REVIEW ARTICLE ROLE OF INFORMATION TECHNOLOGY IN HEALTH CARE SYSTEM IN INDIA ABSTRACT

BACKGROUND & OBJECTIVE: - Information technology (IT) has the potential to improve the quality, safety, and efficiency of health care. Diffusion of IT in health care is generally low (varying, however, with the application and setting) but surveys indicate that providers plan to increase their investments. Drivers of investment in IT include the promise of quality and efficiency gains. Barriers include the cost and complexity of IT implementation, which often necessitates significant work process and cultural changes. Certain characteristics of the health care market—including payment policies that reward volume rather than quality, and a fragmented delivery system— can also pose barriers to IT adoption. Given IT’s potential, both the private and public sectors have engaged in numerous efforts to promote its use within and across health care settings. Delivering quality health care requires providers and patients to integrate complex information from many different sources. Thus, increasing the ability of physicians, nurses, clinical technicians, and others to readily access and use the right information about their patients should improve care. The ability for patients to obtain information to better manage their condition and to communicate with the health system could also improve the efficiency and quality of care. This potential to improve care makes broader diffusion of IT desirable.

METHODOLOGY:- We are taking some example of application of IT in health care in different sector. The following technologies and terms are often included in discussions of information technology in health care: Electronic health record (EHR): EHRs were originally envisioned as an electronic file cabinet for patient data from various sources (eventually integrating text, voice, images, handwritten notes, etc.). Computerized provider order entry (CPOE): CPOE in its basic form is typically a medication ordering and fulfillment system. Clinical decision support system (CDSS): CDSS provides physicians and nurses with real-time diagnostic and treatment recommendations. Picture archiving and

communications system (PACS): This technology captures and integrates diagnostic and radiological images from various devices (e.g., x-ray, MRI, computed tomography scan), stores them, and disseminates them to a medical record, a clinical data repository, or other points of care. Bar coding: Bar coding in a health care environment is similar to bar-code scanning in other environments: An optical scanner is used to electronically capture information encoded on a product. Initially, it will be used for medication (for example, matching drugs to patients by using bar codes on both the medications and patients’ arm bracelets), but other applications may be pursued, such as medical devices, lab, and radiology.

CONCLUSION & DISCUSSION:- Information Technology (IT) is poised to revolutionize healthcare trade through new thresholds in human connectivity. This paper focuses on the expanding role of IT in three distinct but related categories: (a) design and development of healthcare products and services, (b) delivery systems, and, (c) healthcare administration. Through information power that IT enables, capacities of decision-makers are continually transformed in how they link with each other, in the here and now. This not only promotes conventional trade in services and e-commerce and facilitates worldwide convergence in several aspects of healthcare management and organization. However, this process also raises fears and anxieties because the pervasive nature of IT and its uneven diffusion increase some vulnerability where policy safeguards would be needed. The process of IT diffusion occurs at many different points of impact in the international economy. Thus, policy choices have to cater to a wide range of national and regional needs and circumstances concerning rights to health, rights to trade and rights to development. National policies and international regimes need to strike a harmonious balance between these sets of rights. The persistence of unresolved conflicts of rights and conflicts of interests point to the need for new international arrangements to be mandated and resourced. The extent to which this can be achieved is uncertain. This uncertainty is traceable to the ways responsibility for healthcare, authority to design healthcare products and systems, and the power to organize healthcare delivery remain separate or come together. The restructuring of private investments to integrate IT with life sciences in public-private partnerships is a sign of the

growing significance of IT in healthcare. It is also a reminder of how powerfully IT could be harnessed in pursuit of millennium development goals.

INTRODUCTION

Information technology (IT) has the potential to improve the quality, safety, and efficiency of health care. Diffusion of IT in health care is generally low (varying, however, with the application and setting) but surveys indicate that providers plan to increase their investments. Drivers of investment in IT include the promise of quality and efficiency gains. Barriers include the cost and complexity of IT implementation, which often necessitates significant work process and cultural changes. Certain characteristics of the health care market— including payment policies that reward volume rather than quality, and a fragmented delivery system— can also pose barriers to IT adoption. Given IT’s potential, both the private and public sectors have engaged in numerous efforts to promote its use within and across health care settings. Additional steps could include financial incentives (e.g., payment policy or loans) and expanded efforts to standardize records formats, nomenclature, and communication protocols to enhance interoperability. However, any policy to stimulate further investment must be carefully considered because of the possibility of unintended consequences. Healthcare is one of the most essential services in any society. Yet it is the most neglected one across the developing world. A recent report in the newspapers indicates India’s public expenditure on healthcare is a measly 1% of its GDP, making it one of the lowest ranked countries in the list. Even as this document limits the discussion to the still-evolving Indian healthcare industry, the issues raised here are no less relevant to other developing nations Any debate on the state of healthcare as an industry in India will most likely lead to its comparison to the healthcare infrastructure of the developed nations. While it is a foregone conclusion that a socialistic system like the National Health Service (NHS) that is prevalent in the UK and Canada, will never succeed in India. Much of India’s

