Governance healthcare financial lever

GOVERNANCE
HEALTHCARE
&
FINANCIAL LEVER

THE EXPERIENCE ACROSS COUNTRIES, HAS DEMONSTRATED,
GOVERNMENT CONTROLED FINANCIAL LEVER LEADS TO A STRONG
DIGITAL HEALTH GOVERNANCE THROUGH A UHID…
Payer
System
Type
Payer System
[Financial Lever]
Provider System
Digital Health Authority
UHID based Governance
Outcome
Canada
Single
Payer
Provincial MoH
Govt buys services
from Providers
Canada Health Infoway
Digital Health Systems
Transformation
Taiwan
Single
Payer
National Health
Insurance [NHI]
Govt buys services
from Providers
Govt
Transformation
South Korea
Single
Payer
Health Insurance
Review and
Assessment
Govt buys services
from Providers
Health Insurance Review
and Assessment
Transformation
Sweden
Beveridge
Model
INERA
[GOVT]
Govt Owned
INERA
[GOVT]
Transformation
Scandinavian
Beveridge
Model
Govt Govt Owned Govt
Transformation
UK
Beveridge
Model
NHS NHS NHS
Transformation
Australia Hybrid
Medicare 67%,
Private 15%,
OOP 15%
Hybrid NeHTA, ADHA
Transformation
Spain Hybrid
Govt 85%,
Private 15 %
Hybrid
Spanish National Health
System
Transformation
USA Hybrid
Private 50%,
Medicare 28%
Largely Private
Office of National
Coordinator on Healthcare-
IT, Meaningful Use Tax
Incentives. Obamacare.
Moderate Transformation
achieved thru Tax
Incentives. Fragmented
Digital Health
System due to lack of a
Truly National UHID

Case Study – USA Digital Health Transformation

What is the Affordable Care Act
(ACA)?
The Affordable Care Act (ACA) is the
comprehensive healthcare reform signed into
law by President Barack Obama in March 2010.
Formally known as the Patient Protection and
Affordable Care Act—and simply Obamacare—
the law includes a list of health-related
provisions intended to extend health-insurance
coverage to millions of uninsured Americans.
KEY TAKEAWAYS
The Affordable Care Act—also known as Obamacare—
was signed into law in March 2010.
It was designed to extend health insurance coverage to
millions of uninsured Americans.
The Act expanded Medicaid eligibility and created a
Health Insurance Marketplace.
It prevents insurance companies from denying coverage
due to pre-existing conditions and requires plans to cover
a list of essential health benefits.
Lower-income families can qualify for extra savings on
health insurance plans through premium tax credits and
cost-sharing reductions.
Understanding the Affordable Care
Act (ACA)
The Affordable Care Act was designed to
reduce the cost of health insurance coverage
for people who qualify. The law includes
premium tax credits and cost-sharing
reductions to help lower costs for lower-income
individuals and families.

What Is the American Recovery And
Reinvestment Act?
The American Recovery and Reinvestment Act of
2009 (ARRA) is a law passed by the U.S. Congress in
response to the Great Recession of 2008. It is more
commonly known as the "stimulus package of 2009"
or the "Obama stimulus." The package included a
series of federal
government expenditures aimed at countering the job
losses associated with the 2008 recession.
KEY TAKEAWAYS
The American Recovery and Reinvestment Act of
2009 (ARRA was a fiscal stimulus bill signed by
President Barack Obama on February 17, 2009 to
deal with the Great Recession.
The Act consisted of $787 billion in spending (later
raised to $831 billion) in tax cuts/credits and
unemployment benefits for families; it also
earmarked expenditures for health care,
infrastructure, and education.
ARRA was controversial at the time—with
supporters and opponents falling mainly into
political camps—and its role in ending the Great
Recession remains debated to the present day.
Understanding the American Recovery
And Reinvestment Act
The American Recovery and Reinvestment Act
(ARRA) called for a massive round of federal spending
designed to create new jobs and recover jobs lost in
the Great Recession of 2008. This government
spending was intended to compensate for a slowdown
in private investment in the U.S. Congress, and a
streamlined amendments process allowed for passage
in the House of Representatives on January 28, 2009.
The U.S. Senate passed its version on the 10th of
February.

