) in the developed world, and Thailand (Tangcharoensathien, 2015),
and Costa Rica (Pesec, Ratcliffe, and Bitton, 2017) in the developing world, have built highly-effective health
systems using identify-early-address-early approaches. Delivery of such services can take place in multiple
settings, ranging from the out-patient-departments of large hospitals located in cities, to the very homes of
families living in remote rural locations1
. Settings in which critical components of primary care are provided
also include pharmacies2
and diagnostic labs.
Despite its desirability, provision of good primary care is both expensive (the UK National Health Service
spends 51% of its total annual health expenditure on non-hospital-based services, ONS, 2019) and complex,
even more so in a large country like India. Primary care has some key components. These include, among
others, careful and early enrollment / empanelment of a defined population3
, risk stratification of this
population and a proactive outreach to the high-risk patients so that their wellness can be ensured4
, landscape
epidemiology so that the environmental sources of a lack of wellness can be identified (Davenhall, 2012),
1There is evidence though from Japan (Aoki, Yamamoto, and Fukuhara, 2020) and USA (Mafi, Wee, Davis, and Landon,
2017) that primary care that is provided in hospital-based settings tends to be lower-value than community-based care even
when the hospital is the owner of both sets of practices.
2Pharmacies, in developing countries like India, are currently perhaps the principal providers of all forms of primary care
and have a deep presence both in urban and in rural areas (Sabde et al., 2011). However, in the longer run, even as the
availability of comprehensive primary care improves, they could have a strong role to play, particularly in the management of
chronic diseases (FIP, 2019).
3The Costa Rican model emphasises that “geographic empanellment to a specified care team encourages the formation of
relationships that continue over time” (Pesec, Ratcliffe, et al., 2017). The Joint Learning Network has recently published a
report titled “Empanelment: A Foundational Component of Primary Health Care” (Anaman et al., 2019).
4Julian Tudor Hart, a Welsh General Practitioner, through a “contemporary screening for and audits of care of chronic
disease and risk factors; retrospective review of computerised practice records; and comparisons of mortality and social indices
with neighbouring communities”, was able to sharply reduce mortality in his practice relative to other neighbouring practices
over a period from 1964 to 1987 (Hart et al., 1991). Iora (Iora, 2020), a US-based primary care provider, every morning has
a “huddle, when the entire care team invests an hour discussing the health status of the clinic’s population [and] prioritizes
those who require the most attention and directs care around their needs” guided by a “worry score methodology, which
rates each patient on a 1-to-4 scale according to their health status and needs. Patients scoring a 4 require a specific action,
such as immediate outreach from a health coach. If the patient’s outlook turns for the better, their worry score is lowered, a
development celebrated by the team” (Christensen, Waldeck, and Fogg, 2017).
1

3. and care coordination (Simon et al., 2017). It is not necessary that in each primary care setting all of
these components will be deployed together but, from a planning perspective, if it is assumed that each
comprehensive primary health care clinic has the capacity to serve about 5,000 patients5
then the need will
be for about 250,000 fully-staffed clinics serving 1.25 billion people. If there is additional assumption that
a population of 50,000 will need the support of a pharmacy, then there will, in addition, be a need for
close to 25,000 pharmacies which will also need to be connected6
. Similarly for diagnostics facilities, if the
assumption is that one fully-equipped diagnostic facility will be needed per 100,000 population, there will
be a need for 12,500 of them across the country.
The information technology platform will have to enable all this, so that primary care facilities can
effectively serve their patients, communicate with each other where necessary (such as a primary care clinic
and a diagnosis lab), and handle all of the referral services for their patients for higher levels of care. India
has a number of challenges in a number of others areas but has particular strengths in the field of information-
technology that it needs to benefit from. The eventual goal would be to find a way to enable and empower a
dedicated and sharply expanded group of providers, who can harness the power of this capacity. There is no
other way for India, to fit-in what needs to be done with the resources that it has available, and to work with
the very high level of fragmentation that exists in India at all levels, but particularly at the primary care
level (which, if integrated well with the larger systems using information technology, from a service-quality
and responsiveness perspective, may be more desirable than large monolithic bureaucratic structures).
