Why is India’s National Digital Health Mission is likely to succeed?

Why is India’s National Digital Health Mission is likely to succeed?


Last year the Government of India announced the National Digital Health Mission (NDHM). We were asked to review and comment on the draft as one of the stakeholders in healthcare. This inclusive approach to involve the various stake holders was never seen before. We believe that COVID-19 and NDHM has increased the pace of digital healthcare and can unlock USD 200 to 250 billion in next 10 years in terms of primary and secondary impact to the nation’s economic value. Such is the magnitude of the NDHM initiative for India. So will this succeed?

To understand the critical success factors for India, let’s understand some notable failures and learn from them. Also we need to learn from the currently ongoing Covid Vaccination Drive in the country that’s the largest in the world and the fastest that will cover over a billion people.

Notable Failures

We have several tech giants and countries that have invested and failed in rolling out digital health initiatives. Some of these that come to my mind are:

Google Health

I had written in my column on Why did Google Health Fail? (see text below)

Why Did Google Health Fail 1
Why Did Google Health Fail?

IBM Watson Health

Some of the insider views on the closure of IBM Watson Health (shut down on 31 Dec 2020) are as under:

  • Business call by IBM leadership – viability of the case in oncology
  • Muted doctor’s acceptance
  • 50:50 prediction accuracy of the algos
  • Wrong expectations set when initially selling the idea to the doctors and Manipal
  • Difference in clinical pathways of oncologists on the Watson output
  • Implementation was very complex due to the different oncology tumour and stage
  • Oncologists time to teach the system versus doing it by their own experience
    • Doctors believed that they were recruited to treat the patient and not teach the Watson
  • Limited use case of the system
    • More for research than for actual treatment and second opinion

UK NHS Spine Program

As part of the leadership team of one of the vendors involved in the UK NHS Technology initiative and also interacting with the Managing Director of British Telecom Healthcare that was leading the rollout in the UK of the NHS Spine, I gathered that the digital health (in those days-2007, this was not called digital health) in UK had a partial success. The reasons were multi-fold:

  • Exgaggerated benefits of the program
  • Botched up decentralized implementation at the different trust level
  • Multiple stakeholders with their wrested interest
  • Manpower and resources shortages
  • Multi-year delays and costs overruns
  • Poor change management and acceptance at the ground level with the clinical workers
  • And many more issues

African ICT and Digital Initiatives

As part of the Health and ICT Minister’s Panel for Africa, the major issues voiced by the Ministers from the African continent happens to be the disease of Pilotonomics. There have been multiple pilots of initiatives but none have actually fructified to be a mainstream as some of them have been abandoned by the sponsors and the donors as the budgets ran out

Have seen the failures across the Tech Giants, developed world countries and low income countries, the issues of failures are a myriad of technology, sponsorship, change management and end user acceptance.

Why will India succeed?

During the Covid-19 pandemic, India Government initiated a host of digital initiative (see blog Sustainability of Digital Health | Kapil Khandelwal (KK)). The most important being the roll out of the CoWin App for the vaccination of the citizens. For the first time on the world, a billion people would be mobilized through this initiative for their vaccination. With the pace and success of the initiative and the citizen acceptance, we will see that the National Digital Health Mission will succeed. Some of the positives that I am seeing include:

  • PMO and senior Ministers’ and Bureaucrats’ driving this Mission
  • Inclusive attitude to gather all the stakeholder’s voices right from the beginning
  • ICT framework and the National Telemedicine Act also being enacted bringing the decades of differences between the Medical Council of India (MCI) and various players to an end
    • Many doctors have actually started using Telemedicine during the lockdowns

Let’s not belittle the National Digital Health initiatives for shorter political gains!

Also read: Digital Health | Kapil Khandelwal (KK)

Republished Column: A Dose of IT: Why did Google Health fail?

Google Health is not going to be there anymore.