What is the Health Insurance Portability
and Accountability Act
(HIPAA)?
Health Insurance Portability and Accountability Act
(HIPAA) is an act created by the U.S. Congress in
1996 that amends both the Employee Retirement
Income Security Act (ERISA) and the Public Health
Service Act (PHSA). HIPAA was enacted in an effort to
protect individuals covered by health insurance and to
set standards for the storage and privacy of personal
medical data.
Understanding the Health Insurance
Portability and Accountability Act
(HIPAA)
Health Insurance Portability and Accountability Act
(HIPAA) ensures that individual health-care plans are
accessible, portable and renewable, and it sets the
standards and the methods for how medical data is
shared across the U.S. health system in order to
prevent fraud. It preempts state law unless the state's
regulations are more stringent.
KEY TAKEAWAYS
HIPAA law impacts policies, technology, and record-
keeping at medical facilities, health insurance
companies, HMOs, and healthcare billing services.
Noncompliance with HIPAA standards and best
practices is against the law.
The HITECH Act was created to expand HIPAA
privacy and security protections for patients.
Medical identity theft is a concern in the healthcare
community.
This act has been modified since 1996 to include
processes for safely storing and sharing patient medical
information electronically.
Important: HIPAA also has an administrative
simplification provision, which is aimed at increasing
efficiency and reducing administrative costs by
establishing national standards.
Health insurers, health maintenance organizations
(HMOs), healthcare billing services, and other entities
that handle sensitive personal medical information must
comply with the
standards set by the HIPAA. Noncompliance may result
in civil or criminal penalties.

DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Office of the Secretary
45 CFR Part 160
RIN 0991–AB55
HIPAA Administrative Simplification:
Enforcement
AGENCY: Office of the Secretary, HHS.
ACTION: Interim final rule; request for
comments
SUMMARY: The Secretary of the
Department of Health and Human
Services (HHS) adopts this interim final
rule to conform the enforcement
regulations promulgated under the
Health Insurance Portability and
Accountability Act of 1996 (HIPAA) to
the effective statutory revisions made
pursuant to the Health Information
Technology for Economic and Clinical
Health Act (the HITECH Act), which
was enacted as part of the American
Recovery and Reinvestment Act of 2009
(ARRA).
More specifically, this interim
final rule amends HIPAA’s enforcement
regulations, as they relate to the
imposition of civil money penalties, to
incorporate the HITECH Act’s categories
of violations, tiered ranges of civil
money penalty amounts, and revised
limitations on the Secretary’s authority
to impose civil money penalties for
established violations of HIPAA’s
Administrative Simplification rules
(HIPAA rules). This interim final rule
does not make amendments with
respect to those enforcement provisions
of the HITECH Act that are not yet
effective under the applicable statutory
provisions. Such amendments will be
subject to forthcoming rulemaking(s).
DATES: Effective Date: This interim final
rule is effective November 30, 2009.
Comment Date: Comments on this
interim final rule will be considered if
received at the appropriate address, as
provided below, no later than December
29, 2009.

February 19, 2015 - The Centers for Medicare & Medicaid Services (CMS)
oversee the Medicare and Medicaid EHR Incentive Programs, meaningful use
payments, and payment adjustments for eligible professionals and hospitals
including critical access hospitals (CAHs).
Under the Medicare EHR Incentive Program, healthcare facilities may receive a
maximum incentive payments of $44,000 over the course of five sequential years.
The payments first started in 2011 and will continue until the end of 2016.
Meanwhile, the Medicaid EHR Incentive Program confers a maximum of $63,750
over six years. In order to receive these incentives, eligible professionals and
hospitals must prove they are meaningfully using certified EHR technology
(CEHRT) in their practices.
After first-year entities participated (https://www.cms.gov/Regulations-
andGuidance/Legislation/EHRIncentivePrograms/Downloads/MLN_MedicareEHR
Program_TipSheet_EP.pdf) in the program, they could obtain as much as $18,000.
In subsequent years, incentive payments were lower, ending with $2,000 by the
fifth year for Medicare eligible professionals.
In 2009, Congress passed a ruling within the American Recovery and
Reinvestment Act that assigned payment adjustments or penalties
(http://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/PaymentAdj_Hardship.html) to
eligible medical professionals and hospitals that did not meet meaningful use
requirements of CEHRT under the Medicare EHR incentive program. Eligible
providers who do not meet meaningful use will receive one-percent payment
reduction in the first year, which will rise in every subsequent year to a maximum
of five percent.
Healthcare providers who are eligible only for the Medicaid program will not have
the burden of these payment adjustments. For those who serve both Medicare
and Medicaid patients, they will be subject to payment adjustments if they fail to
meet meaningful use requirements.

