Hardest Part of Going Digital May Be Changing How People Work
By Arunima Rajan
A new study by the Max Institute of Healthcare Management at the Indian School of Business (ISB) finds that hospitals adopting NABH's Digital Health Standards (DHS) have achieved substantial improvements in operational efficiency, clinical decision-making, and overall digital maturity. The study, published as a white paper titled ‘Post-Adoption Value of NABH Digital Health Standards: A Multi-Hospital Assessment in India,’ evaluates the real-world impact of digital accreditation across 20 DHS-certified hospitals representing Silver, Gold, and Platinum certification levels. Qualitative interviews and survey responses indicated that hospitals adopt DHS primarily to improve patient care quality (98.1%) and operational efficiency (88.5%), with top-down hospital leadership driving 76.9% of adoption decisions. After certification, hospitals reported marked gains in digital maturity, with the average score rising from 3.42 to 4.35 on a five-point scale. System integration improved from 3.31 to 4.35, while the use of digital records in clinical decision-making increased from 3.00 to 4.37. Strong gains were also reported in data privacy and documentation quality (4.56 each), operational efficiency (4.38), and interoperability (4.29), with the overall value of DHS rated at 4.62 out of 5. One hospital recorded reduced revenue leakage from 33% to 7%. The study highlights that successful implementation depends equally on people and technology. Staff training (85.7%) and workflow redesign (65.4%) emerged as the most demanding implementation efforts. Hospital experiences varied more by facility size, baseline digital maturity, and leadership commitment than by geographic location.With India's healthcare system digitalising rapidly, this study offers some of the first hospital-grounded evidence of what that shift looks like on the ground. The report concludes that NABH DHS is positioned to serve as a practical, long-term framework for sustained organisational change rather than a one-time compliance exercise.
In an interview with Arunima Rajan, Assistant Professor Sandeep Rath of ISB unpacks the study for Healthcare Executive.
Who is paying for the efficiency the survey scores at 4.38?
The DHS journey does involve a period of additional effort, particularly around documentation, workflow redesign, training, and behavioural change. The study also identifies staff training and workflow/process redesign as the most demanding areas and documents the additional burden nursing teams experienced during the transition.
At the same time, the reported efficiency score of 4.38 is a perceived post-certification outcome and should not be interpreted as a time-and-motion study or as evidence of net labour-hour savings. The study reports improvements in areas such as registration, discharge, billing accuracy and interdepartmental coordination, with discharge turnaround being one of the most consistently cited tangible gains.
Therefore, the more appropriate question is not simply “who pays for the efficiency?” but whether digital transformation is designed in a way that shifts work from people to systems rather than merely shifting work from doctors to nurses or other frontline staff.
This is an area where hospitals, technology providers and standards bodies need to continue focusing on usability, workflow redesign, clinical adoption and reduction of duplicate documentation.
When a hospital earns Silver or Platinum, how much of that is the hospital and how much is the software it bought? And should NABH be certifying the vendors too?
DHS is fundamentally an assessment of the hospital's digital maturity and how digital systems are implemented and used within the organisation. It is not a certification of a particular HIS/EMR product.
The study itself found that 71.1% of hospitals relied on vendor-provided systems. However, it also found that hospital IT teams remained central to vendor coordination, implementation, user feedback and customisation.
Therefore, a hospital cannot simply outsource digital maturity to a vendor. The vendor can provide the technology, but the hospital owns the governance, workflows, data quality, clinical adoption and the way the system is actually used.
The quote that “if he gives you a product that makes you capable of Platinum, you get Platinum” is useful because it highlights an ecosystem issue rather than necessarily a flaw in hospital certification.
The hospital and the technology vendor have different but complementary roles. The study found that 71.1% of hospitals relied on vendor-provided systems, but also that hospital IT teams remained central to vendor coordination, implementation, user feedback and customisation. A technology product can enable a hospital to meet certain digital requirements, but certification of the hospital is ultimately about how that technology is governed, integrated into workflows, adopted by users and used to deliver safe and effective care.
Importantly, NABH already addresses the technology-product dimension through its Digital Health Standards certification programme for HIS, EMR and CMS products. This creates a complementary model wherein technology products can be assessed for their conformity with defined digital health requirements, while hospitals are assessed on their organisational capability and implementation of digital health.
Therefore, the answer is not necessarily that every technology vendor should be “certified” through the hospital certification process. Rather, there is value in having credible, independent assessment of both the technology products and the hospitals that deploy them, with the two working together to create greater transparency and confidence in the digital health ecosystem.
Ayushman Bharat Digital Mission alignment is the one thing hospitals rate lowest, at 3.98, and the one place where working harder made no difference at all. Some hospitals told you they are staying away from ABDM because they worry about data security. Most have gone no further than generating ABHA IDs. If certified hospitals are not joining the national system, what is the standard actually connecting them to? And what would change their mind?
ABDM alignment received the lowest post-DHS outcome rating at 3.98, compared with 4.62 for overall value, 4.56 for documentation quality and data privacy, and 4.29 for interoperability.
However, this finding needs to be understood in the context of the complementary roles of DHS and ABDM. ABDM provides the broader national digital health ecosystem and infrastructure, while DHS focuses on building the digital maturity and information-management capabilities within the hospital that enable meaningful participation in such an ecosystem.
In fact, effective ABDM participation ultimately depends on what happens within the hospital. A hospital needs to be able to capture health information in a structured, standardised and interoperable manner before that information can be meaningfully exchanged and used through a national digital health ecosystem.
This is where the multi-maturity-level approach of DHS, Silver, Gold and Platinum becomes important. It provides hospitals with a structured pathway to progressively strengthen their digital capabilities, moving from foundational digitalisation towards deeper integration, interoperability and more mature use of digital information. The study similarly found that smaller hospitals often focused on foundational digital capabilities, medium hospitals on interoperability and system integration, and larger hospitals on optimisation, analytics and AI.