After its launch in May 2008, Google Health has gone through its chequered existence till the Google Execs announced, last week, to withdraw the product by end of 2011. As I epilogue, I will use the PESTC model to conduct the postmortem analysis on the death on Google Health

Politically, 2007-08 was a time when concerns around reforming healthcare reform were at its peak and a one of the key agenda items in the US Presidential war. Such rhetoric on healthcare and need to reform healthcare was politically echoed world over by many leaders. This political analyst wanted to get more bang for the buck on healthcare spend. This meant more business for healthcare ICT to create solutions to address the issues of healthcare access, costs, quality, outcomes and so on. Politically, it made sense for tech heavy weights to put their might in launching healthcare solutions and in this political back drop that Google Health was launched. However since then and Obama’s healthcare reforms bill, not much impact for many tech major’s who waged on healthcare and hence to reassess their decisions to throw their towels in.

Economically, this was the time for world’s worst economic downturn since the Great Depression. Healthcare was seen as anti-recessionary. Tech major’s boardrooms and leadership strategy break outs discussed derisking and growth by enter social sectors such as healthcare, education and so on. Google’s board and leadership could not have been thinking differently when giving thumbs up to invest in healthcare business. However as many tech major now realize that healthcare requires long-term strategic vision and investments to stay in the game. Like many other tech major, Google has other investment priorities in other portfolios of their business such as android OS and mobile phones and devices, etc. It made sense for them to exit out of a sector that requires time and investments to change the way people and clinicians manage health.

Socially, the rise of social media is changing the way people manage information, communicate, exchange content and interact including their doctors and care givers. Google Health failed to capture this trend in their solutions.

Technologically, Google failed to learn from the failures of many others who failed in the past and replicated solutions where there are far more superior solutions and players in the field. Some major gaps, I guess alignment with doctors and clinicians is the first step towards creating a technologically superior solution that can align with healthcare consumers. Secondly, there were hardly any vertical partnerships in healthcare that Google went out to create an ecosystem. Lastly, Google did not integrate their other products such as Google Maps that could provide location aware services to the consumers on their health.

Consumers and competition, contributed to putting the nails in the coffin of Google Health. Google Health focused on one end of the healthcare value chain and did not believe in working in aligning the overall healthcare ecosystem. Moreover, consumers are moving towards mobile-based solutions on their smart handphones that Google Health failed to capture as a trend. Lastly, competition has far better ideas and staying power as health tech solutions is a long-term game.  

With Google Health putting down their shutters on their shop, what are the implications? Firstly, the spotlight now falls on Microsoft HealthVault. Analysts will now try to second guess Microsoft’s response to this development. Health is a very large opportunity that Google may not like to miss. It may come back with an acquisition sometime later.

Google Health, RiP!

Windows 11 for Healthcare: Cosmetic Surgery But the Chronic Aliments Still Persist

Windows 11

Happy Doctor’s Day!


Last week, Microsoft showcased their latest Operating System (OS), The Windows 11. This is the new OS that will upgrade the Windows 10 that runs billions of computers globally. While talking to the analysts, Satya Nadela, the CEO and Chairman of Microsoft envisioned Windows 11 to be the ‘center’ of all the operating ecosystems. I downloaded the developers version on one of my tablet, Lenovo’s Yogabook, to test out the initial impressions of the new Windows 11 and does it meet the vision of Microsoft’s CEO and Chairman

Teething issues with the update to Windows 11

Microsoft has certain minimum hardware and security requirements which prevent existing systems to upgrade to Windows 11. Security enhancements in the new OS, requires TPM 2.0 (Trusted Platform Module) as well as Secure Boot, both security technologies, to run perfectly. This is why Microsoft has not listed Windows 11 support for a huge list of processors that do not come with these technologies. After many workarounds and system checks, I was able to get the Window 11 developer’s version update. This whole exercise took away over 11 hours of time from start to finish! Microsoft views to this is that its part of making more secure as a platform. However, unlike earlier upgrades to Windows 10, where many users complained that their files were deleted, this was not the case this time round.