As India builds out these systems it would be important to learn from the experiences of other countries
that have undertaken similar journeys7
. For example in the United States, a very large $19 billion investment
into health information technology and the passage of the associated HITECH (Health Information Technol-
ogy for Economic and Clinical Health) Act in 2009 (AMA, 2011), has ensured that EHRs “now exist in some
form in most professional practices and hospitals eligible for HITECH incentive payments, more information
is being shared electronically, and the focus of attention has shifted from adoption of EHRs toward more
fundamental issues associated with using health information technology (health IT) to improve health care
delivery and outcomes” but “it has proven challenging to move meaningful use beyond the initial low bar set
by Meaningful Use Stage 1 [and] many barriers to interoperability persist” (Gold and McLaughlin, 2016). It
has also, “unfortunately facilitated the process of just two EHR vendors capturing virtually the entire market
[leading to] vendor lock-in, soaring costs, made it incredibly difficult for new private or public organizations
to enter the market at a meaningful scale, and as a result massively stifled innovation, [and] the fact that
virtually the entire exoskeleton in the US is built on proprietary technologies makes it very hard for the
government or coalitions of philanthropists to exert positive influence”8
. In an important piece, published
soon after the HITECH Act was signed, Mandl and Kohane, 2009 had argued that for the full benefits of
the Act to be realised it would need to facilitate the creation of a “flexible information infrastructure that
facilitates innovation in wellness, health care, and public health” with, for example, system components that
are “not only interoperable but also substitutable”9
.
5The number of 5,000 individuals has been somewhat arbitrarily arrived at. It is broadly consistent with the capacity of
such a clinic to handle about 10,000 consultations in a year, given the range of services it seeks to offer. Brazil’s Family Health
Program teams deliver most services at a community health clinic. The teams contain one physician, one nurse, one medical
assistant, and four to six community health agents who—with other health professionals as needed—perform regular home visits
and conduct neighbourhood health promotion activities. Each team provides care for a geographic region, with each serving
a population of approximately 3,500 (Macinko et al., 2010). In Costa Rica a similar sized team serves a population of 4,500
individuals (Pesec, Ratcliffe, et al., 2017).
6The actual supply of existing pharmacies in India is likely to be much higher. In Ujjain District, by no means one of the
most prosperous districts of India, a detailed survey of pharmacies carried out between June and October 2009 found that there
were 28 pharmacies per 100,000 population, with 58.39 per 100,000 in urban areas, and 8.40 per 100,000 in rural areas (Sabde
et al., 2011), well above the average of two pharmacies per 100,000 population assumed here. If all the clinics are assumed to
also distribute medicines then the effective number, along with the 2 per 100,000 assumed for stand-alone pharmacies, is 22 per
100,000 – much closer to the actual number observed in Ujjain.
7The author would like thank Shreya Bhatt for guidance on the very important set of insights discussed in this paragraph.
8Shreya Bhatt on email (January 29, 2020).
9 In the Indian context, instead of seeking to shape the entire health system, given the strong desire of the government to
own-and-operate its own health systems and to build-and-operate its own tax-financed purchasing schemes such as the PMJAY
(NHA, 2019) despite a very low allocation of resources for them (about 1% of GDP for the government-owned-providers and
0.1% of GDP for the tax-financed-purchasing-schemes (NHSRC, 2018)), an added risk-factor would be if the entire architecture
is designed, built, and executed with only these providers and schemes as their exclusive users, and the much larger space
of formal non-profit and for-profit healthcare providers, pharmacies, diagnostic labs, community health workers, and insurers,
excluded from its purview, the design could become non-inclusive, excessively rigid around current designs of those structures
2

4. 2 The Exoskeleton
In order for any primary care information technology platform to be effective, it would need many health
systems level enablers which can collectively be referred to as the “exoskeleton” of the health system to
which all the other disparate components are attached. (Streveler and Gupta, 2019). Such an “exoskeleton”,
governed or provided by the government or by a neutral body, can ensure the “maximum efficiency as well
as interoperability of the collection, management, and availability of health information in the country”
(Streveler and Gupta, 2019). Some of the key elements of such an “exoskeleton” would include the following.
1. Health Data Dictionary: This “includes a Unique Patient Identifier, a universal coding syntax,
and semantics of each medical reference used. It also contains formats for eClaims and eDischarge
summaries. It also validates standards of all those who have access to the system. It [needs to]
periodically be updated to reflect changes in medical practice and also disseminate the information”
(Streveler and Gupta, 2019). There is an argument to be made that such systems can perhaps be
built “without creating these standards” but, while “interface engines can help in ‘translation’ and
mapping from one language to another but, just as in natural language translation, these translations
are often imprecise [and] in some instances, there is no good translation possible or perhaps there
are multiple translations possible (one-to-many mapping) which only adds its own ambiguity to the
result.” (Streveler and Gupta, 2019). It is important to note that “while a data dictionary can be used
to define the content or meaning of a piece of information, health data exchange standards define how
information should be formatted and bundled into objects/resources in order to be processed by other
systems. For example, the FHIR (Fast Healthcare Interoperability Resources) standard (HL7, 2019)
defines the content and structure of a Task (which can be used to order labs or meds), including who
ordered it, who should carry it out, who it’s for, and the number of ‘states’ it might have from initial
order to ‘in progress’ to successful completion or abandonment. This complements the data dictionary
which will have codes to label the ‘patient’ field and the ‘provider’ fields and other data items, within
the Task object/resource, so that they’re semantically understandable to other systems”10
.
