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EDITORIAL
The Role of Standards for Digital Health and Health Information Management
Suptendra Nath Sarbadhikari

*Corresponding Author
Suptendra Nath Sarbadhikari
Independent Consultant of Digital Health
New Delhi 110075, India
Email: supten@gmail.com

Introduction
1
It has been now more than two years that the (third edition of the) National Health Policy 2017 (NHP-2017) of India has been not
NHP-2017 notes the importance of digital health and it will be elaborated further below. The broad scope of Digital Health
categories such as mobile health (mHealth), health information technology (IT), wearable devices, telehealth and telemedi
JBCR VOL 6 - Issue 1 personalized medicine. Digital health is about electronically connecting up the points of care so that health information can b

 Jan ‐ June 2019 securely. This is the first step to understanding how digital health can help deliver safer, better quality healthcare. The propose
Strategy on Digital Health [2020-24]2 from WHO is defining digital health as “ the field of knowledge and practice associated with a
of adopting digital technologies to improve health, from inception to operation”.

Digital health interventions are applied within a country context and a health system , and their implementation is made poss
number of factors.3 These include:

the health domain area and associated content;

the digital intervention itself (i.e. the functionality provided);
the hardware, software and communication channels for delivering the digital health intervention; and, mediated within
a foundational layer of the ICT (Information and Communications Technologies) and enabling environment, characterized by th
infrastructure, leadership and governance, strategy and investment, legislation and policy compliance, workforce, standa
interoperability , and common services and other applications.

Therefore, for implementing digital health properly, it is of utmost necessity to purvey appropriate Health Information Managemen
HIM is the practice of acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patie
is a combination of business, science, and information technology. 4

The Role of Standards for achieving Interoperability in Digital Health

The NHP-2017 advocates extensive deployment of digital tools for improving the efficiency and outcome of the healthcare sys
policy aims at an integrated health information platform or system which serves the needs of all stake-holders and improves e
transparency, and citizen experience. Delivery of better health outcomes in terms of access, quality, affordability, lowering of diseas
and efficient monitoring of health entitlements to citizens, is the goal. Establishing federated national health information architectu
out and link systems across public and private health providers at State and national levels consistent with Metadata and Data S
(MDDS) and Electronic Health Record (EHR) Standards 5 , will be supported by this policy.

To provide better and cost effective patient care, one needs to exchange healthcare information. For this to happen seamlessly,
dire need of Standards that facilitate this interoperability. A Standard denotes the ability of two or more systems or components to e
information (structural or syntactic interoperability) and to (meaningfully) use the information that has been exchanged (func
semantic interoperability). As the Government of India aims for Universal Health Coverage (UHC), the lack of skilled human resou
prove to be the biggest impediment in its path to achieve targeted goals. Therefore, the model curriculum handbook on health information
6
management has been designed with a focus on performance-based outcomes pertaining to different levels. While a lot of efforts are
being made towards smooth adoption of digital health in India, a significant amount of issues are yet to be sorted out. In another recent
7
editorial I have shown how the NHP-17 is well suited to provide the necessary boost to a digital health ecosystem in India. In India, people
have tried to use some of the global Standards for exchange of health information as early as 2002. 8

To give a boost to implementation of digital health in a countrywide manner, the draft National Digital Health Blueprint (NDHB)9 was put up
in the public domain for comments, and it also mentions a minimal set of standards to be used. It tries to define the standards required for
ensuring interoperability within the National Digital Health Ecosystem. The broad categories for Standards mentioned are those for Consent,
(Clinical) Content Privacy and Security, Patient Safety and Data Quality. Currently for epidemiological purposes, all countries send reports to
the WHO using the ICD classification system (current version is ICD-10, while ICD-11 has been formally released last year and will be
applicable from January 2022). However, for getting better insights into the clinical data, SNOMED CT (a clinical terminology system) is the
globally preferred standard and India has been a country member of SNOMED International since 2014. 5 The basic differences of these two
systems are

1. ICD (International Statistical Classification of Diseases) codes, from the WHO, have limited scope and granularity, summarizes and
aggregates data into broad categories (for epidemiological purposes), and are mono-hierarchical (Each code is grouped into a single
grouping) –

No links to body sites or causes

Groups multiple clinical meanings together using a single code
• Does not always represent sufficient detail for clinical purposes
2. SNOMED CT is broader in scope, more granular, allows data to be grouped and aggregated in different ways (poly-hierarchical), and to be
queried, based on Relationships between the Concepts.

