Year : 2010 | Volume
: 54 | Issue : 3 | Page : 131--136
Public health informatics in India: The potential and the challenges
AV Athavale1, Sanjay P Zodpey2,
1 Professor and Head, Community Medicine, People's College of Medical Sciences and Research Centre, Bhopal, Madhya Pradesh, India
2 Director, Public Health Education, Public Health Foundation of India, New Delhi, India
A V Athavale
Professor and Head, Community Medicine, People«SQ»s College of Medical Sciences and Research Centre, Bhopal, Madhya Pradesh
Public health informatics is emerging as a new and distinct specialty area in the global scenario within the broader discipline of health informatics. The potential role of informatics in reducing health disparities in underserved populations has been identified by a number of reports from all over the world. The article discusses the scope, the limitations, and future perspective of this novice discipline in context to India. It also highlights information and technology related tools namely Geographical Information Systems, Telemedicine and Electronic Medical Record/Electronic Health Record. India needs to leverage its «DQ»technology«DQ» oriented growth until now (e.g., few satellite-based telemedicine projects, etc.) simultaneously toward development of «DQ»information«DQ»-based public health informatics systems in future. Under the rapidly evolving scenario of global public health, the future of the public health governance and population health in India would depend upon building and integrating the comprehensive and responsive domain of public health informatics.
|How to cite this article:|
Athavale A V, Zodpey SP. Public health informatics in India: The potential and the challenges.Indian J Public Health 2010;54:131-136
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Athavale A V, Zodpey SP. Public health informatics in India: The potential and the challenges. Indian J Public Health [serial online] 2010 [cited 2020 Feb 17 ];54:131-136
Available from: http://www.ijph.in/text.asp?2010/54/3/131/75735
During the last quarter of 20 th century, emergence and rapid evolution of microprocessor technology enabled developments in Information and Communication Technologies (ICTs) that heralded an information age, which widened and transformed economic and social activities all over the world.  Governments of various countries especially developed countries harnessed the power of ICTs to initiate "e-health" projects in their respective jurisdictions. Simultaneously, there was an evolution of Health/Medical informatics science which is defined as "The integrative discipline that arises from the synergistic application of computational, informational, cognitive, organizational, and other sciences whose primary focus is the acquisition, storage, and use of information in the health/biomedical domain." 
Along with the inadequacies of health care delivery systems, serious weaknesses in public health infrastructure have been uncovered by countries all over the world who witnessed devastating manmade and natural disasters like 9/11 terrorist attack in United States, Asian Tsunami, etc. 
This has led to the huge investments in public health infrastructure based on application of informatics to public health by developed nations during the last decade. Consequently there is an emergence of a new and distinct specialty area of public health informatics within the broader discipline of health informatics, defined by a specific set of principles and challenges. Public health informatics defined as "the systematic application of information and computer science and technology to public health practice, research, and learning" is simply "informatics" applied to public health practice intelligently and focused on preventive and promotive health. , The scope of public health informatics includes the conceptualization, design, development, deployment, refinement, maintenance, and evaluation of communication, surveillance, and information systems relevant to public health. It requires the application of knowledge from numerous disciplines, particularly information science, computer science, management, organizational theory, psychology, communications, political science, and law. 
The potential role of informatics in reducing health disparities in underserved populations has been identified by a number of reports from all over the world.  In context to India, glaring disparities in equality and access to healthcare between urban and rural regions; unfavorable health indicators; increasing burden of communicable and non-communicable diseases; difficult terrain for the reach of health services especially in north and north-eastern states; alarming situations such as disasters such as famine, floods, earthquakes, epidemics of diseases, etc., necessitate development of public health systems with enhanced capacities to address community health problems. As identified by the World Health Organisation (WHO) ICT related tools such as Geographical Information System (GIS), Telemedicine, Patient's Information System, Decision Support System, Electronic Health Records (EHRs), etc. form the basis of a public healthcare setup.  These may be networked and/or interlinked with patients, common people, health care providers, managers, physicians, and other health workers; and researchers with the help of Internet. Public health informatics discipline in India is in a budding stage. This is exemplified by a steady growth in deployment of ICTs in the region primarily focused on health care services, e.g. Tele-cardiology, Tele-ophthalmology, Tele-oncology, Electronic Medical Records (EMRs), Hospital Management Information Systems, etc. after the start of telemedicine in the year 2000 with Apollo's Aragonda Project in Andhra Pradesh. 