India Case Study - eGovernance and Financial Lever

Modi Govt puts
eHealth in
Manifesto
NIN, Facility
registry
2008 2011 2013
2017
2018
2019
Government
of India’s
National
Knowledge
Commission
Mission Mode
Project on Health,
National e-
Governance Plan and
‘Public Health IT
Study Report’ by
NHSRC
EHR and
MDDS draft
standards
India’s National
Health Policy
Release of
National Health
Stack (NHS) by
NITI Aayog
(Also, MoHFW initiated
process to setup NDHM
as a statutory body)
Launch of the NDHB by Health
Minister
2015
Concept Note on National
eHealth Authority
Multiple consultations on Digital Health architecture by development partners along with Ministry
of Health and Family Welfare (MoHFW)
Ayushman Bharat
(PM Mission Mode
Project)
MDDS
Notification
Telemedicine Guidelines 2020
NDHM Announcement
#AtmaNirbharApnaBharat
2020
Digital Health | India’s Policy Journey So Far..
Over the past few years, in addition to analyzing global best practices, conducting landscape assessments, considerable
consultations were conducted with relevant stakeholders at the center / state, academia, private sector.
National Rural
Health Mission and
Vertical Programs
write their own IT
Systems in Silos

By leveraging the wealth of insights generated from the scheme
data, PMJAY can embrace the power of business intelligence and
make more informed decisions that will lead to better program
outcomes, quality of care, increased affordability and accessibility
for the beneficiaries.
In addition to the core program, this data can also be used to drive
decisions across the larger healthcare ecosystem across varied
stakeholders:
For instance:
• To evaluate the scheme performance and help predict the patient
load across different disease type and geography
• For NHA and other insurance schemes, this data can be leveraged to
leveraged to review Ayushman Bharat holistically, i.e. triangulation
triangulation of PMJAY and data from Health &WellnessCenters.
Centers.
• For policy-makers this data is important to analyze along with other
other healthcare datasets to introduce effective policy interventions.
PMJAY
NHA ++
Policy
Quality of Care,
Affordability and
Accessibility.
Operational
excellence
NHA, other Central
Government
insurance schemes
and Private sector
insurance schemes
under IRDAI
Policy across public
and private sector
providers and payers.
Health system
strengthening, health
policy and universal
health care
A
B
C
Data Insights Driven Universal Health Coverage

Ecosystem, Not system
NationalDigitalHealthEco‐system(NDHE),Federated Architecture, Health Information
Exchanges – ‘Think Big, StartSmall,ScaleFast’
Principles & Building Blocks
Minimum viable set of 35 building blocks, and more can be defined..
Applications & Digital Services
Identified thematic areas for development and deployment of applications
Standards
Recommended minimum viable set of standards, e.g. EHR, MDDS, SNOMED, FHIR..
Institutional Framework
Recommended establishment of National Digital Health Mission (NDHM),
government organization with complete functional autonomy
“The NDHB forms the foundation
on which the edifice of an entire
National Digital Health Eco‐system
can be built in a phased manner.”
- J. Satyanrayana, Chairman,
Committee on NHS
Released Standard Nov 2019
Executive Summary
National Digital Health Blueprint (NDHB)

ELECTRONIC HEALTH RECORD (EHR) STANDARDS
EHR gave the WHAT & WHY
*Version1 in 2013, Version2 in 2016

ल िंग
X
Y
Z
DATA
ELEMENT XXX
1. Library of 1000+ Data Elements,
2. 140+ Code Directories
3. Registry Design
4. Health Information Exchange Concept
5. Governance
Common meaning conveyed by different code sets
Gender
MALE
FEMALE
TRANS
OTHER
பாலினம்
1
2
3
4
HDD
System 1 System 2
DATA TYPE,
DATA SIZE,
VALUE SETS,
CODE DIRECTORIES
MDDS- Health Data Dictionary [HDD] for India for semantic
interoperability.
MDDS gave the HOW
*Drafted in 2013-2014, Notified Standard
since Aug 2018
META DATA AND DATA STANDARDS FOR HEALTH (MDDS)

