Ahmed N and Oke G. The evolution of WHIMS – What healthcare organizations can learn from its genesis, development, and future potential. HPHR. 2021;40.
A lot of development as happened in the healthcare space and one of that is the fact that even the remotest parts of the country, including the often- neglected tribal belts, can obtain diagnosis of their ailments through IoT powered Point of Care Testing (POCT) devices. While the potential for POCT to establish equitable healthcare for the underserved was clear, there was inertia in adopting such technologies at scale. iKure is a tech-driven, social enterprise that meets the rural health care and prevention needs through a unique combination of health outreach initiatives, skills development, and technology intervention. iKure functions on an award-winning operating model. They created a centralized distribution model which consolidates information, equipment and supplies at a central Hub and propagates the same to peripheral care centers or Spokes. A medically trained core care delivery team occupies the central Hubs in places like West Bengal, Jharkhand, Karnataka, Uttar Pradesh, Assam, and Orissa. The Spokes are manned by trained Community Health Workers (CHWs) who under the guidance of the core team deliver essential services with the aid of POC devices. Their portfolio of services has evolved over the years and now includes on-site general medicines, maternal and childcare, computerized eye care, on-site eye glass cutting and edging, pathology services and telemedicine. However, their pioneering product is the in-house developed, low-cost, data-analysis software, Wireless Health Incident Monitoring System. WHIMS is a cloud-based platform that enables collection of accurate wellness information for effective preemptive and preventive action. The platform is designed to stay resilient to erratic power supplies and limited bandwidth through offline storage and timely data uploads.
It has been more than two years since the start COVID-19 pandemic. The pandemic shed light on the fragility of the public health ecosystem. Many countries in the developing world were especially unprepared and underequipped.
Take India for example – considered a developing economy, much famed for its health tourism, and its healthcare facilities. But the entire health industry came under great scrutiny during the pandemic. With just 0.5 beds per 1000 people, which is abysmally small in comparison to the global average of 2.9, the healthcare officials in India were looking at an unfathomable abyss when the pandemic reached Indian mainland. While these numbers may be frightening to some, it hides another appalling fact that most healthcare in India is concentrated in the urban centers. This meant that all those living in the rural areas and tribal pockets generally find it difficult to get access to even basic health care facilities like capillary blood sugar testing.
Of the 1.4 billion people who call India home, 900 million reside in villages and the ‘active internet users’ in rural India have grown by 45% since 2019. While one may wonder if there is any sustainable solution to healthcare access problem in rural setting, its indeed inspiring to see many start-ups who have identified the gaps in infrastructure and aspire to fill them with innovative solutions. Not only has this broadened the potential scope for empowering the underserved, but it has also paved way for technologies that depend on ready availability of internet to solve some of the most basic problems endemic to rural India.
For instance, walking hundreds of miles for a doctor’s consultation is now tackled with telemedicine. And similarly, where access to healthcare infrastructure and equipment has been an issue, internet powered Point-Of-Care Testing (POCT) devices have assuaged it. Now, it is possible for even the remotest parts of the country, including the often-neglected tribal belts to obtain diagnosis of their ailments through IoT-powered POCT devices.
While the potential for POCT to establish equitable healthcare for the underserved was clear, there was inertia in adopting such technologies at scale. The needed impetus to cross the critical threshold came in the form of the pandemic which shifted the point of collection/testing from laboratories/hospitals to at/near home locations.
The government of India has progressively invested in digitizing their services through the NDHM platform and has strived to leverage the COVID-19 crisis as an opportunity to focus on healthcare. Fresh impetus has been given to relevant organizations like National Health Authority (NHA).
After undergoing pilot in August of 2020 in 6 union territories of India, the National Digital Health Mission is set to roll out with the objective of integrating the digital health infrastructure of the country. It seeks to bridge the existing gap among different stakeholders in India’s healthcare ecosystem through digital highways.
The systems that are being built as part of the digital ecosystem are digital health ID, a registry of doctors called Digi-doctor, health facility registry, personal health record and electronic health record. Out of the above, it has been reported that health ID, records of doctors and health facilities are now operational.