Following is the brief description of the ICT applications prevalent in Indian Public Health scenario at present, namely Telemedicine, GIS, and EMR.
Telemedicine defined as "a delivery of health care and exchange of health care information across distance" is emerging as very effective in the domain of public health.  Today telemedicine has become increasingly possible due to a confluence of ongoing technical advances in multimedia, imaging, computers, and information systems, as well as in telecommunications. 
Proven public health potentials of telemedicine are: reduced distance and extra strain for rural habitants to travel to a super-specialty hospital in the city; cost reduction of treatment and follow-up; time saving and timely availability of expert medical services; improved prognosis due to access to standard treatment; maintenance of databases with respect to various diseases and locations; remote training of medical students by experts in the field; updated health information to health care workers and patients; decreased response time for a management of epidemic/outbreak or a disaster, screening for diseases, e.g. rheumatic heart disease through the tele-cardiology program, etc. 
Among the major telemedicine service providers/supporters in India are: ISRO; Department of Technology, Ministry of Communication and Information Technology, Government of India; Ministry of Health and Family Welfare (GOI); State governments; All India Institute of Medical Sciences; C-DAC and Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS) in Lucknow. Also, private firms such as Apollo Telemedicine Networking Foundation (ATNF) in South Asia, Narayana Hrudayalaya, Bangalore and Aravind Eye Hospital based in Madurai, deserve special mentions. , Internationally, the Indian telemedicine pilot projects are also largely being viewed as successful. 
In addition to the advantages in health care delivery, utility of telemedicine in public health practice has been evidenced in Gujarat earthquake in 2001 during post-disaster tele-consultancy activities in Bhuj with the already existing telemedicine infrastructure. Similarly, telemedicine has helped in last Kumbhamela gathering of around 25 million people in tele-consultation of ailing pilgrims and also in monitoring levels of Vibrio Cholerae in the river Ganga. 
Geographical information system
Geospatial solutions comprise of GIS, remote sensing and spatial modeling; generally refer to a description of the characteristics and tools used in the organization and management of geographical data. GIS uses map overlay techniques which view data pertaining to demographics, social infrastructure, health care institutions, and patient's geo-positioned points-all in one view. 
Public health applications of GIS include infectious disease surveillance and control, especially vector-borne diseases; to meet the demands of outbreak investigation and response (where prompt location of cases, rapid communication of information, and quick mapping of the epidemic's dynamics are vital); analysing spatial and temporal trends; mapping populations at risk; stratifying risk factors; assessing resource allocation; planning and targeting interventions and monitoring diseases and interventions over time. 
Evidence is mounting of the promising results with use of GIS from all over the world, e.g. search and rescue operations at Hurricane Katrina in the United States; also from India in Urban Malaria Scheme at Dindigul town in Tamilnadu. 
Electronic medical record/Electronic health record
Electronic Medical Record (EMR)  is the electronic record of the specific health-related event for a person; whilst Electronic Health Record (EHR) is the electronic record for a person of all health-related events before birth till death (womb-to-tomb health record!). These terms describe systems that provide a "structured, digitized and fully accessible [patient] record." 
Advantages of digitalization of an individual's/patient's health/medical record are:
it helps in reduction of error in medical care,it is easy to maintain for a long period,it has low maintenance costs,it is easy to access from any corner of the world if linked to the world wide web,it helps to make proper diagnosis and follow-up,it improves efficiency of health care, andit helps in research.