E-OBJECTS BASED ON FHIR RESOURCES FOR DATA POINT LEVEL
INTEROPERABILITY: PROVIDER TO PAYER AND PROVIDER TO PROVIDER
OPD
eObjects
E-Prescription
E-Referral
IPD
eObjects
E-Preauth
Request
E-Claim
E-Discharge
Summary
Provider
Payment
E-Provider
payment
E-Payment
Remittance
Advice
CHAPTER 5 - Reimagining India’s Digital Health
Landscape: “Wiring” the Indian Health Sector
ACCESS Health [Prof Dennis Streveler and Dr Pankaj Gupta] first wrote the concept of eObjects in NITI Aayog Theme papers, Health System for a NEW India: Building Blocks, Delhi, India,
2019.
Book by NITI Aayog | Health Systems For New India: Building Blocks
*Released Nov 2019

e-Objects: E Claim & Provider e-Objects
Header (Information about
facility, provider and
beneficiary/patient
Clinical Brief(Active Allergies,
Active complaints,
comorbidities, Active
Diagnosis),
Prescriptions (Ordered Rx,
Labs with result, Procedures)
Doctor’s Advice for
admission/follow up
Provider e-Object
• E-ENCOUNTER NOTE
• E-PRESCRIPTION
• E-REFERRAL
• E-DISCHARGE
Payer e-Object
• E-PREAUTHORIZATION
• E-CLAIM
• E-DISCHARGE
• E-PROVIDER PAYMENT
Header (Information about the payer,
provider, plan/scheme identifiers,
beneficiary identifiers)
Plan details( plan ID/no./policy no.)
Facility details(facility ID, specialty,
treating doctor)
Treatment details (procedures,
medications, investigations,
admission details)
Claim cost (package cost, service
cost, IRDA bill buckets & service
codes, standard bill
Data Model & key value pair-
Metadata standards/data dictionary of
India
eObject structures are based on NDHB recommended Standards

NDHM
FOR
AFFORDABILITY
ACCESSIBILITY
QUALITY
HEALTH CLAIMS PLATFORM
FINANCIAL LEVER
EPIDEMIOLOGICAL DATA
ANALYSIS
COVID 19 PANDEMIC
eGOVERNANCE
NDHB
TELEMEDICINE
GUIDELINES
EHR
STANDARDS
MDDS FOR HEALTH
DATA DICTIONARY
AND REGISTRIES
 Telemedicine guidelines released in April 2020. These will ensure an accelerated adoption of NDHB based standards
 National Digital Health Mission announced in May 2020 as part of the Government's response to the Coronavirus
Pandemic. The mandate is to operationalize, execute and implement the National Digital Health Blueprint.
Digital Health | Levers of Change

eClaim Objects
eDischarge Object
eBill
Sent for Claims
Adjudication
ACCESS Health Digital has
launched a Social
Entrepreneurship Accelerator
which can facilitate this
2019.
eObjects are generated on Provider Side

Machine Readable
Common Health Claims Platform
Opportunity for
Industry to innovate
for Claims Auto
Adjudication
AHD-SEA and NHA-
MAP can facilitate this
eobjects
2019.
IRDAI – NHA JOINT WORKING GROUP | IT Infrastructure For Automating Health Insurance Claims
*Released Sep 2019

Epidemiological Lever | The Inevitable Change
Need to stitch multiple disparate systems for supply-chain and epidemiological analysis
Clinical
Experience
Published
Papers
Patient
Data
NDHB Standards based Unified Health
Interfaces for HealthTech and MedTech
Labs,
Radiology,
Pharmacy
Home Care,
Telemedicine
Hospital HIS
and Clinics
EMR
Identify Hotspots, Containment
Strategy, Resource Optimization
We are failing in this
Pandemic because we were
unable to get machine
readable HealthTech and
MedTech Data in Standard
formats for near real time
Epidemiological Analysis

