Healthcare innovations have had a significant impact on patient care, helping people live longer and with an improved quality of life. New treatments, therapies, drugs, and diagnostics are saving lives daily. More recently, advances in health information technology (HIT) have avowed to save lives and reduce costs. Consider the fact that doctors from different corners of the globe can now collaborate in real time, as surgeries are being conducted. Patients now wear electronic monitoring devices that send continual digital information to their healthcare providers about blood pressure and sugar levels, and other monitoring devices remind patients to take their medications. One of the lesser discussed area of healthcare has been the revolution that is occurring in electronic health records (EHRs) implementation and management. But this area of healthcare is also promising to bring about some of the greatest improvements in healthcare, with major benefits to both providers and patients.

The conventional paper-based health records have been in existence for several centuries and are commonly used in Indian hospitals; however, advances in EHR technology have made it possible for the EHR to replace many functions of the traditional paper chart. The use of EHR systems promises significant advances in patient care and may be perceived as key differentiators toward the realization of modern e-health environments. The increased utilization of health-related IT products and its acceptance is one of the keys to implement the vision of Digital India. The most prominent feature of an EHR is that digital records can be modified, formed, and handled by authoritative vendors and staff. With the help of interoperability data can be shared across more than one health care organization. EHR systems cannot only improve the physician competence and minimize costs, but can also encourage evidence-based medicine.

India, as a nation has huge amounts of data. Imagine what can happen when all doctors in the country start creating EHRs. But at present, adoption of an EHR system is slow as compared to other developed nations. The major barriers in the adoption of EHR are interoperability standards issues, lack of funds, and shortage of suitable governance health policies. Despite major concern by the Government of India on adoption of EHR, the impetus is still to be recognized. Though a few hospitals so far have understood the importance of medical data management, the larger part of the market still remains untouched.

Some organizations in the country are at the forefront of the curve. From decades, they have adopted electronic records while rest are still in the planning phase. As per the Healthcare Information and Management Systems Society (HIMSS) Asia-Pacific, there are eight levels of acceptance of EHR varying from level 0 (small or nil) to level 7 (complete implementation). By the end of 2016, only 2.6 percent of hospitals crossed level-6. In the present scenario, a bigger cluster of hospitals (31 percent) were measured at level-3. This is a positive sign. For instance, Max Healthcare and Apollo Group of Hospitals have achieved level-6 from HIMSS Asia-Pacific. Sankara Nethralaya (SN) has also implemented an EMR system in its hospitals and satellite clinics in Chennai, and engaged Tata Consultancy Services (TCS) for the implementation.

Government Initiatives

India has a mixed system of healthcare consisting of a large number of hospitals run by the central and state governments as well as the private sector. The government has shown considerable interest in EHRs and intends to introduce a uniform system for maintenance of EMRs/EHRs by the hospitals and healthcare providers in the country. The EHR system that the health ministry plans to introduce will link hospitals with one another so that patients do not have to carry their medical reports. All they will need to do is quote their Aadhaar number. With intent to let patients' records flow seamlessly between healthcare providers, the Union Health Ministry has invited bids from system integrators to develop software and establish a platform where doctors and patients can access their medical record through a portal and ensure that electronic patient medical record can be shared across various facilities.

To facilitate the system, a National e-Health Authority (NeHA) has been set up that will use Aadhaar-based biometric information to store health records, including the medical history, procedures undergone, diagnosis, name of hospital, drug prescribed, etc., of the patients. All this information will be accessible on a cloud-based e-application to the doctors across departments and among hospitals, ensuring quick transfer of information from one hospital to another. NeHA aims to promote EHR and facilitate its exchange across facilities in a secured manner.

A scheme to set up an Integrated Health Information Platform (IHIP) to create the EHR of citizens and to be made available nationwide online for medical history, with the help of Health Information Exchange(s), has also been approved and is being implemented by the Ministry of Health and Family Welfare (MoHFW). The health ministry has also notified Electronic Health Record Standards Version 2016 for India in December 2016 with the intent to bring standardization and homogeneity, inter-operability in capture, storage, transmission, use etc. of healthcare information across various health IT systems. States/UTs have been advised and are already working on computerization and implementation of hospital information systems (for creation of electronic records) in their hospitals/health facility with support under the National Health Mission.

The shift from paper mode to digital mode will happen in a phased manner in hospitals across the country. The plan is to link central government hospitals and state government hospitals in the first phase and then rope in private hospitals. AIIMS-Delhi successfully implemented the cloud-based EHR system to automate the patient appointment and create a repository of patient record. For unique identification of patients this system recommended the Aadhaar card number as the primary key. Many hospitals in southern states have developed IT systems and are going paperless. States like Telangana have already started capturing unique identification numbers of patients.