In India, the use of EMR is limited to large corporate hospitals and academic medical institutions such as SGPGIMS, Lucknow; SRMC, Chennai; AIIMS, Kochi; CMC, Vellore, etc.  Ideally for a full-fledged public health informatics system it is essential to have an EHR for each citizen of a country. Globally there is a variation in adoption of EHR in the health care systems even in well-developed countries. For example, UK, Canada, and Australia have been markedly successful in this respect but in the United States the growth is as low as only 15% of adoption by primary care physicians.  At present in India, owing to the multiplicity of healthcare providers that leads to interoperability issues; lack of technical standards; paucity of funds; and lack of apt public health governance process, this seems to be far from reality.
The potential of public health informatics
There is evidence to support that the application of information technology to primary health care in India is cost effective and ensure accountability of the services and helps in behavior change of the beneficiaries.  Some current experiments in India, such as the use of Personal Digital Assistants (PDAs) by rural health workers in Rajasthan, the disaster management project run as a part of the Maharashtra Emergency Earthquake Rehabilitation Project in the State of Maharashtra, and the computerized village offices in Andhra Pradesh and Pondicherry, suggest creative ways of using ICTs to improve the health conditions of local people. 
Development of public health informatics promises to address various public health governance issues. 
The broadened scope of applications of public health informatics lies in:
Epidemiological disease surveillance, epidemic/outbreak risk assessment.Disaster management: preparedness, mitigation, and response.Dissemination of health information and health education to the populations.Provision of health care in remote areas and screening for diseases: tele-cardiology, cancer care, tele-ophthalmology, etc.Electronic Health Records/Electronic medical records and their linkages.Updated health statistics: for knowledge of disease burden, other health care statistics, etc.Education and training: continuing Medical Education to health care providers.Development of Decision Support Systems (DSS): for patients and health care providers, e.g. information on antibiotic resistance of common organisms to physicians, development of Health Information Systems, etc.Improving public health governance by high accessibility of health services to remote areas, DSS for disease surveillance and disaster management, development of standard treatment protocols, improving transparency, and efficiency.Public Health Research.
Contemporarily the challenges faced by the novice discipline of public health informatics to grow for the benefit of the underserved population in India emerge out of some public health governance issues and some technical issues related with e-health.
The foremost challenge is of financial investment required to develop, implement, and maintain e-health initiatives to nurture public health informatics. The start-up costs, involving both manpower and expensive technological equipment are substantial.  WHO has recommended around 5% of GDP as an investment in public health expenditure by any state is far from comparison with the present less than a percent of GDP investment in India; a target that needs enormous political will to be reached in the near future. Moreover, the financial investment in public health infrastructure, e.g. up gradation of infrastructure at PHCs, is mandatory for the e-health projects to have a foothold and to thrive on such a renewed infrastructure.
The second most important challenge is the availability of the trained manpower in remote rural areas for establishment and maintenance of the ICTs required for public health informatics. India is said to have a good manpower, but scarcity of trained and skilled manpower is a cause for concern. For example, it can take a long time for any technical snag to be fixed as a technical support is hard to come by in remote areas leading to an ill-maintained tele-consultation center. Moreover, the field of informatics is unfamiliar to most public health professionals. A specially qualified team of public health informaticians and/or physicians with some knowledge of information technology applications is also required to be in place for initiation and furthering of public health informatics nationwide. Also, to impart professional training to build informatics capacity is a substantial challenge by itself.
