Initiatives: National Ayush Morbidity and Standardized Terminologies Electronic (NAMASTE) Portal

India is one of the countries that has developed services of traditional medicine through the official planning process of the health service system. The Government of India has established a separate Ministry of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy (Ayush) to cater the needs of the traditional medicine [1,8] (see Fig. 1).

Fig. 1.

Time line of early Ayush standardization efforts.

1. Need for development of standardized terminologies and morbidity codes for Ayush systems

Standardization in the context of medical terminologies, refers to creation of accepted specifications (e.g. definitions, norms, units, rules) that establishes a common language as a basis for understanding and exchange of information between different parties. Standardization process enhances accuracy, efficiency, reliability, and comparability of health information at local, regional, national, and international levels. International Classifications of Diseases (ICD) is hallmark example for standardization of medical terminologies. ICD is created in the year 1853 and sustained till date with eleven revisions. It is standard to report mortality and morbidity in member states, yielding important information about population health over decades [2].

The hallmark feature of standardization of traditional medicine [in the context of traditional Chinese Medicine (TCM] is well captured by Juan Wang et al. under the principle of “unification, simplification, coordination, and optimization” and by its comprehensive use, refers to developing and applying standards to the various links, processes, and objects of traditional medicine such as: medical care, scientific research, education, industry, culture, and management [3]. The same is applicable for recognized Indian traditional systems of medicine viz., Ayurveda [18], Siddha [1], Unani [1].

A prerequisite for achieving overall standardization of Traditional Medicine (TM) is terminology standardization. The salient reasons for the same are as follows.

• 1.Language barrier: Ayurveda follows Sanskrit, Siddha-Tamil, Unani-Arabic/Persian/Urdu and is comprehendible among the trained vaidyas or hakims only. Though with the advent of syncretic models of training and translated works in vernacular languages (viz., hindi, marathi, gujarati, telugu, malayalam etc.) and English there is a void to represent a standard set of terminologies which can be employed across India and elsewhere.(see Table 3)
• 2.The globalization has resulted in dissemination of Indian systems of medicine across the world and many authors, practitioners of these systems and Indology/Southeast Asian study scholars have come up with voluminous works in english. It is a notable development with a limitation of “multiple english words/expressions depicted as equivalents for a certain traditional medicine term.” [4].(see Table 2)

Table 3.

Chapters of Standardized Unani Terminologies covering 4028 terms.

Sl.No	Name of the chapter.
1.	Tashrih (Anatomy)
2.	Manafi‘ al-A'da’ (Physiology)
3.	Umur Tabi'iyya (Basic Principles of Unani Medicine)
4.	Mantiq wa Falsafa wa ‘Ilm-i Hay'at (Logic, Physiology and Analogy)
5.	‘Ilm al-Adwiya (Pharmacology)
6.	‘Ilm al-Amrad wa Saririyyat (Pathology and Bed side Medicine)
7.	Tahaffuzi wa Samaji Tibb (Preventive and Social Medicine)
8.	Tibb al-Qanun (Medical Jurisprudence)
9.	‘Ilm al-Samum (Toxicology)
10.	Mu'alajat (Medicine)
11.	Jarahat (Surgery)
12.	Amrad-i Niswan (Gynecology)
13.	‘Ilm al-Qabalat (Obstetrics)
14.	Amrad-i Atfal (Paediatrics)

Table 2.

Details of standardized Sidha terminologies.

S.No	DIVISIONS	SUB-DIVISIONS	CODES
1.	Siddha formulations and Principles	11	0.0.1 to 0.10.10
2.	Noi Nadal (Pathology)/Diagnostics	9	1.0.1 to 1.8.25
3.	Maruthuvam (General Medicine)/Diseases	10	2.0.1 to 2.9.4
4.	Gunapadam (Pharmacology)/Therapeutics	13	3.0.1 to 3.12.27
5.	Varmam, Thokkanam (Massage therapy)and Suttigai(Cauterization)-External Therapies	5	4.0.1 to 4.4.6

1.1. Benefits of standardized terminologies and encodable morbidity entities

The development of standardized terminologies and morbidity codes enables- Counting of traditional medicine health services and encounters and measure their form, frequency, effectiveness, safety, quality, outcomes, and cost internationally, It helps make a strong case for inclusion of Ayush interventions in National Health Programmes, facilitates international comparability of practice, research and reporting of morbidity in this part of traditional medicine.