healthcare actually resembles the US healthcare system in its formative stages. Of course the obvious conclusion of such a comparison is how much India lags behind the US. It took most of the later half of 20th century for Healthcare to evolve and mature in the developed world. While the US went from the “pay-for-your-services” or the “Indemnity” model through the “defined benefits concept” of the Managed Care era, and then to the now somewhat popular “defined contribution” models of Consumer Directed Health Plans, the Indian healthcare industry has stopped evolving beyond the “Indemnity” model. At MindTree we feel that what India must devise today is a model that builds on the developed nations’ healthcare models, while retaining a strong indigenous component to suit its unique needs. India, while adopting technology, processes or healthcare models should keep in mind a few key factors. Its huge and diverse population, limited resources and as the World Health Organization (WHO) puts it “commitment to health equity as part of development oriented to social justice”. The western models have been devised by the developed world for the developed world and will not work in the Indian context (especially the rural sector). The current trend to blindly mimic the US healthcare system, especially by the nascent TPA industry, can be potentially harmful to the still evolving Indian healthcare industry. A quick look at some facts and figures: > Size of Indian healthcare industry is estimated at Rs 1000 billion. Of this, pharmaceuticals account for Rs 200 billion (CII-McKinsey study) > On an average, Indian families spend Rs. 600 per month on healthcare which is 11% of the household income (WHO Report) > India's health expenditure is 5.2% of its GDP, whereas most established market economies spend 7-10 per cent of GDP on health. US on the other hand spends over 14 per cent. > Ratio of public to private health expenditure in India is 13% and 87% respectively. Health insurance is extremely marginal as indicated by "Out of Pocket" expenditure percentage of 84.6% - this means that the financial structure of the industry is still in the primitive stages. (WHO report)

Indian healthcare industry: Current Market and Potential

If you analyze the above statistics, the general population on an average is willing to spend as much as Rs. 600 per month per family. The statistics also underline the fact that nearly 85% of the time, this money is spent out of pocket. This shows that the average Indian is willing to spend on healthcare provided the service they get is of high standard. Now, considering that there are more than 140 million upper and middle class people in India, and that they have a far greater ability to spend on healthcare than the per capita national average of Rs. 600, the potential of health services sector is immense. Further, the middle and upper income class is growing at over 4% per annum with combined annual income of over Rs 8200 billion. These people have confidence in healthcare products and services offered by private hospitals and they are willing to pay for quality services. The rural sector poses a different challenge altogether. Any solution to this challenge will need sustainedparticipation from government-private-NGO consortiums. Now given all these, why is it that India lags behind the developed nations in this industry? Why is it that Indians do not have access to high-quality, cost-effective healthcare on-demand? Is it poverty? Is it education or political empowerment or is it simply wrong policies? The mutual reinforcement of poverty and ill-health is something we all understand. There is growing evidence of how asymmetrically resources, efforts and outcomes are distributed between the well-to-do and the poor, both in the urban and rural scenario. Benefit incidence studies consistently show that people living in poverty receive less than a proportional share of public funding for health, relative to the populace above the poverty line. At MindTree we believe that all the above factors lead to the continuation of this crippling problem. But the problem is not unsolvable. The solution exists if we look at how developed nations have handled this. Remember that they had the same issues that India is facing now, maybe 3 or 4 decades ago. It is just that they were enterprising and solved the problem, and India needs to start doing the same. Developed nations are strong in the three “enablers” in the healthcare industry when compared with India. The “enablers” are the Health Insurance Sector, Information Technology and Political Will. Firstly, they have a vibrant health insurance sector (especially the US), which makes risks spread to a much larger base and makes high-end services affordable to a large section of the population. Secondly, they have embraced information technology in a very effective

manner. Thirdly, they have the political will through which they demand accountability from their healthcare industry. Any resident Indian who has traveled abroad, got sick and seen a doctor there will vouch that the Indian doctor is as efficient and capable as his international counterpart (and a lot cheaper too). So the problem is not with the quality of Problems plaguing the Indian healthcare industry Indian healthcare industry – The way forward doctors. What the Indian doctor lacks is the policy, procedure & technology infrastructure around the delivery of care. That is why, at MindTree, we believe that this problem may not be as difficult to handle as we normally think it to be. Let us now take a deeper look into what India lacks in the three “enablers”.