2. Master Registries: Such Registries (such as a Provider Registry and a Patient Identifier Registry)
are needed to “make certain there is ONE authoritative and up-to-date UNIQUE reference which all
applications can utilize when referring to patients, providers, facilities, and geographical locations –
they are created once and updated periodically to reflect the prevalent conditions and reality” (Streveler
and Gupta, 2019).
3. Service Code Registries: These Registries are needed for “listing diagnoses codes, medical service
codes, package codes, drug codes and medical supply codes” (Streveler and Gupta, 2019).
4. A Protocol Server: In healthcare, waste, inefficiency, and low-quality springs not only from poor
communication between entities but an absence of agreement and uncertainty on how a particular con-
dition needs to be treated and what procedures, medicines, and equipment needs to be used (Gawande,
2012; Main et al., 2011). In order to address this concern a number of health systems around the world
have developed detailed evidence-based guidelines, protocols, and essential drug lists (WHO, 2019) to
provide guidance and protection to both patients and providers. To be effective however, these now
have to be moved from standalone reference documents (such as ICMR’s excellent Standard Treatment
Workflows, ICMR, 2019) into an automated server which maintains the most updated protocols and
lists (such as drug lists) which multiple systems can access as needed (on a real-time basis), to provide
the best possible care to their patients.
Several components of the “exoskeleton” are not in existence right now, and those that do exist are
not accessible to the larger universe of providers and patients. However, government organizations like the
and schemes (as it has in the United States), and much of the benefits of this new approach will not be seen by the Indian
consumers of healthcare. An alternate approach may be to seek to build it as a Private Entity with Public Purpose in same
way as entities like National Securities Depository Limited (NSDL) and National Payments Corporation of India (NPCI) were
built. A Technology Advisory Group for Unique Projects (TAGUP) of the Ministry of Finance, chaired by Nandan Nilekani,
had examined the whole question of how such National Information Utilities (NIUs) may be established in some detail, and its
recommendations may well be worth revisiting for their applicability to the current context (Nilekani et al., 2011).
10Shreya Bhatt on email (January 29, 2020).
3

5. National Health Authority (NHA, 2019) and the Indian Council of Medical Research (ICMR, 2019) are
gradually building them up, piece by piece, and could eventually be persuaded to open them for use by a
broader group. In the meanwhile any primary care systems that are built will have to be structured in such
a way that when these components do become more accessible, the primary care efforts can link up to them
smoothly11
.
3 Key Capabilities of a Primary Care Information System
Many Primary care software systems already exist and provide a variety of useful services to their current
clients. Even in the long run it is entirely possible that this field will have multiple solutions on offer, each
designed to service a particular segment of providers and patients. However, in order to be effective, each
of these systems will not only have to have the ability to connect-up to the “exoskeleton” but to also have
some critical capabilities. Some of these are listed below.
1. Hospital Information System (HIS): In any modern health facility, including a primary care fa-
cility, a HIS is essential and serves many purposes. These include aiding “in effectively managing the
facility clinically, administratively and financially”, promoting “seamless communication with other
institutions for eReferrals as well as the sharing of diagnostic results and patient history for those us-
ing services at multiple facilities, thus helping to assure continuity-of-care”, calculating and presenting
“‘dashboards’ for the management to optimize service and fashion incentives based on productivity
and quality measures”, communicating “with health payers to transmit eClaims and receive eProvider
Payments”, assembling and collating “outputs which will ultimately form the basis of the Electronic
Health Record [EHR] and Personal Health Record [PHR]”, which “includes eDischarge Summary ob-
jects, diagnostic results, and clinical reports”, gathering “statistics for the appropriate authorities to
allow calculation of burden of disease, provide epidemiological data, monitor for incipient epidemics
and compare outcomes across facilities”, “providing epidemiological, utilization and quality data for
analysis and action”., and creating “claims (eClaims) to be sent to the appropriate health payer from
information generated by the HIS which is sufficient for assuring that adequate and fair payments are
made in consideration of the services rendered” (Streveler and Gupta, 2019).