Disease Burden
Disease Burden due to Chronic Non
Communicable diseases are a major cause of
morbidity in India.
EXPLANATION
There is an alarming change in disease pattern in India. A
significant increase in share of non communicable disease
is evident (57% in 2020) . India is now the Diabetes capital
of the world (>65M cases). Also, a jump in diseases
related t Mental Health, COPD, Asthma contribute to the
increasing share of non communicable diseases in India.
Even though there is a reduction in communicable,
maternal and peri-natal diseases but the absolute
numbers are still high.
There are numerous factors that influence the
distribution pattern of the diseases. Such as
different geographies, genetic predisposition etc.
etc.
Source: Chapter 2.8, 10th Five Year Plan, Planning Commission, Government of
India
Disease Burden 1990
29%
15%
56%
Non-communicable
Injuries
Maternal Child &
Communicable
Disease Burden 2020
57%
24%
19%
Non-communicable
Injuries
Maternal Child &
Communicable
Disease Burden

Disease Burden and Claims Analysis
Key Findings
Actuarial, Policy and packages based on top 5
disease burden, morbidity segmentation, mortality
by disease, risk calculation based on population
segmentation by NCD burden. Claims Forecasting
based on disease burden and demographics
Cardiovascular Disease burden is the 4th highest but
the Highest category on Claims outflows. Why?
Mental illness, Diabetes and COPD Asthma are top
3 Disease Burdens. Do our Policy design reflect
this? Why not develop specific Packages for them?
Cardiovascular
Tuberculosis
760 / Lac
650 / Lac
440 / Lac
405 / Lac
310 / Lac
Figure 3: Disease Burden Estimates 2005 to 2020
Cancers 9.8 / Lac
2500 / Lac
4375 / Lac
5833 / Lac
Co-
Morbidity
290 / Lac
< 167 / Lac
< 8 / Lac
1500 / Lac
183 / Lac
98 / Lac
141 / Lac
85 / Lac
1 Lac =
100K
8333 / Lac
Diabetes
COPD and Asthma
Maternal Mortality
Mental Health
Diarrheal Diseases
Source: Report of the National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare, Government of India,
2005
2020 Projections as per Internal Calculations from secondary research
Disease Burden

The analytics layer is extremely important, would
translate business use cases into big data strategy
and will seek to answer the following question, what
all data is needed to perform the required analysis,
what all capabilities are to be built within NHA? How
to define the analytical roadmap for the short,
medium and long term?
Descriptive
What is
happening?
Foundation
Setting up
Diagnostic
Why is it
happening?
Predictive
What is likely
to happen?
Prescriptive
What to do?
Analytics Maturity Model
Current Status
Short Term
0-18 Months
Medium Term
18-36 Months
Long Term
36-48 Months
Analytics Layer
How analytics support
business objectives, use
cases, business
partnership etc.
Identify
governance
structure, build
collaborative
networks with
partners and
SHAs
Data Insights CoE Roadmap

eGovernance - Foundation of Resource Optimization
Ambulatory
Resources
Human
Resources
Diagnostics
Healthcare
Delivery
Beds
Devices
Durables
Drugs
Consumables
Vaccines
NDHB recommends single source of truth in the forms of Registries and Identifiers
Supply
Chain

THANKS!
Dr Pankaj Gupta
Head – ACCESS Health Digital
digital.health@accessh.org
Twitter: @pankajguptadr, @accesshdigital
LinkedIn: drpankajgupta, accesshdigital

Comparative Study - UHID of Different Countries
Appendix

Global Learnings : Countries using Single UHID across Health Systems
Name of the
Country
Population
Covered(in
Millions
approx.)
National
Unique
Health
Identifier
Used
(Yes/No)
Federated
ID
structure
used
(Yes/No)
Description Sources
Countries Using a Single UHID across the Health System
England 67 Yes No
An NHS number is a 10-digit number, like 485 777 3456. NHS
number is unique to every individual. It helps healthcare staff
and service providers identify you correctly and match ones
details to their health records. NHS number is assigned after a
child is born or the first time they get NHS care or treatment.
This number is valid for life unless you're assigned a new
number due to a reason like adoption or gender reassignment.
https://www.nhs.uk/using-the-
nhs/about-the-nhs/what-is-an-
nhs-number/
Ireland 4.9 Yes No
An Individual Health Identifier or IHI is a number that uniquely
and safely identifies each person that has used, is using or may
use a health or social care service in Ireland. In case patient
records with the same demographic details are provided for
seeding (authentication), the same IHI number will be assigned
to each patient record thus helping identify duplicate records
within your system. It is important to note that the IHI Register
will not merge provided duplicate records for your Consumer
System.
https://www.ehealthireland.ie/A
2I-HIDs-Programme/Individual-
Health-Identifier-IHI-/
Israel 8.6 Yes No
Each citizen has a unique patient ID. Patients have the right to
get copies of their medical records from hospitals and health
plans, and patients can book appointments and access many
components of their EHR online (such as lab test results), but
full records are not generally available.
https://www.commonwealthfun
d.org/international-health-
policy-center/countries/israel