 Cyber Security is at the Forefront

The healthcare industry is a major target for hackers since the information contained in patient records includes everything a hacker needs for identity theft – this includes all personal information, and in the case of billing records, banking, and financial information. All details being in one place, makes security of medical records a major concern and one that seems to be experiencing increasing bumps in the road. There have been numerous breaches in all areas of healthcare and things do not seem to be getting better. With so many portals to access the information, systems have a hard time securing the content. This will continue to be a huge concern for all participants.

Medical identity theft and data breaches can be prevented to a large extent by strong cyber health laws along with powerful encrypted data storage and exchange in EHR systems. India needs to take immediate steps to formulate a detailed legal framework for EMRs and EHRs. The laws need to be worked to protect the privacy of individuals and their sensitive personal data, while, at the same time, giving sufficient flexibility to medical and health industries to continue their research and related activities.

Keeping all this in mind the Government of India has set up NeHA to deal with privacy and confidentiality aspects of EHRs. Stringent security measures and guidelines will be mandated, and this would go a long way in protecting the patients and their data as also their respective handling in the hands of medical and health related industries.

Global Market

The global market for electronic health record was valued at USD 23.22 billion in 2016 and is expected to exhibit a CAGR of 5.7 percent from 2017 to 2025, to reach an estimated value of USD 38.29 billion by 2025, predicts Transparency Market Research. Significant advantages associated with EHR systems and financial incentives by government of various countries are among the major factors driving the growth of EHR market worldwide.

Benefits of EHR systems include up-to-date patient information, reduced healthcare cost in the long-term scenario, quick access to patient-related data, reduced medical errors, increased patient participation, and improved efficiency of healthcare providers. These advantages encourage healthcare providers to equip themselves with technically advanced EHR systems, and thereby drive the market growth. Factors such as rapid technological advancement with data access through smartphones, need for improved efficiency and quality of service delivery to sustain in the intensively competitive healthcare industry, and increasing disposable income are also expected to fuel the growth of the market.

Hospital use was identified to be the largest end-user segment in the year 2016. Hospitals generate tremendous medical data on a daily basis. Hence, EHRs have become an integral part of patient data management owing to the convenience and increased productivity. The benefits offered by the in-house EHR systems such as cost and time saving to the large-scaled hospitals are responsible for the revenue growth. The segment is expected to remain the top end-user sector of the global market exhibiting a promising 5.1 percent CAGR from 2017 to 2025.

Geographically, North America, which is the cumulative market for the United States and Canada, accounted for a massive 46.2 percent of the global market in 2016, primarily due to favorable government policies such as pay for value and rapid inclination toward installation of EHR platforms across the care provider segment. Europe and Asia-Pacific are also among the leading contributors of revenue to the global market and are expected to remain high-growth regions over the forecast period as well. The Asia-Pacific market, especially, is expected to offer the most promising opportunities for growth in the EHR market with a thriving and rapidly digitizing healthcare industry in emerging economies such as India and China.

The global market features a largely fragmented vendor landscape, with the presence of a large number of small and large players. Leading vendors in the global EHR market are adopting inorganic growth strategies such as M&A to expand their reach across high-growth potential regional markets, consolidate consumer base, and strengthen their market presence. For instance, Quality Systems Inc. acquired HealthFusion, a developer of cloud-based EHRs for physician practices, toward the end of 2015. The acquisition is anticipated to enhance the market share of Quality Systems' in SaaS-based healthcare products in the ambulatory market segment. In addition, this acquisition will add over 3000 physician practices, ambulatory centers, and medical billing services that employ HealthFusion's EHR to Quality Systems' client base.

Some of the companies are also focusing on introduction of customized EHR systems based on individual client needs. Cerner, Allscripts, McKesson Corporation, MEDITECH, Epic Systems Corporation, and NextGen Healthcare are some of the well-established players in the market. In addition, some of the emerging players in the industry include eClinicalWorks, Healthcare Management Systems, Healthland, and CureMD Healthcare.

 Road Ahead

The private sector has a limited form of EHR but it has not yet started the exchange of health information to improve quality of care. However, the situation is changing due to efforts being made by the government and industry. High demand for healthcare IT services in healthcare as a result of increasing government spending is expected to propel the EHR market in the country.

Complete EHR implementation would be possible only with the joint efforts of all the stakeholders, which include the central government, state governments, healthcare providers, medical associations, IT industry, etc. Though an integrated initiative has not been started in the country, several works have been initiated, which are leading to the implementation of EHR, such as the guidelines for EHR standards and meta-standards issued by MoHFW. The Ministry of Electronics & IT has also been supporting the development and deployment of digital health solution for a long time by sponsoring R&D projects in various areas, including EMR system for oncology.

With the advent of technology, the government's Digital India initiative, the increase in advanced medical facilities across the country, the rise of self-care, and increasing use of homecare devices, the volume of useful healthcare data that will be generated in the near future is bound to increase exponentially. Such data, when utilized in the right manner can help in better analyzing health indicators and improve the overall healthcare services provided. Thus there is a dire need to maintain a centralized system for digitization of medical records.

We have just scratched the surface of what technology and healthcare can do together – the best is yet to come!

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