Following completion of the intervention, participants completed 8-week post-enrollment and 16-week post-enrollment surveys and participated in semi-structured exit interviews.
One thing that the pandemic has made clear is that the government cannot work alone. It is more important than ever to partner with grass-root organizations who are striving to solve similar challenges. One of the primary reasons to do so is that these organizations, as a virtue of their operations, embody the collective insights and empathy of all downstream beneficiaries.
The pandemic has served as a blessing in disguise by enabling previously competitive heterogenous players to overcome their differences to work synergistically towards a common end goal. Such collective action was most resilient in the social entrepreneur ecosystems which was acknowledged by the World Economic Forum when they awarded 50 organizations as the Top Last Mile responders of India. These organizations not only achieved equity and value maximization for themselves and their beneficiaries but also for other players in the ecosystem.
One such organization is iKure, a social enterprise founded by Sujay Santra to deliver curative, primary and prevention services to underserved communities in India.
iKure is a tech-driven, social enterprise that meets the rural health care and prevention needs through a unique combination of health outreach initiatives, skills development, and technology intervention.
iKure functions on an award-winning operating model. They created a centralized distribution model which consolidates information, equipment and supplies at a central Hub and propagates the same to peripheral care centers or Spokes. A medically trained core care delivery team occupies the central Hubs in places like West Bengal, Jharkhand, Karnataka, Uttar Pradesh, Assam, and Orissa. The Spokes are manned by trained Community Health Workers (CHWs) who under the guidance of the core team deliver essential services with the aid of POC devices.
Their portfolio of services has evolved over the years and now includes on-site general medicines, maternal and childcare, computerized eye care, on-site eye glass cutting and edging, pathology services and telemedicine. However, their pioneering product is the in-house developed, low-cost, data-analysis software, Wireless Health Incident Monitoring System (WHIMS).
Figure 1 – Community Health Worker assisted Telehealth Service at patient’s home
WHIMS is a cloud-based platform that enables collection of accurate wellness information for effective preemptive and preventive action. The platform is designed to stay resilient to erratic power supplies and limited bandwidth through offline storage and timely data uploads. It facilitates real-time communication of data and insights between the Hub and the Spoke. The real beauty of the platform lies in its capability to dynamically adapt to the changing needs of the healthcare professional striving to provide value-added personalized care at the spokes (peripheral care centres). Another factor promoting its penetration into rural India is iKure’s establishment of positive-sum partnerships with a plethora of healthcare organizations working at the grass-root result.
The net result is an ecosystem of complementary entities who not only feed data to WHIMS but also leverage the same in a synergistic manner to prevent, diagnose and treat illnesses. These include local NGOs for ground mobilization, Hospitals for secondary and tertiary care, and research organizations for clinical and technical knowhow of various ailments.
Figure 2 – Examination of patient at the Hub by trained medical professional part of the core team
One of the benefits of WHMIS is the fact that Data analytics can be done easily. Also, being a digital solution, it can help generate actionable insights that can be used to create better healthcare products and services using evidence-based evaluation. Data analytics is important
to improve the quality and affordability of treatments across regions. Using its in-house capabilities, iKure can capture, analyze and process various sorts of data in its attempt to deliver value to beneficiaries. This included, capturing inputs related to eating habits, adherence to medication and hygiene best practices. A significant use case of such data collection that became more pertinent during the time of the pandemic, was its capability to track and identify the source for the contagion-spread. iKure was able to leverage such insights to recommend containment and infection prevention strategies to local governmental bodies.
WHIMS also has a well-incorporated billing system which makes seamless and simple while making financial data readily available. Inventory management is also easily done. It is therefore easy to track transactions, transfers, refunds, expiration dates, and types of stocks. Furthermore, WHIMS creates more awareness of healthcare brands among populations in rural environments. Such awareness increases utilization of products and services that aid in achieving basic standards of personal and family hygiene. This is why other healthcare brands would like to partner or collaborate with iKure.
This technology aids clinicians in rapidly accessing essential patient data such as the medical history, vitals, body metrics and it can assist real-time clinical decision-making. For iKure, customer privacy and patient confidentiality is of highest priority and thus they employ an anonymization technique that successfully protects the privacy and data of the patients and maintains a balance between utilization and privacy.