2. Digital Health Records: Digital records comprising Electronic Health Records (EHRs) to be used
by clinicians and Patient Health Records (PHRs) to be used by patients, are “largely a collection
of information which is collected from other digital sources – digital diagnostic results, physician
orders from placed using the Hospital Information System, digital outputs from those same systems
(discharge summaries, A&E reports, L&D reports, OR reports, anaesthesia records, progress notes
and on and on)” (Streveler and Gupta, 2019). The two main flows of information for these are
“from the provider-side Hospital Information Systems (HIS) and from the payer-side Health Insurance
Information System(s) (HIIS) from the payers” (Streveler and Gupta, 2019). “Changing to digital
records however raises important issues of security, privacy, and confidentiality of personal patient
information” (Streveler and Gupta, 2019) which are crucial to continually address. “It seems most
sensible to leave the information where it is now (at the facility, at the payer) and use a ‘Google-like’
directory of links (URLs) to access the information across a Health Intranet. The ultimate ‘chaperone’
then for the personal data is the facility where it originated. This lack of a single ‘big brother’ might
mitigate some of society’s concern about patient confidentiality” (Streveler and Gupta, 2019).
3. Objects: Five Objects of particular interest to digital health (drawn from Streveler and Gupta, 2019):
(a) An eClaim object contains information about a request for reimbursement (“provider payment”)
for either of inpatient stay or an outpatient encounter from the provider rendering the services to
an appropriate payer who covers this beneficiary.
11The Ministry of Health and Family Welfare, after some years of work, and a detailed public consultation, has recently
released a National Digital Health Blueprint (NDHP) which contains most of the components of the Exoskeleton and has, in
addition, proposed the creation of a government-owned implementing body, the National Digital Health Mission (NDHM) with
responsibility for overseeing the implementation of the NDHP (Jalan, 2019). However, see footnote 9 for a note of caution
associated with government-ownership of NDHM.
4

6. (b) An eDischarge Summary contains summary information about each inpatient hospital stay.
(c) An eProvider Payment contains information about the transmittal of funds from payer to provider
in satisfaction of an eClaim accompanied by a justification about how the settlement was calcu-
lated
(d) An eEncounter Form contains summary information about each clinic visit and each hospital
outpatient visit
(e) An eReferral contains information about either a request for services to a higher level of care (an
upward referral) OR the return of a patient to a lower level of care (a downward referral) for
followup and continuing monitoring and care
4. Artificial Intelligence: In order to provide comprehensive primary care to close to 5,000 patients,
using a very large number of approved protocols, covering a wide-range of conditions (Mor, 2020), will
need good “Rule-Based AI” (Artificial Intelligence) to guide providers, and “Deep-Learning-Based AI”
for image and other data processing from diagnostic devices available at the primary care center which
can then provide accurate inputs to the “Rule-Based AI” (Davenport and Kalakota, 2019). In addition
“NLP-Based AI Chatbots” will be useful in primary care settings for “for patient interaction, mental
health and wellness, and telehealth” (Davenport and Kalakota, 2019). These AI capabilities will need
to be well integrated with the core information technology platforms for effective primary care12
.
5. User Interface: While, in the long run, as has happened in service industries such as banking,
restaurants, and airlines, healthcare providers will eventually become “native” users of computer and
smart-phone technologies, this is not currently the case and their refusal to engage with these technolo-
gies from their positions of relative power is an important impediment to the wide-spread adoption of
these technologies with direct implications for costs and coverage of care being provided to patients.
In order to overcome this key barrier, a great deal of effort will need to be expended in ensuring that
the user-interfaces are seamless and challenges such as problems of connectivity and back-up even in
remote and field settings have been satisfactorily addressed. Also given the proliferation of the means
through patients and providers seek to interact with each other, any primary care software program
will have to allow for that.
4 Lessons from Other Primary Care Systems
It is possible that none of the systems currently on offer have all the components that are needed but several
have components that are important to study and learn from. Some of these examples are listed below.
1. Integrated Design: Iora Health (Iora, 2020), a dedicated primary health care delivery company,
whose approach comes closest to the ideal in terms of provision of comprehensive primary care, early
in the development of their model concluded that “commercially available Electronic Health Records
were not only unhelpful, but greatly hindered our ability to deliver optimal care” since the “software
focused primarily on the coding and billing of individual visits” and not on “features core to our model
including dynamic scheduling, issue based documentation with multiple contributors, task delegation,
proactive clinical decision support, and real time data to support population management” (Schutzbank
and Fernandopulle, 2014). They therefore decided to create their own technology platform and in the
process learnt the value of four key lessons, along the way “the [need for] tight relationship between
delivery innovation and software development, the benefits of Agile development, the value of having
the clinicians at all levels as part of the software development team, and different ways to think about
clinical information” (Schutzbank and Fernandopulle, 2014).