METHODOLOGY & DISCUSSION: - Today, less than 10% of the Indian population is covered by some form of health insurance. However, this sector is rapidly growing. Industry experts predict that the health insurance market size will grow to Rs 130 billion by 2005. Given its sheer size, India is one of the most promising countries in the world for the development of its health insurance market. Some organization strongly feels that the robust insurance sector will provide the necessary financial foundation for the healthcare industry to thrive. Some organization foresees that health insurance industry is poised for serious growth in India. It is expected to be the main driver for raising quality consciousness and increased demand for better standards, hospital accreditation and sophisticated patient information systems. Some organization believes that Indian corporates will be a market segment for private insurance providers, developing the market for third party administration of insurance packages. It is expected that the major international health insurance players will establish networks of affiliated hospitals and may seek direct involvement in the development of new facilities, especially cost-effective diagnostic centers. Some organization has worked closely with major healthcare players in the US healthcare insurance industry. The essence of this experience is that the success of an insurance company is directly proportional to the amount of data it can capture during the healthcare delivery and particularly at the point-of-care that will drive the IT revolution in most hospitals across urban India. (This subject is covered in the remainder of this document) Some

organization also believes that although the healthcare insurance sector is very promising in the urban healthcare market, it will not play any significant role in developing the rural healthcare market. The government has come up with different rural healthcare schemes but we believe that this will not take off in the current shape and form; unless a level-playing field is established by the government so private insurance players find the rural market lucrative to enter. The penetration of Information technology in the Indian healthcare industry, if notnon-existent, is abysmally low. Some organization believes that investment in information technology is critical to any healthcare organization’s survival - it is true today and will be more so in the coming decades. Overwhelming evidence exists in developed nations that investments in information technology (IT) and business transformation (BT) have impressive payoffs throughout the healthcare system. Health insurance sector Information technology fact, technology investments and deployments are distinguishing factors between hospitals and health systems that are economic winners and those that are faltering. Hospitals and health systems that invest in IT (and BT) have better control of expenses, higher productivity, and more efficient utilization management. More importantly, they channel otherwise wasteful expenditure towards building healthcare infrastructure of the country either through privatepublic cooperation or through a government-NGO-private consortium. However, the Indian healthcare industry is plagued by the “ROI” syndrome when confronted with IT investment. In developed nations, any doctor’s practice no matter how small, has access to a PC and an Internet connection. They have to maintain detailed medical records and by law are required to archive them for a couple of decades. In India we have this strange problem around the way the general populace goes about getting healthcare. There is a general apathy towards one’s own health. Most Indians go to the doctor only when they have very bad symptoms and have to be hospitalized. Hardly a few would go in for regular checkups or preventive visits. This problem is especially acute in the rural areas. On the other hand, if the doctor plans to do something to improve the quality of life of their patients by providing preventive care awareness their efforts are often humbled by the system. Consider this scenario; a well-meaning doctor in a regular outpatient clinic invests in a PC, the associated software and support staff to maintain a patient’s medical record. A patient’s medical record is complete only if all morbidity

occurrences, medications & outcomes are recorded diligently and chronologically. In most situations, after the first visit, the patient may or may not come back to the same doctor, which in turn will create a gap in the patient’s medical record rendering it useless. The doctor on the other hand is stuck with his investment and does not realize any ROI either in terms of adding higher value to the patient care which will translate into better earnings or improving patient health, or the satisfaction of providing timely interventions which make the patient remain loyal to the doctor. Some organization believes that this ROI lose-lose predicament can be solved. In fact with a little bit of enterprise this can be quickly turned into a win-win situation, as we will understand in a while. Pharmaceutical companies vie for the doctor’s time to push their drugs. However, if one takes into account that half of the time Medical Reps (MR) will not actually speak with the doctor (due to the appointments being cancelled by the clinic or the doctor being too busy to see the MR etc.) and if they do, 90% of conversations are less than two minutes in length (with mental contact often being 10-15 seconds), it is clear that this very significant expenditure is not operating as effectively as one may have hoped. Also, the doctor expects to be remunerated for the time spent listening to the medical rep. To avoid this bottleneck, Pharmaceutical companies have introduced an increasingly popular way of doing this drug related marketing activity called eDetailing. eDetailing is emerging as an effective means for pharmaceutical companies to reduce their sales force expenses - without losing sales - and interact with the physicians by giving value additions. For the pharmaceutical company, eDetailing allows the MR to be more productive and make more effective sales calls each day (virtually and face-to-face) while building stronger and more trusting relationships with the physicians - by handing them control. This interactive exchange meets the physicians' needs in terms of content and time - and is a value-add to them. Some of the current eDetailing activities being initiated by some pharmaceutical companies utilize integrated video-conferencing capabilities, Internet access and high-speed telecommunication lines that allow physicians to interact with distant sales representatives at any time. Our ROI dilemma is solved when the Pharmaceutical organization leases this desktop/palm PC to the doctor. In return the Pharmaceutical organization recovers this investment by reduced face-to-face calls and can make the doctor feed valuable point-of-care related data back to the Pharmaceutical companies. Even better, if the patient agrees to take part in this marketing, (by way of participating in clinical trials or