Global Learnings : Countries using Single UHID across Health Systems
Name of the
Country
Population Covered(in
Millions approx.)
National Unique
Health Identifier
Used (Yes/No)
Federated ID
structure used
(Yes/No)
Description Sources
Countries Using a Single UHID across the Health System
Norway 5.4 Yes No
All residents have a unique personal identification number, used
in primary care and for hospital medical records. Virtually all
GPs use electronic health records and transmit prescriptions
electronically to pharmacies.
https://www.commonwealthfund.org/internat
ional-health-policy-center/countries/norway
Taiwan 23 Yes No
Everyone in Taiwan carries an electronic NHI card bearing a
unique personal identifier to access care. The card encodes
personal information, insurance data, notes from recent medical
visits, diagnoses, drug prescriptions, drug allergies, major
illnesses, organ donation consent, palliative care directives, and
public health records (including immunizations).
https://www.commonwealthfund.org/internat
ional-health-policy-
center/countries/taiwan#:~:text=Health%20
System%20Statistics&text=Taiwan's%20na
tional%20health%20insurance%20(NHI,%2
C%20civil%20servants%2C%20and%20oth
ers.

Global Learnings: Countries using National Identifier as Unique Health Identifier
Name of the
Country
Population
Covered(in
Millions approx.)
National
Unique Health
Identifier Used
(Yes/No)
Federated ID
structure
used
(Yes/No)
Description Sources
Countries Using National Identifier as Unique Health Identifier
Slovenia 2 Yes Yes
Slovenia uses both UIN and UHI, and the two numbers are
highly linked by the central population register (CPR). The
process starts with birth registration. When a baby is born, the
birth is registered by the health personnel electronically at the
hospital before the family is discharged. The three unique
numbers, namely the UHI, UIN, and tax number of each
individual, are used for various services across multiple sectors
throughout the individual’s life. Data collected through these
transactions can be linked and retrieved using the unique
identifiers.
https://www.ncbi.nlm.nih.gov/pmc/ar
ticles/PMC6800486/
South Korea 51
Yes, linked with
Unique
Identification
Number
Yes
Family Relationship Registration (FRR), Resident Registration
(RR), and vital statistics are used to link Personal Identification
Number (PIN). The RR number is widely used, including as a
UHI to access benefits through the national health insurance
(NHI) system. Individuals’ RR numbers are used to link
information stored in different databases, such as those in
relation to health, income, property, tax, and family relationship,
to calculate the contribution rate. The RR card is issued to all
citizens 17 years of age and older, and it can be presented to
access health care without having to carry a separate health
insurance card.
https://www.ncbi.nlm.nih.gov/pmc/ar
ticles/PMC6800486/

Global Learnings: Countries using National Identifier as Unique Health Identifier
Name of the
Country
Population
Covered(in
Millions
approx.)
National
Unique
Health
Identifier
Used
(Yes/No)
Federated
ID
structure
used
(Yes/No)
Description Sources
Countries Using National Identifier as Unique Health Identifier
Sweden 10
Yes, linked
with Unique
Identification
Number
Yes
The Swedish personal identity number (PIN) a ten-digit-PIN is
maintained by the National Tax Board. In health care, the PIN is
used for vital statistics (date of birth, date of death), but it is also
the unique identifier and the key variable when matching
between different registers including The Patient Register it is
used to trace patients and their medical records. The Swedish
PIN serves as a unique identifier in Swedish health care, and in
many other areas of the Swedish society. Furthermore, the PIN
is the key variable in all large register linkages in Swedish
medical research
https://www.ncbi.nlm.nih.gov/p
mc/articles/PMC2773709/#:~:t
ext=In%20conclusion%2C%20
the%20Swedish%20PIN,linkag
es%20in%20Swedish%20medi
cal%20research.
Thailand 70
Yes, linked
with Unique
Identification
Number
Yes
A personal identification number (PID), is assigned to each Thai
citizen, the PID is used to identify whether the child is a Thai
citizen, and if he/she is, the child is automatically enrolled into
the national health insurance scheme. each hospital’s health
care information system creates its own patient identification
number, this number is linked to the individual’s national PID.
Then, health care professionals use the PIDs to check patient
eligibility, track health care services provided, and process
claims, among other activities. PIDs ideally make electronic
medical records sharable among health care providers. Thai
citizens use chip-containing citizen identification cards to access
health services.
https://www.ncbi.nlm.nih.gov/p
mc/articles/PMC6800486/