Windows 11 minimum system requirements

Processor: 1 gigahertz (GHz) or faster with 2 or more cores on a compatible 64-bit processor or System on a Chip (SoC)
RAM: 4 gigabyte (GB)
Storage: 64 GB or larger storage device
System firmware: UEFI, Secure Boot capable
TPM: Trusted Platform Module (TPM) version 2.0
Graphics card: Compatible with DirectX 12 or later with WDDM 2.0 driver
Display: High definition (720p) display that is greater than 9” diagonally, 8 bits per color channel
Internet connection and Microsoft accounts: Windows 11 Home edition requires internet connectivity and a Microsoft account to complete device setup on first use.

Cosmetic Surgery in the Windows 11 Operating System

There are a few positives in the first look at Windows 11 OS, the user interface is much cleaner, intuitive and clears all the patchwork of interfaces from earlier Windows OS in Windows 10. There is a feeling of an immersive experience. When I attached my system to external high-end curved monitor, the experience was very fabulous. For the doctors who want to view the radiological images, this would be a plus.

Windows 11 Desktop on External Monitor
Windows 11 Desktop on External Monitor

Chronic Aliments Still Persists

Moving on to congratulating Microsoft on their efforts, let me critique Microsoft on the issues that still persist from the previous OS that it need to really work and iron out for the new OS to be a real clinical workplace productivity enhancer. Some of these options are very easy for Microsoft to incorporate with its final release of Windows 11 to the world at large. Here are some of my views, I will add more as I do use the new OS in the next few weeks to come.

Windows Dictation and Read Aloud Tools

I have been using Windows dictation tool to get many of my documents typed out. However when I say certain medical terms under ICD 10 or names of molecules or medications, there is a typo returned in the typed output. I have seen a demo of Microsoft Azure tools for healthcare that are available to enterprise cloud and app developers of Microsoft, why should it be so difficult to roll this out for students, medical workers on their retail license of Windows 11? After setting the regional setting to India, Indian accents and Hinglish is still not available. Microsoft keyboard on my android phone has been trained for the last 2 years, Windows 11 can take the same from the information stored on their Keyboard App on Android and use those to train the dictation tool. Read Aloud Tool still has a Caucasian woman and cannot Hinglish words well or recognize them.

IoT Device Integration

There are several devices that the doctor can control right from his desktop in his clinic without having to get up and switch or off during diagnosis. Amazon and Google has been working perfectly with on IoT devices through Alexa and Google Assistant. Cortana is still lagging on the same functionality and experience. Unless the Microsoft CEO and Chairman in his statement on being in the center meant that we may have to use the Windows 11 desktop and get over to Google Assistant (on the Android App or browser) or Alexa to command the IoT devices connected to the network.

Pen Writing and Annotation

There are enhancements in the pen settings. However the current handwriting recognition is same as the Windows 10. Fast scribbles of the prescription still show as typos. The auto completion of medical terms still give garbles. The pen annotation of radiological reports still need to give micro-level pinpointing at 10x zoom. Still the same experience continues from Windows 10.

Microsoft Teams Integration

Microsoft Teams which was more for enterprise customer as a video conferencing and virtual collaboration app is now fully integrated into Windows 11. This means the doctors and their patients can freely teleconsult through their desktops

Multiple Desktops

This was a feature in the MacOS for years is now introduced in Windows 11. Doctors can now have multiple desktops for their outpatients, inpatients, personal and other work and personal workplace segregation.

Android Apps in App Store

This is just a feature in the App store. We still have to see the power of running these app on the Windows OS run systems. One of the main reasons for updating the developer version was to check the apps compatibility on Windows 11 desktop.

The Rhythm of Blues

As the Windows 11 is a developer version of the OS. Please be prepared for the system to crash and show you blue screen a few times in a day.