drug-efficacy programs) they might be compensated with free samples or by getting a direct discount from the Pharmaceutical organization on their products. This same PC then can be utilized to capture patient records, connect to the insurance companies’ systems and transact with other healthcare delivery organizations. Once this model becomes popular, government/independent regulatory bodies like IRDA can bring in interoperability standards to capture and exchange healthcare data (like EDI, HL7 or ANSI for transactions and ICD or CPT for codification of diseases, diagnoses and procedures as in the US). This is a workable option for everyone. The Indian IT industry on its part needs to whole-heartedly participate in this by offering a special “Rupee” price list for the Indian healthcare industry to develop, maintain, reengineer or deploy new solutions. The Indian IT industry is perceived to be neglecting the domestic markets. This attitude must change fast in order to make a lasting difference for India’s future generations. Following the May 2004 Elections, India has a new government in place. The new United Progressive Alliance (UPA) government's Common Minimum Program (CMP) has placed greater focus on the two social sectors of education and health. The document mentions that the UPA government will rise public spending on health to at least 2-3% of the GDP over the next five years, with exclusive focus on primary healthcare. Foreign Direct Investment (FDI) in the insurance sector also has increased over the past few years. Many global players find the Indian healthcare market conducive to do business. The UPA government also states that a national scheme of health insurance for poor families will be introduced. The government will step up public investment. The new health minister has already mentioned that he wants government spending on healthcare to increase substantially, with special emphasis on improving facilities in rural areas. The budget announcements are positive for the sector.

Political will The announcements are expected to drive demand for healthcare services by providing better access to masses and encouraging private participation for setting up and expanding

existing facilities. Fiscal incentives on life saving medical equipment are expected to encourage the continuous upgrading of technology. More healthcare facilities will opt for quicker replacements of medical equipment and stateof-the-art technology. We welcome this trend and hope that the government will implement more policies to improve the face of healthcare in India. Emerging technology trends in the next decade Changing scenarios in the insurance industry, demands from corporate India, economics of administering and delivering healthcare and politics are creating a muchawaited change in the Indian healthcare industry. Another contributing factor is advancements in pharmaceutical/life sciences and information technology. MindTree predicts that among the above forces that will provide major impetus to the Indian healthcare revolution, IT will play a critical role in shaping the future of Indian healthcare industry. MindTree believes that vigorous introduction of Information technology in the healthcare continuum will ensure that both the urban and rural sectors of India have access to affordable, quality healthcare on-demand. We feel that the major applications & technological advancements that will shape the Indian healthcare industry in the coming decade. Computerization at point-of-care Absence of computerization at point-of-care (be it at an urban clinic/hospital or a rural primary health center) severely hampers the data capturing process necessary to determine medical efficacy, outcomes management, to prevent medical errors etc. MindTree believes that automation is paramount and can happen in one of two ways: 1) Insurance-driven approach: Insurance companies and corporate India will seek direct involvement in the development of new ambulatory facilities, costeffective diagnostic centers and Physician networks. These entities will band together and form Integrated Delivery Networks (IDNs). Standardized electronic transactions will facilitate efficient, cheap and real-time access to data throughout the IDN. MindTree foresees that this standardization will happen both voluntarily and through government legislation. All these will result in physicians/hospitals capturing and maintaining patient medical records including other patient-doctor encounter related data as well. 2) Pharma-driven approach: Pharmaceuticals will aggressively promote eDetailing by providing physicians with PCs. Pharmaceutical companies will dictate thecapturing and

maintaining of health records in a standard format to facilitate data mining. Alternately,

physicians that do cashless transactions will utilize this PC to work with Insurance organizations/TPAs. Working with multiple such Insurance organizations/TPAs will in itself ensure that the transactions are made in industry standard formats. MindTree believes that any standardization in the Indian healthcare industry will gravitate to using one or more of the available 1) messaging and coding standards (HL7, ICD, CPT, ANSI etc.).

US is now realizing that its aging population will exert extreme pressure on its healthcare system, so much so that there is a chance of a complete break down. Advancement in the medical field combined with better quality of care will increase the life expectancy of the general population. Together with the population growth rate, this would mean that with time, more and more people would require longterm healthcare. This puts tremendous pressure on the already weak healthcare delivery and financing system. If appropriate actions are taken

now and a robust healthcare infrastructure is created within the next decade, India will not be left without alternatives. Groundaltering changes in the healthcare industry can only occur when a variety of market forces recognize it as a common problem and then unite in agreement to solve the problem.

PREPARED BY: - Jaishree Soni, NEERAJ Sharma, (STUDENT), INTERNATIONAL INSTITUTE OF HEALTH MANAGEMENT RESEARCH, NEW DELHI

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