Availability of these terminologies in electronic format enable- Digitization of Traditional Medicine (TM) diagnoses data with facilitated integration into Electronic Health Record (E.H.R) systems and utilization of powerful terminology portals such as Systemized Nomenclature of Medicine – Clinical Terms (SNOMED-CT), Logical Observation Identifiers Names and Codes (LOINC)., and interoperable standards such as Health Level Seven International-HL-7.

Joint use of ICD-11 TM Chapter and other International Classification of Diseases-ICD-11 Chapter (e.g. Neoplasm, Patient Safety, Injuries) can enhance adverse-event reporting and enable integration of TM into insurance coverage and reimbursement systems, in line with larger WHO objectives relating to universal health coverage and link TM practices with global conventional medicine norms and standard development.

In summary, standardization of terminologies and diagnostic classifications helps promote academic development and propagation of achievement, to standardize management, guarantee the quality and safety of medicine/treatment procedures, aids to promote the modernization and international communication to achieve good economic and social benefits. This aids to achieve guiding and supporting a series of activities for the purpose of the comprehensive development of traditional medicine [3].

1.2. Status of AYUSH related terminology and diagnostic classification standardization in India

The effort of standardisation of diagnosis and terminologies of Ayurveda, Unani, and Siddha (A-S-U) systems of medicine is a work in progress in India since 1946 with Bhore Committee [4] recommending up-gradation of Indian Systems of Medicine by standardization and rationalization [5]. The subsequent significant developments viz., setting up of “Central Research Council of Indian Systems of Medicine and Homoeopathy – CCRIMH (1969), creation of department of Ayush (1995) [6] and subsequent up gradation of the same to dedicated ministry (2014) [7] have cemented this effort.

Before the umbrella initiative of National Ayush Morbidity and Standardized Terminologies Electronic (NAMASTE) Portal was launched few discrete yet very important steps have been attempted in the direction of creating standardized nomenclature-based documents (See Fig. 2), which are as follows.

• A.National Pharmacopoeias & Formularies on Ayurveda, Siddha & Unani (provides English equivalents of plant/animal/mineral origin drugs and disease names as glossary in Annexure) [8].
• B.In the year 2008–2013 an AYUSH funded project titled “Ayurveda Encyclopedia” was carried out at -NIIMH, Hyderabad (CCRAS) culminating in the publication of lexicographical information with applied details for 3000 words. This initiative also has led to the development of accessory tools to carry out literature research such as e-Samhitas, lexicon editing tool etc., and further expertise to carry out works related with Ayurvedic terminology.
• A.Publication of Ayurveda, Siddha, Unani, Homoeopathy Essential Drug Lists (EDLs) −2013 [9].
• B.WHO project(s) on “Standardization of Ayurveda, Unani, Siddha Terminologies (2010)” [10]. and Benchmarks for training in traditional/complementary and alternative medicine: benchmarks for training in Ayurveda [11], Siddha, Unani published by World Health Organization etc.,
• C.Use of OPD-Disease CODES for 84 Conditions for Reporting Morbidity statistics from Central Council of Research in Ayurvedic Sciences (CCRAS) clinical units.
• D.ICD-10 tagging and arrangement of contents as International Classification of Primary Care (ICPC) for archiving of clinical studies for Ayush systems in AYUSH RESEARCH PORTAL (http://ayushportal.nic.in) for better comparability of data, communication, integration [12].
• E.National Accreditation Board for Hospitals & Healthcare Providers (NABH) [13], National Accreditation Board for Testing and Calibration Laboratories (NABL) [14] quality certifications for Ayush hospitals, clinical setups, laboratories through quality council of India (QCI)
• F.Short-listing of medical conditions for medical Insurance coverage for Ayush treatment modalities [15].

Fig. 2.

Timeline of activities related with Ayurveda, Siddha, Unani Standardized terminologies, Morbidity Codes and other developments.

1.3. Contrast between standardization efforts of traditional Chinese medicine (TCM) and Indian Systems of Medicine (ISM)

It is pertinent to note that the under the aegis of World Health Organizaiton (W.H.O) the efforts made to standardize the terminologies and employ diagnostic classification (coding) for traditional Chinese medicine (TCM) in Western Pacific Region (lead by China, Japan and South Korea and other regional members) began as early as 1981 with an event for organizing “Working Group for the Standardization of Acupuncture Nomenclature” [17] and further deliverable in the form of WHO International Standard Terminologies on the TM in the western pacific region [16] and finally culminated in the inclusion of traditional module chapter [26], module-1 for TCM in eleventh revision of International classification of disease. In contrast to these developments, the efforts made towards standardization of terminologies and development of diagnostic classification (coding) in India and neighboring countries which house rich, live traditional medicinal practices such as Ayurveda, Siddha, Sowarigpa, Unani is very recent. The initial steps in this direction have formally began in the year 2010 with the advent of W.H.O funded projects under appraisal Project Work (APW) and Direct Financial Cooperation (DFC). It has acted as an engine to further this cause and lead to the development of benchmarks for training & first phase work on standardized terminologies of Ayurveda [17], Siddha, Unani [18].

