Tuesday, December 13, 2016

Unique Health Identification and Aadhar: A case for mandatory linkage

All India Institute of Medical Sciences (AIIMS) has requested the Ministry of Health for a mandatory linkage between Unique Health Identification (UHID) and Aadhar. This seems like a simple and a straightforward suggestion but deep down it has major implications for delivery and democratisation of healthcare. I would argue that this linkage should be mandatory for all hospitals, both public and private primarily because it empowers the patients to have access to their own medical records.
As part of the digital initiative, AIIMS issues a UHID to each patient, who visits the hospital for the first time. In subsequent visits the patient is expected to reproduce this number. The UHID plays an instrumental role in documenting the patients entire journey in the hospital. With this it is possible to track, the date and time of the patient visit, the departments where the treatment was offered, the tests and the sub-tests that were undertaken and their results, if the patient was admitted (in-patient) then date and time of the ward in which the patient was admitted, the procedures performed, date and time of discharge, the release description (such as cured, expired etc.) and the diseases codes. Within AIIMS, availability of this data helps the doctor to develop a more accurate medical history of the patient. Also, this significantly reduces the burden on the patient to either produce past medical records or recall all the necessary treatments or procedures done. This has significant impact on quality of care by reducing the risks of medical errors and negligence, better patient management, avoiding unnecessary investigations, etc. In practice, however, there are many patients that are either unable to produce records of their previous visits to the hospital or do not recall the UHID number, as a result of which a new UHID is issued and in the process, precious medical history of the patient is lost. Aadhar has a potential to resolve this issue. Aadhar is a nation-wide unique identification which is used for multiple purposes, therefore, significantly easier for patient to reproduce and if this is linked to the UHID then it is much easier for the doctors to access the medical history without putting any burden on the patient. Moreover, the patient has cheap and reliable access to his own medical records.
A medical record is the property of the patient and just like any property its value depends on proper identification, accurate documentation, easy transferability and the rights to access it. If all hospitals UHID are linked to Aadhar then it has the potential to create a universal health records for the patient. With Aadhar the patient can request the hospital to transfer his medical records to his digital locker which he can access from anywhere at any time. This will lead to democratisation of healthcare delivery.
Let me illustrate this with an example. Consider a patient from a village in Bihar who is visiting a district hospital for an ailment. Under the Digital India initiative, the District Hospitals are expected to maintain a Hospital Management Information System (HMIS) that records the details of patient visits, disease, treatment offered and outcomes (cured, referred, expired, etc.).  If this information was linked to the patients Aadhar, then this could potentially be stored in the patient’s digital locker. Now suppose the patient is referred to a tertiary healthcare such as AIIMS (more than 50 percent patients in AIIMS come from UP and Bihar). With easy access to the digital locker at any time, the patient can transfer all the past medical information to the doctor in AIIMS who will have a far more accurate medical picture than a scenario in which he has to rely only on the testimony and the records of the patient. Such a portability of medical records has significant impact on the quality of care that the patient receives by reducing the risks of medical errors and negligence, better patient management, avoiding unnecessary investigations, etc.
Perhaps in the future it would be possible to link all medical visits, from the primary health centres, community health centres, secondary hospitals to the tertiary care hospitals, to the Aadhar. This will help in the development a comprehensive health record of the patient that is accessible anywhere at any time.
As a first step in the development of a comprehensive health record of the patient it is important that the government makes it mandatory for all the hospitals to link their UHID to Aadhar and give digital access to the patient to their own medical records which can be stored in the digital locker. To achieve this the government must take steps to ensure that basic data on each patient is collected in all hospitals:
1.     Date and time when the patient was admitted.
2.     Vitals of each patient: Weight, Height, BP, Hypertension, Diabetic.
3.     Disease code using the ICD-10 codes.
4.     Date and time stamp when the patient was discharged.
5.     Discharge outcome: Cured, Death, LAMA, etc.

In conclusion, linking UHID to Aadhar allows for the development of the comprehensive health records of the patients. It empowers the patient with the right to access his own medical records anywhere at any time. An important step in the democratisation of healthcare delivery.

Tuesday, November 29, 2016

Demonetization and its Behavioral Consequences: A Positve Welfare Impact


Demonetization has come as a shock to everybody. The main target of this shock therapy were people dealing with black money and terrorism, nevertheless, it has affected everybody. By and large people have questioned the implementation but very few have criticized the policy and its intention. However, I believe that it will have large behavioral consequences that could have a positive welfare impact. There is no doubt that such a drastic move is pushing people, primarily those in the informal economy, to open bank accounts and actively use them. This might seem trivial and transactional but it has behavioral consequences. Opening and actively using a bank account could potentially lead to behavioral shifts towards decline in wasteful expenditure and increase in savings. Research in behavioral economics has shown that most of us suffer from not taking the right (rational) actions even when we know what is the right thing to do (for example, we keep postponing our decisions to exercise), economist call this time inconsistent behavior. Savings behavior is also subjected to such time inconsistency. To be able to save requires discipline to curtail our present consumption, and save more for tomorrow. Research has also shown that such behavioral issues play an instrumental role in in explaining why people are poor. Fundamentally poor people lack the instruments and the discipline to save. One possible solution to this is to “nudge” people to take the right action, however, demonetization has gone one step ahead to “compel” people to open a bank account and actively use them for savings and expenditure.
Prior to demonetization I had conducted a survey of new age “taxi aggregators” drivers to understand why they were giving up a regular job at traditional taxi companies and joining these new companies for variable income. Though most of them were joining to make more money but they also valued the payment policy of these new companies. The drivers in these new companies are not paid in cash but every week money is deposited in their bank account. They said that this led to reductions in wasteful expenditure and also building a bank balance became a matter of pride. The drivers placed a high value on this and credited the new age companies for inculcating this discipline. Many of them believed that they were saving lot more than before when they were working in traditional taxi companies which paid in cash. What this highlights is that if informal workers were to rely more on banks as a method of receiving their wages and making payments, it then has the potential to resolve behavioral issues related to savings and consumption. Unfortunately, behavioral issues cannot be resolved easily, sometimes coercion is required to do the right thing.