Not Everyones OS for Healthcare in India

Microsoft has bumped up the minimum requirements for upgrading to Windows 11. As per Microsoft their justification is 3-fold

  • Security: Windows 11 requires hardware that can enable protections like Windows Hello, Device Encryption, virtualization-based security (VBS), hypervisor-protected code integrity (HVCI) and Secure Boot. The combination of these features has been shown to reduce malware by 60% on tested devices. To meet the principle, all Windows 11 supported CPUs have an embedded TPM, support secure boot, and support VBS and specific VBS capabilities.
  • Reliability:  Windows 11 will now be in a supported and reliable state. By choosing CPUs that have adopted the new Windows Driver model and are supported by our OEM and silicon partners who are achieving a 99.8% crash free experience.
  • Compatibility: Windows 11 is compatible with the apps you use. It has the fundamentals of >1GHz, 2-core processors, 4GB memory, and 64GB of storage, aligning with our minimum system requirements for Office and Microsoft Teams.

IT hardware asset refresh cycles in India are not driven by change of operating systems requirements. As many of the old desktops and laptops will not be meeting the minimum criteria laid out by Microsoft, many of the older systems will be running on Windows 10 till they are refreshed in healthcare and their consumers. Let’s understand, Indians don’t buy new phones or desktops and laptops every year because there is a new model (as Apple assumes it to be).

I will continue to add over here as I come across the good, the bad, the ugly about Windows 11 as I test the OS futher.

Statutory Disclaimer: folks wishing to download it can do so from the Microsoft Insider website. However, people other than developers are highly recommended not to download the build as of now. This is because such early beta testing versions are full of bugs that are only ironed out as and when beta testers report them to Microsoft.

What’s the Fear of WhatsApp Privacy Policy and your Fearlessness of Your Healthcare Information on Aarogya Setu?

WhatsApp Privacy Policy

The Fear, The Fake and The Facts – The New Pandemic on Chats

Monday morning when I woke up there and switched on my phone, there were hundreds of messages forwards and group chats if we should delete out WhatsApp accounts and either move the group to a new chat platform called Signal. In the fear of not losing out of the connects in my WhatsApp Groups, I also downloaded the Signal App. However two times it crashed and was not able to connect with my contacts. Over the day there were the fake propaganda being floated against WhatsApp. Let’s understand, India is one of the largest cohorts of users for any App and with over 750 million smartphones such negative propaganda to move towards open App platforms so that those who want to propagate their malicious negative agenda to the masses. These could be in the form of the following:

  • Communal, news written with the intention of inciting religious and communal passion
  • Violence, Criminal and sexual.
  • Integrity and Authenticity
  • Questionable Practices and Rituals (Occult, Blackmagic)
  • Bullying and Terrorism
  • Misinformation (bank shutdown, currency devaluation, economy)
  • False Health Advisories, we see an uptick in these during the Covid-19 pandemic
  • Spreading false information about competition
  • Political misinformation
  • Satire
  • Propaganda
  • Personal Defamation

WhatsApp has been working proactively with Governments across the world to curb this and had in fact deployed an army of factcheckers of over 10000 to do so. It is well evident that of the malice that have floated through Facebook and WhatsApp during the recent CAA, Farm Bill, Sushant Singh murder, etc which can be classified in the points above. One pertinent question that I would like to ask. Why is the backlash against WhatsApp privacy policy the peak only in India? There is nothing against WhatsApp in other countries. A point to ponder as to why and who wants to bring WhatsApp down in India just because it has acted wisely and ruthlessly against the cronies. WhatsApp India (and not WhatsApp Inc from the US) made a public statement (its an India centric issue)

WhatsApps Clarifications on the Privacy Policy

WhatsApp issued a statement to clarify their stand. These are:

  • WhatsApp cannot see your private messages or hear your calls and neither can Facebook
  • WhatsApp does not keep logs of who everyone is messaging and calling
  • WhatsApp cannot see your shared location and neither can Facebook
  • WhatsApp does not share your contacts with Facebook
  • WhatsApp groups remain private
  • The user can set their messages to disappear
  • The user can download their data
  • The company, in its blog emphasised that this update includes changes related to messaging a business on WhatsApp, which it claims is optional.

