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Journal Scan
Electronic Health Records in India: Challenges and Promises
Nisha B Jain*, Samiran Nundy
Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
Article Information
Pai MMM, Ganiga R, Pai RM, Sinha RK. Standard electronic
health record (EHR) framework for Indian healthcare system.
Health Serv Outcomes Res Method 2021;21(3):339-362. [Doi:
10.1007/s10742‑020‑00238‑0].
Background
India has an ever‑growing need for quality health care owing to
its large population. India follows a quasi‑federal structure of
governance where health is on the concurrent list of the Indian
constitution. The health‑care system in India is at the cusp of
its transformation and major credit for this paradigm shift goes
to a digitalization of health care.
The electronic medical record (EMR) is a digital version of a
paper record related to a patient’s medical history documented
inside the hospital and is not designed to be shared outside an
individual clinical practice. On the other hand, an electronic
health record (EHR) is a comprehensive report of an
individual’s overall health. The EHR is a collection of various
different medical records and this digital record of a patient
which can be accessed anytime anywhere. However, these two
terms are often being used interchangeably. The EHR forms the
core of India’s goals of digitalizing the health care system.[1,2]
In India, EHR adoption gained popularity in the last decade.
The 2019 coronavirus disease (COVID‑19) pandemic has
further highlighted the importance of the need for a robust
EHR system in place. The COVID Vaccine Intelligent
Network (CoWIN) is an open‑source, centralized digital
service provider which tracks records of India’s vaccination
drive against COVID‑19.[3] CoWIN is a good example of how
digital technology is integral to our fight against COVID‑19.
This article authored by Pai et al. (from the Department
of Information and Communication Technology, Manipal
Institute of Technology, Karnataka, India) published in Health
Received: 10‑10‑2021 Revised: 26-10-2021 Accepted: 06‑11‑2021 Available Online: 08-12-2021
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Website: www.journaljme.org
DOI: 10.4103/JME.JME_94_21
278
Services and Outcomes Research Methodology in their latest
issue has conceptualized the implementation of EHRs in the
Indian public sector.
It highlights the status of the health information system in India’s
three‑tier health care setup. The primary, secondary and most
tertiary health‑care centres have paper‑based documentation.
Not only human but monetary and infrastructure resources
also get used up in storing and maintaining these paper‑based
records with the risk of being misplaced during patient referral
being a major setback. Currently, a few tertiary care facilities
in India have started to maintain EMR, but the information
is retained by the primary hospital and is not transferable or
accessible when the patient is referred for specialized care
elsewhere making interoperability difficult.
The authors suggest a framework for collecting, processing
and storing the data for EHR with ease both in rural and urban
India with emphasis on cloud computing the data for easy
accessibility. The authors bring out a solution to the problem
of interoperability of software in India. Health records can
be made interoperable by standardization of the terminology
and group sharing.
They have researched into various models adopted for
maintaining EHR worldwide and proposed cloud‑based
standardized EHR model for public health‑care facilities
which is secure and provides a solution to access patient health
information from various levels of the health‑care system in
India. The proposed model uses the Aadhaar Card to serve
as an ID to retrieve health records. This model assists in the
reviewing of a longitudinal record, consisting of all health
data, laboratory reports, treatment details, discharge summaries
across one or multiple health facilities.
Address for correspondence: Dr. Nisha B Jain,
Department of Surgical Gastroenterology and Liver Transplantation, Sir
Ganga Ram Hospital, New Delhi, India.
E‑mail: nishabjain1811@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
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is given and the new creations are licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
How to cite this article: Jain NB, Nundy S. Electronic health records in
india: Challenges and promises. J Med Evid 2021:2:278-9.
© 2021 Journal of Medical Evidence | Published by Wolters Kluwer - Medknow
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Jain and Nundy: Electronic Health Records in India: Challenges and Promises
The authors have not only proposed the EHR model but also
have validated it with real patient data of 60 patients from
PHCs and 40 patients from CHCs. The test results have been
error‑free in capturing and sharing of patient data at various
levels of our health‑care system making it feasible despite the
odds we face both in rural and urban India.
Commentary
We believe that the EHR is the new future of the Indian health
care system. The authors in this article have recommended
a framework for collecting, maintaining and processing the
information in a standardized format. They have suggested
that the EHR model should be linked ID like the Aadhar card
for every citizen so that personal medical and health records
are linked and stored associated with a unique number.
However, the drawback of the study is that the authors have
made a framework for linking health care at government‑run
primary, secondary and tertiary centres. The majority of
the population still seek treatment at the nearby clinics and
private nursing homes; probably because the primary health
centres in rural areas are not open round the clock and for
emergencies, they get referred to higher centres due to lack
of availability of expertise and specialty infrastructure. The
core of documentation at clinics and private nursing homes are
paper‑based case sheets as maintaining digital health records
at these setups would add to financial burden and are thus, not
attractive. The only way forward to digitalizing the document
and records at the private setup needs incentives from the
government for setting up the software and infrastructure.
The article describes the intricate details of an integrated EHR
system starting from online registration details, admission,
laboratory investigation, radiological reports, prescriptions to
discharge summary. More importantly, it has emphasized the
usage of terminologies and a standard coding system like the
International Classification of Diseases making it easily
transferable to another hospital at referral. In reality, the crux of
its successful implementation at PHCs and CHCs will demand
not only high‑speed internet connectivity but more manpower.
There is a need for PHCs and CHCs to be well equipped and
well‑staffed with designated personnel for data maintenance, as
medical staff would not be well versed with technology at rural
centres. We suggest that these persons be well trained; first, to
understand various modules of the system and its operability
and then get integrated with this system.
We propose the appointment of ad hoc trainees to aid in
maintaining digital health. This would not only contribute
to economic growth through job creation but also enable
Journal of Medical Evidence ¦ Volume 2 ¦ Issue 3 ¦ September-December 2021
efficient work by medical personnel without compromising
the care of the patient. A regular audit of the documents and
cross‑verification is much needed when aided staff are involved
in maintaining data.
EHR systems across the globe are maintained through the
effective use of a unique identifier. The authors have suggested
the usage of Aadhar ID. India does not have a comprehensive or
sector‑specific (for health care) data security act. Aadhar is not
backed by a strong security system making patient information
vulnerable to getting hacked. Recently, the government has
tried using Aadhar for ensuring COVID‑19‑related vaccination
but there were issues related to its users without compromising
on data security. The Aarogya Setu or the Indian COVID‑19
contact tracing, syndromic mapping and self‑assessment
mobile application, which was implemented by the government
in 2020 came under criticism on grounds of data security and
could not be made mandatory.[4]
Recently, the Government of India has launched the Ayushman
Bharat Digital Mission to support the integrated digital health
infrastructure of the country. This aims to create a seamless
online platform ‘through the provision of a wide range of data,
information and infrastructure services, duly leveraging open,
interoperable, standards‑based digital systems’ while ensuring
the security, confidentiality and privacy of health‑related
personal information.[5] We hope this achieves what it sets out
to do but we also think there will be difficulties ahead related
mainly to accurate and comprehensive implementation and
issues of privacy.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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