WHMIS enables the use of point of care devices which have become the hallmark for delivering quality care in peripheral parts of the country. The POC devices are mounted on to a smartphone and the health workers in the communities are trained to use them for diagnosis. In such manner, tests like hemoglobin estimation, urine analysis, and blood sugar tests can be easily done. Additionally, with the help of modular POC devices, the camera of the smartphones can be used to detect cancer, digitize health cards, and manage inventory.
WHIMS has reached about 8.2 million people living across seven states in India and about 50,000 health cards have also been issued so far. Between 2018-2019, 130,000 accessed primary health care and 76,251 people benefitted through access to regular medical supplies. Also, 550 women benefited from incentive-based income by working as community health workers. Lastly, about 97.9% of patients are strongly satisfied with their services, 77.91% find iKure services economical and 70.59% find iKure services accessible. While these numbers are great on paper, the impact generated can be sustainable only be achieving synergy amongst other players in delivering holistic care.
Figure 3 – Utilization of WHIMS empowered Point-Of-Care Diagnostic Device to measure blood pressure at the comfort of Patient’s home in periphery
What WHIMS essentially facilities is the foundation for the establishment of a ‘Collective Adaptive System’. An ecosystem where heterogenous players adapt dynamically to changing environmental stimuli to achieve progress towards an end objective that also benefits the other entities in the ecosystem. Strategic partnerships with organizations like IBM enable iKure can leverage the data collected from WHIMS to obtain longitudinal analysis of community and individual health using deep learning and artificial intelligence capabilities. Empowered by actionable insights from WHIMS, iKure is now enroute to building a conducive ecosystem for managing chronic diseases, enabling door-step diagnostic services, and progressing medical research for diseases endemic in rural India.
While the potential for a scaled version of WHIMS is huge, public-private partnership will be key to leveraging the facilitatory technologies to achieve equity and value maximization. And the ecosystem model that flourished during the crisis setting of the pandemic must be nurtured, sustained and scaled through personalized incentives to all participating players.
Figure 4 – Smartphone enabled Point-Of-Care Diagnostic Device that enables transfer cardiac function data with concerned specialists stationed at the Hub
The objective of the article is to analyze how WHIMS by iKure is striving to solve the problem of healthcare access in rural India and share actionable insights that can be adopted by global readers. Writing the article involved studying existing literature delineating the problem of healthcare access in India and WHIMS by iKure. The secondary research was bolstered by robust primary research involving interviews with iKure Leadership team and staff.
The result, discussion and conclusion were developed after a conversation with the executive team, the middle management, the representatives and finally the beneficiary patients of iKure. This was also discussed relative to available solutions and evidence.
Our conversation with the leadership team and Dr. Tirumala Santra Mandal in particular, made us understand the challenges that led to the conceptualization of WHIMS. While iKure strives to achieve zero mortality in primary care, the current climate of resource constraints in the Indian health ecosystem makes focus on primary care relatively less viable compared to focus on secondary or higher levels of care. The above restlessness resulted in the inception of WHIMS – To convert their urge into action. It currently serves as the robust foundation upon which all subsequent preventive, primary and curative interventions thrive.
The thought and effort that went into progressively refining WHIMS resulted in the digital ecosystem playing a vital role when India faced the pandemic. For instance, during the first wave, the country faced near-insurmountable in-situ bottlenecks in health infrastructure, such as shortage of drugs, equipment, beds at hospitals. In this period, iKure leveraged its digital ecosystem and its army of trained Community Health Workers to decentralize primary care.
By doing so, they played a critical role in ensuring mild to moderately symptomatic cases did not unnecessarily occupy the hospital beds that could potentially serve severely ill COVID-19 patients. Here, mild to moderately symptomatic patients refer to those COVID-19 patients that can be treated successfully through out-patient type services when screened proactively or diagnosed early in disease progression (1st week of symptoms).