Global Learnings : Countries using multiple IDs linked to a single Unique
Health ID (Federated Model)
Name of the
Country
Population Covered(in
Millions approx.)
National Unique
Health Identifier
Used (Yes/No)
Federated ID
structure used
(Yes/No)
Description Sources
Countries using a multiple IDs linked to a single Unique Health ID (Federated Model)
Australia 25 Yes Yes
The Healthcare Identifiers (HI) Service is a national system for uniquely identifying
healthcare providers and individuals.
As part of the HI Service, every Australian resident is allocated a unique 16 digit
IHI. All individuals who are eligible for Medicare, or who are eligible for a
Department of Veterans’ Affairs (DVA) pension, automatically have an IHI
assigned. A person can have multiple Medicare IDs which where generated
during the time of treatment and have to be linked to IHI at the central level for
authentication and validation of the individual.
https://www1.health.gov.au/internet/main/pu
blishing.nsf/Content/pacd-ehealth-
consultation
https://www1.health.gov.au/internet/main/pu
blishing.nsf/Content/pacd-ehealth-
consultation-faqs
Canada 37
Yes, managed at
provincial level
Yes
Since healthcare is funded and governed at a provincial level, and each province
has different privacy regulations, it would have been extremely difficult to design
and execute a pan-Canadian identifier. Therefore the decision was made to
develop registry services to support client (patient), provider, location, and
terminology domains. These complex registries were a key component of the
Health Information Architecture Layer (HIAL) and the common services and
service bus. Registries (also known as directories or repositories) accurately
identify patients and authorized clinicians. Virtually all Canadians and practicing
physicians have been uniquely identified in the registries that are established in
each province and territory. Provincial-level identifiers already existed to support
the funding and payment of healthcare services, with functioning client (patient)
registries for each province.
https://www.infoway-
inforoute.ca/en/solutions/digital-health-
foundation/electronic-health-records
Estonia 1.3 Yes Yes
Each person in Estonia that has visited a doctor has an online e-Health record
that can be tracked. Identified by the electronic ID-card, the health information is
kept completely secure and at the same time accessible to authorized individuals.
The Estonian eHealth system centers on a central digital infrastructure. Local
healthcare systems connect to the central platform, sending and receiving
healthcare data. The portal is connected to one person through personal
identification cards. Functioning very much like a centralized, national database,
the e-Health Record actually retrieves data as necessary from various providers.
https://accessh.org/wp-
content/uploads/2015/10/Estonian-
eGovernance-Case-Study.compressed.pdf
https://www.integratedcare4people.org/med
ia/files/CaseProfileEstonia.pdf

Name of the
Country
Population
Covered(in
Millions approx.)
National
Unique Health
Identifier Used
(Yes/No)
Federated ID
structure
used
(Yes/No)
Description Sources
France 65 Yes Yes
Hospital-based and office-based professionals and patients have a unique
electronic identifier, and any health professional can access the record and
enter information subject to patient authorization. Interoperability is ensured
via a chip on patients’ health cards. Patients have full access to the
information in their own records, paper or electronic, either directly or
through their GP. The sharing of information between health and social
care professionals is planned as part of the deployment of EHRs to nursing
homes.
https://www.commonwealthfund.org/
international-health-policy-
center/countries/france
Germany 83 Yes Yes
For the unique electronic identification of German residents when availing
themselves of public healthcare services, a special health insurance ID
number has been introduced. This ID is based on the social insurance
number, which now every newborn baby receives. Using a specific
mathematical algorithm, the health insurance ID is generated form this
number, but does not allow reconnecting to the initial social insurance
number – this was a data protection requirement. This national electronic
registry of statutory health insurance IDs is managed by the health
insurance companies through their trust agency health insurance number,
which creates the IDs on the basis of the social insurance IDs.
file:///C:/Users/lenovo/Downloads/Te
legram%20Desktop/Germany_Coun
tryBrief_eHS_12.pdf
New Zealand 4.8 Yes Yes
The National Health Index number (NHI number) is a unique identifier that
is assigned to every person who uses health and disability support services
in New Zealand. The complexity of hospital care and the wide variety of
primary care providers has led to the development of independent clinical
information systems. Important information relating to an individual patient
is often held in more than one place. The NHI number allows all this
information to be brought together. Most DHB patient management
systems use the NHI number as a medical record number, and most
require an NHI number before a patient can be admitted or have tests
done.
https://www.health.govt.nz/our-
work/health-identity/national-health-
index