It is ironical to note that when the TCM was all geared up to be included in ICD-11, TM Chapter as Module-1, the developments from Indian side have dampened. The efforts geared traction after 2016 with revival of project under the heading “Harmonization of Ayurveda Terminologies (HAT) by Basic, Fundamental Research working group [26] of Central Research Council of Ayurvedic Sciences (CCRAS), Ministry of Ayush, Government of India and eventually took shape of common dashboard in the form of “National Ayush Morbidity and Standardized terminologies electronic (NAMASTE) Portal [19]” launched by by Shri Narendra Modi, the Hon'ble Prime Minister of India on the occasion of 2nd Ayurveda Day (17th October 2017) at All India Institute of Ayurveda (AIIA), New Delhi [20]. The developments happened at breakneck speed as it was essential to prepare set up to test these codes before approaching World Health Organization to consider our request to incorporate Ayurveda, Siddha, Unani morbidity codes under ICD-11, TM Chapter, Module-2. While these developments are happening Singh RH, Rastogi S have expressed concern for not securing berth for Ayurveda under ICD-11 demonstrating the importance and urgency of the work involved [21].

1.4. Feature of National Ayush Morbidity and Standard Terminologies Electronic (NAMASTE) Portal

1.4.1. Key Features

• ➢Single window dashboard for Standardized terminologies and national morbidity codes for Ayurveda, Siddha, Unani (and for Sowa Rigpa in due course of time)
• ➢Open access to browse and utilize the contents for all stakeholders viz., Ayush students, medical practitioners, medical record & coding personnel, hospital administrators, public health experts, policy makers etc.,
• ➢An Intuitive user-friendly data entry module for submission of aggregate statistics on monthly basis.
• ➢Comprehensive Data Visualization module to view, time-series, periodical aggregate data and trends like viewing top 10 disorders etc.,
• ➢A data networking platform connecting Ayush systems of medicine with Central Bureau of Health Intelligence [22], National Health Mission [23], National Ayush Health Mission [24] and other key health care related portals in India.

1.4.2. Utility of NAMASTE Portal

• •Code based reporting of Morbidity and Reason for encounter based on the services provided by Ayush systems across India.
• •Futuristic double coding system for reporting using both Ayurveda, Siddha, Unani National Morbidity Codes and ICD-10/11.
• •Single coding system employing ICD-10/11 for Homoeopathy, Yoga & Naturopathy system of medicine may report by single coding system by ICD – 10/11.
• •A repository of information for differential diagnosis, research, Insurance coverage.
• •Serves as information repository for further development of W.H.O International Terminologies of Ayurveda, Siddha, Unani & ICD-11, Chapter-26, Module 2.

The development of NAMASTE portal was quite challenging owing to very narrow, demanding timelines (less than a year from conception of the idea to launch – October 2016 to October 2017). Further as the drafts needed to be prepared by consultative process the process was all the more intriguing. But due the leadership and pragmatic outlook of the participating experts the process could be followed with a fruitful outcome within stipulated time. Though there were working drafts available for Siddha, Unani the exercise for Ayurveda terminologies has to be taken up a fresh. The narrative provides glimpse of guidelines, which steered the whole process. This covers the development process for standardized terminologies and national Morbidity codes for Ayurveda, Siddha and Unani systems of medicine:

A. The core principles followed during shortlisting and draft preparation of standardized terminologies which are in line with W.H.O standardized terminology development mode. The same are as follows.