However, the full potential of WHIMS came to light only during the second wave when the pandemic moved out of care centers and into the homes of patients. The second wave in India saw hospitals, polyclinics, and nursing homes unable to manage the patient inflow across the country. As a result, healthcare providers started advising mild- moderate patients to quarantine and subsequently receive treatment from the safety of their homes through telehealth. During this period, WHIMS empowered iKure to reap the full benefits of their assisted Point-Of-Care (POC) devices and services that leverages trained Community Health Workers.
The combination of WHIMS and POC enabled iKure to bridge the demand vs. supply gap of healthcare. Therefore, the firm progressively equipped their armory with a portfolio of complementary POC medical devices secured through strategic device partnerships. Subsequently, vital diagnostic measurements were made available at the patient’s doorsteps, outreach camps and iKure clinics with the assistance of CHWs. This model reduced the burden on traditional healthcare facilities, thereby ensuring optimum use of resources as per patient criticality.
iKure is now prospecting the expansion of its POC Device portfolio through collaboration with other impact-driven organizations striving to maximize value and bridge inequity in primary care. To name a few, iKure is exploring AI-enabled POC Fetal Doppler for advanced-level screening and detection of high-risk pregnancy, Braveheart patch with IBM for detecting cardiac ailment at an early stage, and Remeduo for detecting and screening diabetic retinopathy.
The pandemic has widened the legacy fractures in healthcare and shown impact-driven organizations the significance of complementary collaboration. iKure’s story serves as a testimony that value maximization potential is possible for other players in an ecosystem who are striving towards a patient-centric common objective. The partnerships and alliances stuck during the pandemic crisis were vital in ensuring quality care was available till the last mile of the value chain, regardless of whether that involved remote terrains or rural hinterlands.
More importantly, the pandemic nudged the founding team to realize the need to create an insight/capability sharing mechanism and identify appropriate pathways that can empower other co-actors in the health ecosystem to add value synergistically. The platform enabled players to provide remote monitoring services, early screening tests to break the infection chain, vaccination drive as a collective measure to reduce the demand for hospital beds and oxygen support. It facilitated a common platform that brought the local self-help groups, NGOs, healthcare providers to create a shared space for people from the fields of art and culture to create awareness, interest, and support for the rural villages. It also garnered support from the UN.
The collective effort gave iKure moments of joy, witnessing how diverse professionals came together to create a synergistic entity – One that was far more empathetic to all downstream stakeholders and far more capable at tackling the pandemic crisis. This feat was recognized by the World Economic Forum, for which iKure was named as one of the Top 50 Last Mile responders.
As India and the rest of the world shift focus from COVID-19 relief to recovery efforts, one must not miss out on the more significant transformation in people’s minds. The pandemic has caused a shift towards positive health-seeking behavior amongst patients and the healthy population, one that is progressively improving for the better. While the move towards personalized medicine is dominating higher levels of care delivery, the need for holistic care is gaining impetus in the primary and preventive space.
Both have one requirement in common- The need for interoperable data systems that leverage historical health records and analyze real-time health data from POC devices to provide longitudinal health analysis. While such a connected and accountable health ecosystem seems like a mere chimera, the first step can be taken in the right direction today so that we mitigate the adverse impacts of future pandemic threats. One of the steps needed to build a healthcare system that we need and rightly deserve is integrating WHIMS with health care data systems. While the first steps have already been taken, more impetus is required to achieve an organic and sustainable model for data-generation, sharing and utilization.
There lies tremendous potential in expanding and integrating WHIMS with local/hyper-local healthcare data systems, especially in developing countries. However, in order to sustain viable scaling, effort should be taken to ensure that model is customized to the needs, and challenges of the ecosystem wherein it will be utilized. WHIMS is one of those technologies that have the potential to build the healthcare ecosystem we not only need but rightly deserve.
The authors of this article acknowledge the contribution of iKure team during the development of this article. All images have obtained due permission from the executive team.
Both authors of this manuscript hereby state explicitly that there is no personal or financial conflict of interest. No funding was received for this article. Dr Tirumala Santra Mandal, AVP-Research and Communication who is a member of iKure leadership team provided answers to questions and made clarifications on some data.
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