Therefore, I would not interpret the 3.98 score as indicating that DHS is failing to connect hospitals to ABDM. Rather, it highlights that hospital-level digital maturity and national-level interoperability need to progress together. DHS can help create the underlying capabilities, particularly structured and standardised digital health information, while ABDM provides the ecosystem in which that information can ultimately be exchanged and used.
The study also shows that ABDM adoption is not uniform. Some hospitals had progressed towards interoperability, while others cited data-security concerns. One larger hospital in the study had achieved hospital-wide interoperability at M3 level.
The next opportunity is therefore to make the DHS–ABDM pathway even more explicit: helping hospitals progressively build the digital maturity and structured-data capabilities required for ABDM, while addressing concerns around security, technical integration, implementation support and the practical value of participation.
The report says hospitals think about cybersecurity after something goes wrong, not before (p.29). Consent is still on paper because nobody is sure what a digital signature is worth in a medico-legal case. The DPDP Act is on the books but not yet in the workflow. What is the realistic risk sitting inside a certified hospital today? And should a hospital be allowed to pass at any tier without a hard floor on security and consent?
The study does identify cybersecurity as an area where investment has often been reactive, with some unresolved gaps around infrastructure, vendor capabilities, data storage and operationalisation of the DPDP Act.
At the same time, this should not be interpreted as meaning that DHS-certified hospitals are inherently insecure. Certification demonstrates conformity with the applicable standards and requirements assessed at the time of assessment; it should not be equated with zero cyber risk or permanent security assurance. Cybersecurity is an evolving risk, and therefore the focus has to move beyond point-in-time compliance towards continuous risk management, monitoring, incident preparedness and improvement.
The persistence of paper-based consent also needs to be viewed in context. The study identifies continuing legal ambiguity around digital consent in medico-legal situations, which is an ecosystem-level issue and not simply a hospital-level technology gap. Importantly, NABH has taken these learnings forward in the evolution of the Digital Health Standards. The next editions of DHS have been aligned with the requirements of the DPDP Act at an operational level, while keeping in mind the maturity pathway and varying capabilities of healthcare providers. This is important because the objective is not to impose a uniform technology or compliance burden on every hospital, but to establish an appropriate baseline and progressively strengthen requirements as organisations move from foundational to more advanced levels of digital maturity. Thus, there should be a non-negotiable baseline of cybersecurity, privacy and data-protection safeguards across all levels of digital maturity, with progressively enhanced requirements as hospitals move towards higher levels of digital maturity.
Similarly, wider adoption of digital consent will require greater legal and regulatory clarity. The study itself points to the need for sustained policy advocacy in this area.
Your own conclusion is that DHS mostly puts a stamp on digitisation that was happening anyway (p.27). Costs come first, returns arrive later and are hard to trace. Small hospitals feel the pinch most. Picture a 60-bed hospital in a tier-2 town, deciding this year whether to go for Silver. What is it really buying? And on what evidence would you tell it to go ahead, or to wait?
The study found that smaller hospitals often begin with lower digital maturity and face a disproportionately higher implementation burden. But it also found that these hospitals can achieve significant transformation through DHS, including moving away from paper, improving documentation, establishing more structured workflows and building digital governance.
The study found that 98.1% of respondents cited improving patient care quality as a motivation for pursuing DHS and 88.5% cited operational efficiency. Overall value was rated 4.62/5.
For a 60-bed hospital, therefore, the proposition is not necessarily “buy technology and get an immediate ROI.” It is about getting a structured framework and benchmark for digital maturity, identifying gaps, improving processes and building capabilities in a phased manner. The financial question is legitimate. The study itself acknowledges that ROI remains difficult to establish and that the burden is greater for smaller hospitals. My view would therefore be that a smaller hospital should not pursue DHS simply because it is a badge; rather, it should pursue it when digital transformation is a strategic priority, and it should choose a level that is appropriate to its readiness and pursue the journey in phases.
You built the sample around metro and non-metro, then found that the divide barely mattered. What separated the hospitals that got through this was the person at the top. A CEO in a small non-metro hospital walked the wards during training to make sure people used the tablets (p.15). Leadership initiated 95 per cent of these journeys. If commitment at the top is the thing that decides the outcome, was geography the wrong axis to build the study on? And what does a standard do about a hospital where the leadership is simply not interested, since that is the one thing certification cannot supply?
The study deliberately included geography as one of the dimensions because infrastructure, connectivity and workforce capacity can differ significantly between metro and non-metro settings.
However, the findings suggest that leadership commitment, baseline digital maturity, hospital size and accreditation level are stronger differentiators of the adoption experience than geography alone. Leadership-led initiation was identified in 95% of the hospitals studied.
So, I would not say geography was the wrong axis. Rather, the study demonstrates that geography by itself is insufficient to explain digital maturity.
And this is actually an important role for a standard. A standard cannot create leadership commitment, but it can provide leadership with a structured framework, defined expectations, an external benchmark and a mechanism for institutionalising digital practices beyond the tenure or interest of an individual leader.
The report is valuable precisely because it does not present DHS as a frictionless journey. Digital transformation requires investment, workflow redesign, behavioural change, training and sustained leadership commitment. The important finding is that hospitals nevertheless reported meaningful gains in patient safety, documentation quality, operational efficiency, interoperability and overall value.
The next phase is to ensure that these gains are sustained, that implementation becomes easier, particularly for smaller hospitals, and that the digital ecosystem moves beyond hospital-level digitisation towards interoperability, ABDM integration, data-driven intelligence and greater value for patients and other stakeholders.
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