• 1.Combining the existing drafts of Ayurvedic clinical (2500), non-clinical terms (5453) along with english translation/definition which were already attempted in due consultative process. The work was successfully carried out by IPGTRA, Gujarat Ayurved University, Jamnagar, and National Institute of Ayurveda (NIA), Jaipur [25].
• 2.Followed by this further refinement was done by categorizing the same with further additions in the diagnostic terms section (signs/symptoms etc.) in to the following ten categories (Table No.1)
• 3.As far as possible no new/syncretic sanskrit terms are added. The terms which are part of coded literature from Charaka, Sushrutha, Vagbhata and other important Ayurveda texts were considered.
• 4.For English expression to the extent possible it was attempted to provide Accurate reflection of the original concept of sanskrit terms. Further now neologism (new terms were coined in English.
• 5.The same approach was followed by Siddha [26], Unani [27] groups which published the works in the year 2012.
• 6.Presentation of the content in general contains tabulated list with −1. Code 2. Terms in original languages viz. sanskrit (for Ayurveda)/tamil/(for Siddha)Arabic, Persian and Urdu (for Unani) in Devanagari script and IAST (for Ayurveda), Tamil script with equivalent roman diacritical marks (for Siddha) and ‘Alawi Nasta'liq for 3. Transliteration with diacritical marks 4. Description (with possible english equivalents). For Ayurveda a long definition was also provided where ever necessary.

Table 1.

Details of standardized Ayurveda terminologies.

Group	Title	Descriptions	Code Base	Number
SAT-A	mūlabhūta-śabdaḥ	Basic and Fundamental Terminologies	SAT-A TO SAT-A.318	318
SAT-B	śārīraḥ	Structure and Function	SAT-B to SAT-B.300	300
SAT-C	vyādhi viniścaya/nidāna	Diagnosis & Disorders) General Etiological Factors	SAT-C to SAT-C.175	175
SAT-D	liṅgam/lakṣaṇam/cihnam/saṁsthānam/vyañjanam/ākṛtiḥ	signs & symptoms	SAT-D to SAT-D.9400	9400
SAT-E	National Ayurveda Morbidity codes	NAMC	A-W	2895
SAT-F	Dravyam	Pharmacognosy and Pharmacology	SAT-F to SAT-F.565	565
SAT-G	Auṣadhakalpanā	Preparation of Medicines	SAT-G to SAT-G.197	197
SAT-H	Āhārakalpanā	Preparation of Food and Beverages	SAT-H to SAT-H.116	116
SAT-I	Cikitsā	Treatment	SAT-I to SAT-I.663	663
SAT-J	svasthavṛttaḥ	Preventive and Promotive Health	SAT-J to SAT-J.124	124
Total number of terms/concepts				14753

1.5. Development of Ayurveda, Siddha and Unani Morbidity Codes

The ontology framework and classification strategy adopted for Ayurveda/Siddha/Unani Morbidity Codes in NAMASTE Portal is as follows.

• 1.Diagnostic term/Entity is described in Ayurveda/Siddha/Unani classical texts with description of signs/symptoms.
• 2.Diagnostic term/Entity is employed by Ayurveda physicians in day to day practice at some or other level of understanding pathology and arriving at final diagnosis.
• i.At dosha/dhatu/mala level indicating involvement or impending development of another condition further aiding in deciding upon treatment, prognosis.
• ii.At affected end organ level based on anatomy e.g, diseases of nose/throat etc.,
• iii.Based on causative factor e.g. poisoning/treatment complications/lifestyle related health issues etc.,
• iv.Based on epidemiology w.r.t. conditions such as worm infestation or other infections
• v.Codes describing characteristics of people in terms of constitution, state of health, pregnancy, stages of aging etc.,
• vi.
  Codes describing treatment outcome essential for stopping treatment and take the course of action to next logical state.

  

  Schematic diagram for Ayurveda, Siddha, Unani Morbidity codes.

1.6. Benefits of NAMASTE Portal

• 1.Real time morbidity data collection.
• 2.Identification of areas of strengths of the various systems under Ayush.
• 3.Brings to light, the volume of services provided by Ayush systems which can help in future policy decision making.
• 4.The diagnostic guidelines provided along with the disease would serve as a helping tool in diagnosis and enable cross verification of diagnosis with the case records.
• 5.Helpful in regulating the healthcare delivery system in Ayush systems by providing standardizing diagnostic terminologies, thus overcoming the barrier of the diagnosis being written in sanskrit-arabic-tamil languages in case of Ayurveda, Siddha, Unani systems.
• 6.The diagnostic codes can serve as a tool for documentation in various other programmes such as outreach activities.
• 7.This is the first ever initiative taken by the Ministry of AYUSH, Govt. of India as steppingstone for sustainable maintenance of Ayush health statistics across the country by adopting uniform terminologies. Furthermore, unique code based AYUSH terminologies would certainly bring an uniform pattern of indicating disease terminologies for academic, research as well as serving the purpose of clinical practice. The ultimate transformation would be uniform presentation of evidence in the country and the world at large. The development and maintenance of this portal would be an important milestone for reporting the contribution of Ayush system of medicines in the health care system of the country.