Presently mappings are available from to SNOMED CT to ICD-10 and its various adaptations. Therefore, if any system is SNOMED CT
enabled, it is possible to report according to ICD-10 or 11 as may be the statutory requirement for epidemiological and public health
10
purposes. Another emerging standard for clinical and administrative information exchange is HL7 FHIR that has also been recommended
9
in the NDHB draft. The acronym FHIR alludes to F – Fast (to design and to implement), H – Health, I – Interoperable, R – Resources
(Building blocks). “Fast” is relative – no technology can make integration as fast as we’d like. “FHIR” (pronounced “Fire”) is a fertile source of
puns. As mobile technology is rapidly proliferating and advancing, FHIR has the advantage of being used for mHealth. SMART (Substitutable
11
Medical Applications Reusable Technologies) on FHIR is increasingly being adopted by many countries worldwide. Some examples of
these SMART technologies include: OAuth2, OpenID Connect and HTML5 As the hospital care shifts more and more towards home care and
tele homecare, innumerable connected devices – wearables like IoMT (Internet of Medical Things) will need to be connected seamlessly.
The IoMT is an amalgamation of medical devices and applications that can connect to health care information technology systems using
12 13
networking technologies. The International Telecommunication Union (ITU) has adopted the Continua Design Guidelines (CDG) E2E
(End to end) Reference Architecture, as proposed by the PCHA (Personal Connected Health Alliance), to connect through various
interoperable standards: the personal health devices, person health gateways, health and fitness services, and healthcare information
systems.

14-17
I have been tracing the evolution of health informatics and health information managers in making healthcare delivery more informed.
18
Further they also show the role of unlearning and relearning in effectively assimilating information for better healthcare delivery. They can
facilitate change management and capacity building (through training and retraining) that will take care of the most difficult, “People”
component and to some extent the “Process or Workflow” components, leaving the technocrats to advance healthcare technology further. In
the Parliament, the Allied and Healthcare Professions Bill, 2018 was introduced in Rajya Sabha by the Minister of Health and Family Welfare,
19
on December 31, 2018. The Bill seeks to regulate and standardize the education and practice of allied and healthcare professionals. This
bill includes Health and Information Management Professionals as one of the recognized categories. On a related note, the Union Cabinet
has approved the restructuring of National Health Agency as "National Health Authority" for better implementation of Pradhan Mantri – Jan
Arogya Yojana (Ayushman Bharat). 20

Digital health and health information management are becoming today’s reality in India. Therefore, there is an urgent need to encourage the
education and training of health information managers, with a particular focus on the role of standards for health information exchange.
This will enable and empower them to successfully implement digital health interventions throughout India. This, in turn, will lead to better
and more health information that can be analyzed for making informed decision and policy making to improve the health indicators of India.

Conclusions and Recommendations

While the NHP-2017 is bold in its thoughts and foresight, for facilitating digital health, a lot more needs to be done soon. As the HIM
professionals are very well trained and suited to ensure that the health information and records of a patient are complete, accurate,
protected and meet the desired and stipulated medical, legal and ethical standards. Therefore, all health information managers must be
made aware of the role of Standards for interoperability, to ensure safe and smooth adoption of digital health in India, leading to informed
and safer healthcare delivery.

Acronym Expanded Form

AB-PMJAY Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana

CDG Continua Design Guidelines

E2E End to end

EHR Electronic Health Record

 EMR Electronic Medical Record

FHIR Fast Health Interoperability Resources

HIM Health Information Management

HIT Health Information Technology

HL7 Health Level

HTML5 Hypertext Markup Language 5

ICD International Statistical Classification of Diseases

ICT Information and Communications Technologies

IoMT Internet of Medical Things

IT Information Technology

ITU International Telecommunication Uniond

MDDS Metadata and Data Standards

mHealth Mobile Health

NDHA National Digital Health Authority

NDHB National Digital Health Blueprint

NDHM National Digital Health Mission

NHP or NHP-2017 National Health Policy 2017

PCHA Personal Connected Health Alliance

SMART Substitutable Medical Applications Reusable Technologies

SNOMED CT Currently this is not to be expanded. Historically it stood for Systematized

