The great Indian healthcare delivery pyramid
Multi-speciality and single-speciality clinics are the backbone of the country’s healthcare delivery, yet are the least impacted by the medical-tech startup boom.
The private sector bears the disproportionate burden of healthcare delivery in India — research shows that nearly 70% of the population relies on private sector for their healthcare needs and this number has been increasing in the last two decades. Yet, not all private sector healthcare is made equal.
In spite of this heavy reliance on private healthcare providers, perhaps even as a result of it, the service offerings and quality ranges widely. Every clinical establishment — from a single-room local general practitioner’s clinic to a huge super speciality hospital in a metro — acts as a healthcare provider working in a claustrophobic silo contributing very little to the overall betterment of healthcare delivery.
In the era of ‘digital India’, we’ve come to agree with the National e-Health Authority (NeHA) concept note that “technology can play an enabling role…in improving the efficiency of the healthcare system and also in improving the quality of care.” This grand objective requires “a fundamental shift in the way information is accessed and shared across the health system,” the note argues. But before we get there, we must perhaps understand how health information is captured and shared (or not) currently.
The Pyramid
For ease of understanding and theorising, we divide the private healthcare delivery system in India into eight layers on a pyramid.
Super speciality hospitals: At the very top of this pyramid are the super-speciality hospitals. They are scarce, no more than one or two to every metro city, where there are a few tens of specialities and a few hundred beds.
Typically, these hospitals cater to rare/niche treatments in specialities such as interventional cardiology, cardiothoracic surgery, neurosurgery, oncology, organ transplantation and poly-trauma care. Therefore, they tend to be referral hospitals, though, in India, it is not often the case.
Multi-speciality hospital: Just below the super-speciality hospital is the multi-speciality hospital. These are typically a chain of hospitals but can be standalone too. Every metro and tier-2 city will have several of them, even tier 3 cities have a few.
A multi-speciality hospital also has several specialities, however, they can be more basic as general medicine, pediatrics, orthopaedics etc. While ideally these also are best served as referral hospitals, Indian patients tend to find their own ‘specialist’ for their healthcare needs.
Mid-size hospital: Next level is mid-size hospitals with about a hundred beds, found in every city and town. Typically, this has a few basic specialities such as medicine, surgery, obstetrics, paediatrics, and orthopaedics with a range of infrastructure like lab, x-ray, ultrasound, CT scan, catering to its needs.
Single speciality hospital: Then come the modern single-speciality hospitals. These are usually small hospitals with less than 100 beds or sometimes as big as mid-sized hospitals mentioned above that cater to a single speciality or a small group of inter-related specialities. — infertility and maternity care centres, orthopaedic hospitals and cancer care hospitals are exemplary of this. Also belonging to this category are day care centres like eye and dental hospitals.
Multi-speciality clinic: Next is multi-speciality clinics, or polyclinics as some of us prefer to call them, with a few specialist physicians, typically offering care in related specialities. This could be a mix of cardiology, endocrinology, OB/GYN, neurology, gastroenterology, pediatric, pulmonology and general physicians.
By virtue of being clinics, these don’t offer inpatient facilities, offer only non-emergency care and run for only a few hours everyday. However, they are usually equipped to perform small procedures and provide day care.
Single speciality clinic: An IVF clinic is a simple example. These tend to be clinics with 1–3 speciality-focused physicians, typically one senior and a couple of junior physicians.
Imaging clinics and labs: Then are the imaging clinics (X-Ray, CT, MRI) and labs (pathology, etc.,)
Neighbourhood clinic: And then come the friendly neighbourhood general physicians at the very bottom.
IT in the healthcare pyramid
Within the healthcare delivery pyramid, information and communications technology (ICT) integration varies vastly from one category to the other. There is some form of electronic health records (EHR) at the top of the pyramid i.e. hospitals. Either by compulsion of insurance providers or by the need of law or by virtue of having foresight, hospitals with inpatient facilities have long maintained electronic health records — the quality or appropriateness of which we will not focus on in this article.
Super speciality and multi-speciality hospitals spend tens of crores of rupees yearly to own or maintain their own custom-developed software. This software is typically an integrated hospital management software (HMS), which keeps record of a patient’s journey through their systems — from appointments, diagnosis, prescription, lab reports, discharge summaries to billing and pharmacy transactions. A large team of IT and admin professionals are often employed to ensure the smooth running of this software.
Mid-sized and single-speciality hospitals too have some kind of hospital management system, though might be lower on the sophistication and integration scale. While patient registration, appointments and billing are managed through the HMS, much of the physician’s workflow is not often integrated into this technology.
Multi-speciality clinic is an underserved market. Clinics are not required by law to maintain EHR yet. Therefore, most software developed for this market tend to focus on the administration of the clinic and record keeping, rather than on maintaining patient records to improve healthcare delivery. They tend to address only a part of a doctor’s daily workflow, sometimes even counter-productive to the objective of easing healthcare delivery.
Single speciality clinic is an unserved market, except perhaps for the aforementioned clinic administration software repurposed and posed as physician’s software.
Neighbourhood clinics run on the power of the friendly physician’s memory and compassion, while imaging clinics and labs rely on software provided by the original equipment manufacturers (OEM). These software vary widely in quality and are often of non-intuitive, user-unfriendly design.
The challenge of the underserved market
The unserved and underserved markets (single-speciality and multi-speciality clinics) are also uniquely challenging for tech companies. These clinics are fragmented, making the sales process highly dependent on the foot-salesperson. By the very nature of how these clinics operate — devoid of documentation, dependent on one senior doctor who is the power-centre etc. — any software that doesn’t specifically address pain-points are seen as vain. This forms the classic conundrum of tech companies not understanding the physician’s needs and physicians not wanting existing tech solutions, making this market unattractive.
On the other hand, the unserved and underserved market above cater to a significant chunk of the population’s non-emergency healthcare. It is typically a person’s first point of contact with the healthcare system, this is also the first place of diagnosis and medication. Quality data collected at this stage can help patients maintain a robust history of ailments, which can save time and energy when they are referred to tertiary (speciality) hospitals.
Yet, there is a gaping hole here in the collection and maintaining electronic health records. Much of existing software solutions offer little or no help to the physician, often acting as a mere data entry system. For instance, most of today’s solutions for clinics have a common feature for generating prescriptions — there is either a search field or a drop-down field where the physician manually finds the medicine s/he wants to prescribe and clicks on it. For doctors who are used to scribbling their prescription on a piece of paper — and having no need to change their ways, yet — current technology is of no use.
So, the way it is today, is technology really transforming healthcare in India? If it is not, then what do we need to make it transformational?