WhatsApp’s official Statement shared by The Verge:

“As we announced in October, WhatsApp wants to make it easier for people to both make a purchase and get help from a business directly on WhatsApp. While most people use WhatsApp to chat with friends and family, increasingly people are reaching out to businesses as well. To further increase transparency, we updated the privacy policy to describe that going forward businesses can choose to receive secure hosting services from our parent company Facebook to help manage their communications with their customers on WhatsApp. Though of course, it remains up to the user whether or not they want to message with a business on WhatsApp.

The update does not change WhatsApp’s data sharing practices with Facebook and does not impact how people communicate privately with friends or family wherever they are in the world. WhatsApp remains deeply committed to protecting people’s privacy. We are communicating directly with users through WhatsApp about these changes so they have time to review the new policy over the course of the next month.”

Hence the issue is not for the normal consumer. Let me also voice your concerns around the privacy policy which I have read end to end and accepted should center around the following points which you should consider and then decide if you would like to use the WhatsApp chat platform or not

  • WhatsApp Message Policy
  • WhatsApp Encryption
  • WhatsApp Device and Connection Policy
  • WhatsApp Location Policy
  • WhatsApp Data Sharing with Facebook
  • WhatsApp Ads Policy
  • WhatsApp Minimum Age
  • WhatsApp Ban Policy

Those using iOS and Android phones have you not accepted something similar when you activated your newly acquired mobile phones permitting Apple and Google. So what’s the issue with WhatsApp? They are not a phone/device company? So go ahead and read your agreement with iOS and Android/Google on your smartphones once again and compare that with WhatsApp’s Privacy policy.  

WhatsApp Privacy Policy on Healthcare Data (if any)

Back in April 2020, we had engaged with WhatsApp India leadership to enable CovidBots for various states on the 108 and 104 helplines to reduce the call volumes on the command centers. We had interacted with the Government Relations, the Legal Head, WhatsApp India MD, Facebook India MD, Head of Partnerships. The first question off the bat from WhatsApp was that every Chief Minister of India was given an approved number to communicate to their citizens of their state on Covid, why a new service. The second issue pointed out by WhatsApp India was is the CovidBot similar to Aarogya Setu App. If yes, WhatsApp India would not permit such a chatbot. Now my question to all in India is, if you can provide your location data and movement to now an officially mandated Government App, WhatsApp was just not interested in allowing any of their partners to collect location data of the people of India through their platform.

The second issue around the healthcare data privacy that WhatsApp was concerned before they approved a CovidBot was protecting the identity and masking healthcare data of the masses and nothing should be allowed to go through their WhatsApp platform. As you may be aware WhatsApp is a US headquartered company and is legally bound by a much more stringent HIPPA Act which our Aarogya Setu would fail if it was implemented in the US.

The third issue with WhatsApp in allowing any healthcare chatbot was that they had to actually write and clear a global policy on healthcare during pandemics and emergency. Their global policy team at their headquarters actually. India was the first country that was approved by WhatsApp to roll out a CovidBot in the world. Then Israel and others followed.

My limited point to all the fear and fake has been that a company like WhatsApp (now Facebook) is equally concerned in allowing what is legally feasible on their chat platform through their WhatsApp for Business and Facebook handles while the local Aarogya Setu does not even meet a basic privacy filter. So why is there so much fear around your privacy?

Let me conclude by saying, when you buy an expensive high-end smartphone on Apple or Android platform, please decline their terms and condition. The expensive toy in your hand will just be a brick. Please throw that expensive brick in your hand to protest for privacy on Aarogya Setu at Shaheen Baug.      

Also Read: Coronavirus in India: ‘Facebook, WhatsApp seek more data than Aarogya Setu app’ – Rediff.com India News