Nomenclature in Medicine – Clinical Terminology

UHC Universal Health Coverage

WHO World Health Organization

References :
1. Ministry of Health and Family Welfare, Government of India, National Health Policy 2017. Available from :
https://www.nhp.gov.in//NHPfiles/natio nal_health_policy_2017.pdf
2. World Health Organization, Draft: Global Strategy on Digital Health 2020-24, Available at:
https://www.who.int/docs/default-sourc e/documents/gs4dh.pdf?sfvrsn=cd577 e23_2
3. American Health Information Management Association , Careers: http://www.ahima.org/careers/healthinf o
4. World Health Organization, WHO Guideline: Recommendations on Digital Health Interventions for Health System Strengthening, 2019,
Available from: https://www.who.int/reproductivehealth /publications/digital-interventions-healt h-system-strengthening/en/
5. National Health Portal, Ministry of Health and Family Welfare, Government of India, EHR Standards. Available from :
6. Ministry of Health and Family Welfare, Government of India, Model Curriculum Handbook – Health Information Management, 2015-16,
Available from: http://mohfw.nic.in/sites/default/files/M odel_Curriculum_Handbook_Health.p d f
7. Sarbadhikari SN, Digital Health in India - as envisaged by the National Health Policy (2017), Guest Editorial, BLDE University Journal of
Health Sciences , 2019, 4: 1-6
8. Choudhary A, Karwa S, Health Monitoring System for the Elders and Invalid, Proc. of RIT-2003, CMRI, Dhanbad, 2003: 9-19.
9. Ministry of Health and Family Welfare, Government of India, Draft National Digital Health Blueprint, 2019, Available from:
https://mohfw.gov.in/sites/default/files/ National_Digital_Health_Blueprint_Re port_comments_invited.pdf
10. SNOMED International, SNOMED CT Basics: https://confluence.ihtsdotools.org/displ ay/DOCSTART/4.+SNOMED+CT+Bas ics
11. HL7 International, HL7 FHIR SMART App launch Framework:
12. Alliance of Advanced Biomedical Engineering, Internet of Medical Things Revolutionizing healthcare:
13. International Telecommunication Union, Recommendation ITU-T H.810, Interoperability design guidelines for personal connected health
systems: Introduction , 2017.
14. Sarbadhikari SN How to Make Healthcare Delivery in India More “Informed”, Education for Health, Volume 23(2), August 2010: 456.
15. Sarbadhikari SN & Srinivas M, Health Informatics and Health Information Management, In, Gyani G & Thomas A, Eds, Handbook of
Healthcare Quality and Patient Safety, Jaypee, New Delhi, 2nd ed, 2016, Sec. 4, Ch. 17: 206-216.
16. Sarbadhikari SN, Medical Informatics: A Key Tool to Support Clinical Research and Evidence-based Medical Practice (Ch 15), In, Babu AN,
Ed, Clinical Research Methodology and Evidence-based Medicine, 2nd Ed, 2015: 179-191.
17. Sarbadhikari SN, Sood JM. Gamification for nurturing healthy habits. Natl Med J India 2018; 31: 253-4 Available
from:http://www.nmji.in/text.asp?2018 /31/4/253/258236
18. Sarbadhikari SN, Unlearning and relearning in online health education, (Ch 21) In, Biswas R, and Martin C M, Ed, User Driven Healthcare
and Narrative Medicine, IGI Global, Hershey, USA, 2011: 294 – 309.
19. Rajya Sabha Bill. Available from : http://164.100.47.4/BillsTexts/RSBillTexts/asintroduced/Allied%20Health-RS%20Intro-E-311218.pdf
 20. Press Information Bureau, Government of India, Cabinet approves restructuring of National Health Agency as "National Health Authority"
for better implementation of Pradhan Mantri – Jan Arogya Yojana. [Cited 2019 Feb 12]. Available from :
http://www.pib.nic.in/Pressreleaseshar e.aspx?PRID=1558214

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