12 In the health technology applications market there are many unsupported claims made that will need to be carefully sifted
through in order to identify the truly valuable innovations. A recent study of publications of impact evaluations by “twenty
top-funded private US-based digital health companies” found that in their studies “healthy volunteers were most commonly
studied [and] few studies enrolled high-burden populations, and few measured their impact in terms of outcomes, cost, or access
to care” (Safavi, Mathews, Bates, Dorsey, and Cohen, 2019). There is however emerging evidence of the positive impact of
these tools using Randomised Control Trials in settings such as mental health and suicide prevention (Torok et al., 2020).
5

7. 2. User Interface & Landscape Epidemiology: IKP-TechPrima (ICTPH, 2016), the Primary Care
technology platform of the IKP Centre for Technologies in Public Health, a Chennai based non-profit,
as in the case of Iora, driven by poor experiences with off-the-shelf EHR systems, was built from
scratch. Among other things, in order to address physician resistance to the use of software, it built
its data-entry capabilities with a “clinical focus and user-friendly options such as selection of pre-filled
symptoms and diagnoses (instead of free-text entry by typing) which reduced errors, minimized data
entry time and also helped in automated analysis” (ICTPH, 2016). It also has other features such as
“family enrolment for all households in the catchment with geo-tagging for effective disease profiling
and surveillance” (ICTPH, 2016).
3. Operating in Remote Areas: Primary Care Providers who operate in remote areas (sometimes
even those who serve in not very remote areas) using a combination of field level workers (Mor, Bang,
Chaudhuri, Mohan, and Ravikanth, 2020) and fixed-clinics, face a number of challenges, including
information-technology related ones such as, for example, that of intermittent connectivity. The Com-
munity Health Impact Coalition (CHIC), working with a number of partners seeks to “catalyze the
adoption of high-impact community health systems” by addressing many of these challenges (CHIC,
2020). Medic Mobile (Medic Mobile, 2020), a core member of the CHIC, “serves as the technical
steward for the Community Health Toolkit (CHT), a global public good, and has built the CHT’s
Core Framework, which, for example, powers offline-first apps that run locally on the mobile phone or
the computer, and automatically synchronise in the background whenever connectivity becomes, even
briefly, available”13
.
4. Artificial Intelligence (AI) and Machine Learning (ML):
(a) AI for Patient Interaction: One of the best examples of this comes from Babylon Health
(Babylon, 2020a), a UK registered company with operations in Rwanda (Babylon, 2018) and
UK (Babylon, 2020b). In order to serve their patients more effectively they have developed a
powerful AI engine which understands and recognizes “the unique way that humans express their
symptoms [and] using this knowledge, combined with a patient’s medical history and current
symptoms, it provides information [to the doctor] on possible medical conditions and common
treatments” (“Babylon NHS AI Portal Demo”, 2019).
(b) AI for Mental Health & Wellness: In this context the work of two behavioral applications
from India, Wysa (www.wysa.io) and Healthifyme (www.healthifyme.com) look promising. Both
the applications use AI (Artificial Intelligence) tools, combined with fixed-rules drawn from aca-
demic literature, to power their applications. Wysa is a “AI-enabled, empathetic, text-based
conversational mobile mental well-being app” that showed statistically significant improvement in
self-reported mood amongst “high users” when compared with “low users”, albeit with a modest
effect size (Inkster, Sarda, and Subramanian, 2018). Healthifyme is focused on obesity reduction
using similar approaches and, while a direct evaluation of its impact is not available, that of a
directly comparable application, Noom (www.noom.com), finds that “77.9% of study participants
reported a decrease in body weight while they were using the app” with “22.7% of all app users
experiencing > 10% weight reduction compared with baseline”14
(Chin et al., 2016).
(c) AI & ML for Image Analysis: A very good example of the power of these technologies
is provided by Niramai, a Bengaluru based company, which has developed a “computer aided
diagnostic engine [for breast cancer screening] that is powered by Artificial Intelligence [which]
uses a high resolution thermal sensing device and a cloud hosted analytics solution for analysing
the thermal images” (NIRAMAI, 2017).
5 Conclusion
This document provides an outline of what a primary care technology solution for India will need to look
like if it is to support the delivery of comprehensive primary care nationwide. There are many providers
13Shreya Bhatt on email (January 29, 2020)
14Also see footnote 12.
6

8. who are making an effort to build such solutions out they are underfunded and need support to go the full
distance.
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