Name of the
Country
Population
Covered(in
Millions
approx.)
National
Unique
Health
Identifier
Used
(Yes/No)
Federated
ID
structure
used
(Yes/No)
Description Sources
Singapore 5.8 Yes Yes
The National Health Identification Service (NHIS) is a patient
master index, linked to various healthcare centers in
Singapore. It allows the NEHR( National Electronic Health
record) to match patient records from across the health
domain in the country. Singapore has a National Registration
Identity Card (NRIC) required for all permanent resident age
15 years and older. The NEHR adaptive enterprise
architecture uses registry services to support patient, clinician
and facility, and document services. Patient identification is
delivered as a core service (within the service-oriented
architecture) that is executed using master data management
software and a probabilistic matching algorithm that is tuned
for the Singaporean data.
https://ec.europa.eu/health/sit
es/health/files/ehealth/docs/e
v_20180515_co23_en.pdf
https://perspectives.ahima.or
g/accurate-patient-
identification-a-global-
challenge/
Spain 46 Yes Yes
The introduction of unique patient identifiers and smart Health
Identity Cards (TIS) , the development of the eCR and
electronic prescriptions followed multiple paths and variety
with regard to the degree of implementation. The first
necessary step was to enhance a single system of patient
identification valid across the country independently of where
the TIS were issued.
https://www.euro.who.int/__d
ata/assets/pdf_file/0004/1288
30/e94549.pdf

Global Learnings : Countries using multiple IDs but no Single Unique Health ID
Name of the
Country
Population
Covered(in
Millions
approx.)
National
Unique
Health
Identifier
Used
(Yes/No)
Federated
ID
structure
used
(Yes/No)
Description Sources
Countries using a multiple IDs but no single Unique Health ID
United
States of
America
(USA)
330 No No
In the USA, different health care service organizations
create their own patient identification numbers, making it
difficult to connect one individual’s health records from
different health care providers. To connect health records
from disparate health information systems without a national
UHI, one must perform statistical matching based on
multiple patient characteristics. Hence, in the USA, the
Health Insurance Portability and Accountability Act of 1996
(HIPAA) mandated the Secretary of Health and Human
Services to develop standards for issuing national UHIs to
individuals, which is currently under works
https://www.cms.gov/Regulat
ions-and-
Guidance/Administrative-
Simplification/Unique-
Identifier/UniqueIdentifiersOv
erview
https://www.ncbi.nlm.nih.gov/
pmc/articles/PMC6800486/

Single UHID
Either UHID is the National Identifier or is
Linked to the National Identifier
Effectiveness of UHID based
eGovernance and Portability of Health
Data
3 3 3
2 2 2
1 1 1
*Scoring done by collective knowledge and inputs from experts. Quantitative scoring sheet can be provided later.

Some Important Terms
 Unique Health Identifier (UHID)- A Unique Health Identifier is a unique number generated and
assigned to a patient to identify him/her uniquely across healthcare facilities and healthcare
programs in a country
 Unique Identifier (UID)- A unique identifier is any identifier which is guaranteed to be unique among
all identifiers used for those objects and for a specific purpose. At a national level to uniquely identify
individuals.
 Federated ID Management - "Where UHID can serve as a primary key for all disconnected healthcare
applications. Even though a state is free to decide a state or facility specific local identifier, it will be
required to link the local identifiers to the UHID, followed by a successful authentication through the
National master patient index. The UHID thus facilitates linking all the surrogate IDs or local health
identifiers assigned to the patient by various facilities and healthcare programs together through a
federated patient identifier management."

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