1.7. Capacity building and on-boarding procedure

The Ayush health care service units intending to report on NAMASTE portal will be provided with necessary one to two days training by master trainers; Followed by this user credentials will be created to facilitate data entry of consolidated month wise statistics to the NAMASTE Portal.

So far 80–82 Ayush facilities under Ministry of Ayush, Centre of Excellence (CoEs) and other selected State government run hospitals are uploading the data. Further, real time double coding has been introduced in AYUSH Hospital Management Information System (A-HMIS) in 100 hospitals from November 2018. Due to Covid-19 pandemic the efforts towards sensitization about NAMASTE Portal have been slowed down. However, the efforts are being revived and the sensitization programme across India on mission mode will be carried out from the month of November 2021.

1.8. Methodology & metrics collected under NAMASTE portal

• I.Collection of morbidity Statistics at OPD level and IPD level on daily basis followed by Compilation of the same on monthly basis.
• II.The data is segregated as per the Ayurveda, Siddha, Unani morbidity codes and ICD-10 further stratified by age, new registration or repeat consultation in case of OPD and number of discharged patients against each morbidity code in case of IPD is uploaded to NAMASTE Portal.

1.9. NAMASTE portal-way forward

The launch and modest beginnings of NAMASTE portal serve as prime steps in the process of effective reporting of service delivery attempted by Ayush streams at the ground level with substantiated metrics. The work on preparation of terminologies, specific morbidity codes related with Sowa Rigpa, Yoga, Naturopathy and Homoeopathy are due and to be incorporated at the earliest. There is a need to sensitize the entire Ayush diaspora to be part of this major development and effort are on with a dedicated “NAMASTE sensitization programme” for the same.

The work initiated by Bureau of Indian Standards (BIS) for creating Ayush Standards resulted in release of five standards documents which are based on NAMASTE terminology [28]. Which are as follows.

• 1.IS 17424: Part 1 : 2020 - Glossary of Ayurvedic Terminology Part 1 Standardized Terminology for Fundamental Principles
• 2.IS 17424: Part 2 : 2020-Glossary of Ayurvedic Terminology Part 2 Standardized Terminology for Diagnosis and Etiological Factors
• 3.IS 17424: Part 3 : 2020-Glossary of Ayurvedic Terminology Part 3 Standardized Terminology for Foods and Beverages
• 4.IS 17424: Part 4 : 2020-Glossary of Ayurvedic Terminology Part 4 Standardized Terminology for Medicinal Preparations
• 5.IS 17424: Part 5 : 2021-Glossary of Ayurvedic Terminology Part 5 Standardized Terminology for Body Structure and Function

In continuation of the above, there is a need to release similar documents for Siddha, Unani, Yoga&Naturopathy and Sowa Rigpa Systems of medicine.

The portal is serving as the purpose of terminology repository for development and release of SNOMED CT Ayush Extension in collaboration with National Resource center for Electronic Health Records (NRCeS), CDAC, Pune [29]. This initiative serves the purpose of availability of Ayurveda, Siddha, Unani terminologies as part of International Medical Terminology repository enabling translation of the same into various other languages and effective interoperability.

Further, the NAMASTE Portal team is actively engaged with World Health Organization for the development of international terminologies and Module-2, Traditional Medicine Chapter [26], ICD-11 for Ayurveda, Siddha and Unani Systems. The documents are expected to be release by the end of year 2023.

2. Conclusion

It is heartening to report that the use cases developed by implementation of NAMASTE portal and subsequently real time usage under Ayush Hospital Management Information System (AHMIS) have convinced World Health Organization to take forward the work related with “Ayurveda, Siddha, Unani International terminologies and Inclusion of Ayurveda, Siddha, Unani morbidity codes under ICD-11, TM Chapter, Module-2. There is also keen interest among external medical terminology groups such as SNOMED-CT to prepare translations based on these terminologies. These are all welcome outcomes of an effective, pragmatically conceived project which was achieved with due diligence and focus.

Source of Funding

Nil.

Author contribution

SRT (Saketh Ram Thrigulla) Concept, Data collection, analysis and drafting of the article.

SN (Srikanth Narayanam) Draft guidance and finalization.

Conflict of interest

Nil.