Application of digital technologies in primary healthcare: Opportunities & challenges

In October 2018, the Astana declaration on primary healthcare (PHC) reiterated the call for universal health coverage1. To make this vision a reality, several operational strategies have been suggested. One of these strategies is the use of digital technologies. Further, these technologies have been endorsed by the World Health Assembly for supportive care at home and in the community, clinical and consumer decision-making, digital education of the providers to improve quality and safety and health information systems2. Increased visibility of digital technologies and a stronger realization of its potential to be a disruptive transformer in the health sector were also felt during the COVID-19 pandemic3. However, large scale implementation is required in the PHC settings. There are several opportunities in India which can make this vision a reality, but many challenges need to be addressed at the policy and operational levels.

At the policy level, the deployment of digital technologies has been advocated for improving the efficiency of the health system in India4. The National Digital Health Blueprint has been released5 and the Ayushman Bharat Digital Mission has been announced6. One can now create an Ayushman Bharat Health Account with a unique health identification number and use it for all health related applications in public and private healthcare institutions (https://healthid.ndhm.gov.in). Healthcare professionals and facilities can also be registered with a unique identification number. Universal Health Interface has been envisioned for various digital health services, data exchange and consent management using the open application programming interface policy7. Thus, software applications developed on various platforms can be linked and digital applications can be scaled up in the PHC as the availability of computing infrastructure has improved manifold in the last decade.

Many States have supplied computers to PHCs and tablets or smartphones to multipurpose health workers and accredited social health activists8. Information technology has also been implemented in a lot of public and private hospitals. Familiarity of health human resources with information technology has also gone up with the use of social media both in social and professional spheres. Wi-Fi (Wireless Fidelity) is reaching out to even remote rural areas where many people now have mobile phones. High-speed National Optical Fibre Network connection to every panchayat area is being provided by the Government of India9. Computing power is continually increasing and, cloud computing, big data analytics and artificial intelligence algorithms are becoming more accessible. Although healthcare costs are rising with the use of advanced medical technologies10, hardware and software costs of digital health technologies are coming down. Therefore, insurance companies and other payers are now considering the adoption of digital technologies to reduce the overall cost of healthcare11.

If PHC teams get access to digital technologies, some of the unmet needs, particularly in remote rural areas, can be met with telehealth. Digital connectedness can be used for developing coordinated or integrated care. People having access to their digital health records can provide these to healthcare providers, wherever needed, whether in PHC or hospital. However, implementation of digital technologies in the PHC cannot be actualized in isolation, as it is dependent on several issues beyond the health system such as the availability of uninterrupted internet connectivity and electrical supply, large data storage space, bandwidth, computing speed and policies on data sharing and data use. The policy for teleconsultation and e-prescription has been approved during the COVID-19 pandemic12, but the policy on e-pharmacy is yet to be formulated.

The standard terminologies developed and licenced in high-income countries for coding of clinical concepts and exchange of data are paywalled. These standards should be open and free from intellectual property rights. In India, open standards for electronic health records (EHRs) are available13, but a lighter version of EHR is needed for PHC where diagnosis, procedures, medicines and laboratory tests are limited in number. Besides clinical use, EHR data can also be utilized for medical research and for the development of artificial intelligence (AI). Hence, interest in the data of EHRs is growing14. Deployment of AI may minimize the errors and improve the quality of care, but if AI is based on selective EHR data, errors may also occur. In that case, who should be held accountable, healthcare provider or AI producer? Therefore, policies on liability issues, data sharing and data use are needed15,16, and several design issues also need to be addressed.

Should digital system designing for PHC be done at a central level? The problems may differ between communities, so the solutions may also be different. States, local bodies and health institutions should be encouraged to innovate and find frugal digital solutions in a decentralized manner to fulfil local needs17. A system developed step by step in a modular format without altering the local workflow according to the requirement of the stakeholders will be readily accepted and may last longer compared to the systems developed one time using turnkey project development approaches at the national or international level. If the software, hardware and technical support supplied by the contracted company are proprietary items, sustaining these systems beyond the contract period is a challenge. Therefore, competent technical human resources are needed in-house to understand, support, modify or integrate existing digital systems.

In India, several health programmes use digital technology for aggregate as well as for case-based reporting18. However, these digital applications work in silos and pose implementation challenges at the PHC level. For example, there are separate digital applications for registration of (i) eligible couples and under-five children for reproductive, maternal and child health services (RCH Portal); (ii) >30 yr olds for risk assessment, screening and referral for five non-communicable diseases (NCD Portal) and (iii) tuberculosis cases (Nikshay Portal), etc. PHC teams need to enter data of a person in several applications as services related to many vertical health programmes are to be delivered to the same person. The key tenet for reducing the burden of data entry on the health workforce should be that no data are entered into a computer more than once. Therefore, a need for an enterprise architecture framework has been felt to drive the digital transformation of PHC in India18.

To address the issues related to multiple portals, an Integrated Health Information System for PHC (IHIS4PHC) has been developed in an urban health centre of Chandigarh19 based on three principles: (i) address all healthcare needs of the community, people and patients, healthcare providers and administrators; (ii) cover all services including promotion, prevention, diagnosis, treatment and care and (iii) use open-source free standards and software where customization cost is low and the system is flexible, that is, if future needs arise, it remains user modifiable at the local level. In the integrated application, two open-source software systems have been used: (i) District Health Information System Version 2 (DHIS-2) tracker and (ii) Open Medical Record System (openMRS). DHIS-2 was customized to enrol household members in family folders and to capture all healthcare services provided in the community for various national health programmes, but for curative services, openMRS was used in the clinic19. Open API policy can be used to integrate these applications and other portals, i.e. RCH, NCD, Nikshay, etc., with the National Integrated Health Information System.

However, implementation of IHIS4PHC involved not only the installation of hardware and integration of software but also an augmentation of other resources, for example, the enhancement of the cognitive ability and motivation of the staff. Many changes had to be done in the organizational workflow, so teasing out the impact of digital intervention became difficult. Nevertheless, household surveys done earlier and one year after the implementation of the IHIS4PHC reported that perceptions about PHC services, especially for chronic diseases, had improved19, and the experience of healthcare providers and patients was also positive20.

However, a critical question is – how much money should be invested in digital health technologies given the competing priorities? Concurrent evaluation designs should assess whether with digital health technology one can do more work in less time, or that more time is needed to do the same work. The health provider will need more time if data entry is to be done by the same person. In that case, more healthcare providers will be needed, and if digital technology can cut down on the time, then, fewer human resources will be needed. Ultimately, the real test is whether the use of digital health implementation cuts down on time and/or costs and improves the end-user’s experience. Evidence of effectiveness on access, coverage, quality, safety and health status also needs to be established21. Therefore, there is a need for cost-effectiveness/cost-benefit analysis and opportunity cost assessment before scaling up digital health interventions in PHC settings.

In summary, so far only a few integrated digital health solutions are available to support the whole range of PHC functions in clinics and communities. New initiatives on digital health must have an implementation science component with a realistic evaluation such that mid-course corrections can be made whenever problems are encountered, and cost-effectiveness can be established. Digital health can be an enabler of the PHC system, provided it is supported by regulations on interoperability, privacy, security and safety, and is primarily built to meet the needs of service provision in an integrated manner.