Developing the coherent and integrated national public health information systems  would be the third challenge for public health informatics. Clear definitions of public health data needs and their sources, development of data collection and communication standards-to facilitate data quality, comparability, and exchange; and establishment of policies for accessing and disseminating data in a useful manner-thus to have a common health information system framework, are the basic requirements of a good public health information system. In Indian scenario of health care delivery developing interoperability standards and provision of sufficient bandwidth among many stakeholders, e.g. government and private health care providers for data sharing, is a difficult task. Electronic information sharing and data exchange provide means to develop a closer integration between public health and clinical care activities, e.g. automated data flow from clinical and laboratory information systems to public health, would be more challenging in later stages of development of informatics in public health. Furthermore, with the advancement of technology, consideration of scalability of the already existing ICT infrastructure is of great importance at the planning stage itself to ensure sustained usability of such systems to avoid extra cost inputs and thus to increase efficiency.
Fourthly, resistance to the development of ICT systems by stakeholders such as health professionals, managers, and even the users of the systems can create further problems once systems are implemented and may limit its use. For example, there needs to be in place a critical mass of patients who will use the telemedicine facility at a PHC.  The majority of physicians are unconvinced with advantages of ICTs in health care and unfamiliar with use of such newer technologies leading to reluctance to adopt them. From the user's perspective, there is the absence of treatment by emotion and lack of human touch. Furthermore, the low literacy rate and diversity of language act as hurdles for adoption of these systems. Lack of basic amenities such as transportation, electricity in rural areas worsens the situation.  Extensive motivational and capacity building activities are required to be implemented to harness maximum output from the facilities made available. Ignoring this issue would prove to be detrimental for the quality of services to the underserved populations and for the maintenance of the ICT-driven public health facilities.
Lastly, privacy, confidentiality, and security are important issues which persistently accompany with the application of an ICT-based informatics system.  Definite guidelines and policies have to be framed for authentication of data access and use. Proper techniques to preserve the confidentiality of the patient data and security of the systems are crucial.
The Way Forward
Besides the obscurity of enhancing public health informatics capabilities in India there is a silver lining. Government has shown its willingness to invest 2-3% of GDP as a public health investment stepwise during next 5 years. The government's 11 th Five-Year-Plan (2007-2012) allocated 2000 million rupees (about US$ 50 million) to telemedicine.  Encouraged by the steady growth of its telemedicine programme, ISRO launched HealthSAT-in 2005, with the aim to connect rural hospitals to specialist centers in the cities and to bring telemedicine and medical education needs to the poor on a larger scale.  Apart from this, initiatives such as Tele-ophthalmology Project; National Telemedicine Grid; National Onconet Project; National Medical College Network; and National Digital Medical Library Consortium are noteworthy developments for consideration under XI th 5-year plan. Although, this growth which has been "technology" oriented until now; India needs to leverage it simultaneously towards development of "information" based public health informatics systems in future. To this effect, Integrated Disease Surveillance Project (IDSP) is one of the important initiatives by the Health Ministry toward obtaining data regarding various diseases' burden in the country. The plan also ensures budget allocation for computerization and networking of health care system, i.e. PHCs, rural hospitals, district hospitals, and super-specialties. Recommendations for inclusion of information technology under the medical curriculum, integration of the infrastructure such as Central Bureau of Health Intelligence, National Institute of Communicable diseases, etc., are some of the welcome moves by the government. 
Although as compared to other developing countries, India has a unique distinction to have indigenous satellite communication technology with large trained manpower in this sector; the great demanding task lies in further capacity building and implementation of measures to retain this power to the nationwide application of public health informatics. National Rural Health Mission (NRHM) is a pioneering initiative to provide quality health care access which raises enormous demands on the training and capacity building infrastructure.  It can provide a huge platform to benefit mutually by initiating ICT-driven programs with an additional program component for capacity building in public health informatics, e.g. e-enabling accredited social health activist (ASHA) to carry out assigned public health activities. Formulation of Indian public health standards is one of the ground-breaking steps in NRHM as it attempts to define the quality of public health services and their standards.  Also, GIS-based resource mapping for the District Health Plans under NRHM is proposed to be undertaken for a countrywide roll out. 
Under the rapidly evolving scenario of global public health, the future of the public health governance and population health in India would depend upon building and integrating the comprehensive and responsive domain of public health informatics.
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